“This is part of emergency medicine now”: A qualitative assessment of emergency clinicians’ facilitators of and barriers to initiating buprenorphine

Abstract

Objectives Despite evidence demonstrating the safety and efficacy of buprenorphine for the treatment of emergency department (ED) patients with opioid use disorder (OUD), incorporation into clinical practice has been highly variable. We explored barriers and facilitators to the prescription of buprenorphine, as perceived by practicing ED clinicians. Methods We conducted semistructured interviews with a purposeful sample of ED clinicians. An interview guide was developed using the Consolidated Framework for Implementation Research and Theoretical Domains Framework implementation science frameworks. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. Results We interviewed 25 ED clinicians from 11 states in the United States. Participants were diverse with regard to years in practice and practice setting. While outer setting barriers such as the logistic costs of getting a DEA‐X waiver and lack of clear follow‐up for patients were noted by many participants, individual‐level determinants driven by emotion (stigma), beliefs about consequences and roles, and knowledge predominated. Participants’ responses suggested that implementation strategies should address stigma, local culture, knowledge gaps, and logistic challenges, but that a particular order to addressing barriers may be necessary. Conclusions While some participants were hesitant to adopt a “new” role in treating patients with medications for OUD, many already had and gave concrete strategies regarding how to encourage others to embrace their attitude of “this is part of emergency medicine now.”

Perspectives About Emergency Department Care Encounters Among Adults With Opioid Use Disorder

“…Some comments revealed specific opportunities to facilitate improved care for patients with OUD seen in the ED, including offering on-demand treatment and ED staff training on stigma, OUD, and OUD treatment. Given recent advances in resources and support for treating OUD in EDs 4 , 37 , 38 , 39 they should be capable of making these changes; however, implementation will require optimized training to reduce stigma and enhance care for patients with OUD.…”

Challenges in Treating Opioid Use Disorder Beyond the Waiver

“…But a waiver is just one obstacle among many. 4,5 For example, in Arizona, a large insurance company offered $5,000 for us to obtain our waivers. This incentive led to a significant portion of our physicians' (including residents) taking a training course and obtaining their waivers; however, for multiple reasons, there has not been any significant change in buprenorphine prescriptions.…”

“…Some ED physicians find this to be an insurmountable challenge. 5 Having an institutionalized, standardized process can facilitate both initiation and follow-up. 7 Indeed, although some physicians feel comfortable prescribing buprenorphine even for 1 dose, many more will if they know that there is a process in place that does not both start and end with them.…”

“…7 Indeed, although some physicians feel comfortable prescribing buprenorphine even for 1 dose, many more will if they know that there is a process in place that does not both start and end with them. 5 Interdisciplinary support can facilitate this process. 7 The elimination of the Drug Addiction Treatment Act of 2000 waiver requirements We appreciate the interest in our editorial calling to eliminate the X-waiver requirement to improve access to care for people with opioid use disorder.…”

“…If emergency clinicians need further convincing, the legal precedent for doing so is becoming increasingly difficult and dangerous to ignore. 5…”