Drug overdoses, the majority involving opioids, were up 30% in 2020, and record levels in 2021. Addressing the overdose crisis requires multiple strategies, but treatment with medications for opioid use disorder (MOUDs) is a cornerstone of the response. MOUDs like methadone and buprenorphine substantially reduce overdose as well as opioid-related morbidity and mortality from other causes such as infections. But there are many barriers—including logistical and regulatory challenges, knowledge or beliefs about MOUDs, and stigma—that leave many patients without access to lifesaving treatments.
Two new studies, co-authored Margaret Lowenstein and a team of researchers, offer evidence about how to increase effective OUD treatment, focusing on emergency departments (EDs). Patients come to EDs following an overdose, for complications of substance use, or simply looking for help, and EDs are poised to offer low-threshold treatment by starting medications during the ED visit. This is supported by strong evidence showing that initiation of buprenorphine in the ED more than doubles treatment engagement at 30 days after the ED visit.
The first study, published in Annals of Emergency Medicine, describes the implementation of a multicomponent strategy to increase ED-initiated buprenorphine at Penn Medicine. The research team previously identified barriers to treatment initiation in the ED. To overcome these barriers, they used behavioral design strategies to help clinicians better identify treatment opportunities, reduce friction related to prescribing and referral, and support patient engagement and care linkage.
Results showed a sixfold increase in buprenorphine use in patients with OUD, going from three percent of ED encounters to 23%. Despite the overall improvement, there was a substantial variability among clinicians, with treatment rates ranging from 0% to more than 60% of OUD-related encounters depending on the treating clinician. These results mirror findings in other settings, which show that even among X-waivered providers, there is wide variability in buprenorphine prescribing in practice.
This wide variation among clinicians was also the motivator for the next steps, which included efforts to nudge clinicians towards more evidence-based care by making treatment more of a default process. The second study, published in NEJM Catalyst, details the participatory design approach taken to make this happen.
By the time physicians saw patients, it was often too late, and patients were experiencing severe withdrawal or had simply left. Both physicians and nurses supported a nurse-driven process with OUD screening in ED triage coupled with automated prompts to both nurses, physicians, and/or advanced practice providers to perform assessment and treatment of OUD and to deliver evidence-based treatment interventions.
Together, these studies provide early evidence about potentially scalable strategies to increase ED-initiated OUD treatment with implications for policy and practice.