Implementing Programs to Initiate Buprenorphine for Opioid Use Disorder Treatment in High-Need, Low-Resource Emergency Departments: A Nonrandomized Controlled Trial - 16/08/23
, John Rotrosen, MD a, Phoebe Gauthier, MA, MPH b, Gail D’Onofrio, MD c, d, e, f, David A. Fiellin, MD c, d, e, f, Lisa A. Marsch, PhD b, Patricia Novo, MPA, MPH a, David Liu, MD g, E. Jennifer Edelman, MD, MHS d, e, f, Sarah Farkas, MA a, Abigail G. Matthews, PhD h, Caroline Mulatya, PhD h, Dagmar Salazar, MS h, Jeremy Wolff, BA h, Randolph Knight, MD i, William Goodman, MD, MPH j, Joseph Williams, MPH f, Kathryn Hawk, MD, MHS c, d, fAbstract |
Study objective |
We hypothesized that implementation facilitation would enable us to rapidly and effectively implement emergency department (ED)-initiated buprenorphine programs in rural and urban settings with high-need, limited resources and dissimilar staffing structures.
Methods |
This multicenter implementation study employed implementation facilitation using a participatory action research approach to develop, introduce, and refine site-specific clinical protocols for ED-initiated buprenorphine and referral in 3 EDs not previously initiating buprenorphine. We assessed feasibility, acceptability, and effectiveness by triangulating mixed-methods formative evaluation data (focus groups/interviews and pre/post surveys involving staff, patients, and stakeholders), patients’ medical records, and 30-day outcomes from a purposive sample of 40 buprenorphine-receiving patient-participants who met research eligibility criteria (English-speaking, medically stable, locator information, nonprisoners). We estimated the primary implementation outcome (proportion receiving ED-initiated buprenorphine among candidates) and the main secondary outcome (30-day treatment engagement) using Bayesian methods.
Results |
Within 3 months of initiating the implementation facilitation activities, each site implemented buprenorphine programs. During the 6-month programmatic evaluation, there were 134 ED-buprenorphine candidates among 2,522 encounters involving opioid use. A total of 52 (41.6%) practitioners initiated buprenorphine administration to 112 (85.1%; 95% confidence interval [CI] 79.7% to 90.4%) unique patients. Among 40 enrolled patient-participants, 49.0% (35.6% to 62.5%) were engaged in addiction treatment 30 days later (confirmed); 26 (68.4%) reported attending one or more treatment visits; there was a 4-fold decrease in self-reported overdose events (odds ratio [OR] 4.03; 95% CI 1.27 to 12.75). The ED clinician readiness increased by a median of 5.02 (95% CI: 3.56 to 6.47) from 1.92/10 to 6.95/10 (n(pre)=80, n(post)=83).
Conclusions |
The implementation facilitation enabled us to effectively implement ED-based buprenorphine programs across heterogeneous ED settings rapidly, which was associated with promising implementation and exploratory patient-level outcomes.
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| Please see page 273 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Donald M. Yealy, MD. Specific detailed information about possible conflicts of interest for individual editors is available at editors. |
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| Author contributions: RM, JR, and LM obtained funding. RM, KH, JR, PG, GD, DF, LM, PN, DL, EE, SF, AM, CM, DS, and JWo contributed to the concept, protocol development, and data management, and they all, along with RK and WG, provided administrative, technical, or material support for the supervision and conduct of the trial and data collection. AM and CM planned and performed the main statistical analyses. KH, RM, PG, and Jwi synthesized and interpreted formative evaluation data. RM, KH, and PG drafted the manuscript. All authors provided critical revision of the manuscript. RM takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The main study was supported by funding provided by the National Institute on Drug Abuse through the Clinical Trials Network (CTN) through grants provided to each participating node: New York Node, UG1DA013035 (Rotrosen/Nunes) and Northeast Node: UG1DA040309 (Marsh). |
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| All authors report grant or contract funding from NIDA for this study, which includes support for travel to scientific conferences. |
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| Role of the Funder/Sponsor: The NIDA CTN Research Development Committee reviewed the study protocol, and the NIDA CTN publications committee reviewed and approved the manuscript for publication. The funding organization had no role in the collection, management, analysis, and interpretation of the data or decision to submit the manuscript for publication. |
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| Trial Number: NCT03544112 |
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| This study was approved by the Biomedical Research Alliance of New York institutional review board. |
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Vol 82 - N° 3
P. 272-287 - septembre 2023 Retour au numéro
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