Understanding current practice of opioid use disorder management in emergency departments
      across Canada: A cross-sectional study

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ABSTRACT

Objective

Opioid-related deaths are increasing at alarming rates in Canada, with a 34% increase from 2016 to 2017. Patients with opioid use disorder often visit emergency departments (ED), presenting an opportunity to engage patients in treatment. Buprenorphine-naloxone is first-line treatment for opioid use disorder, but current management in the ED is unknown. This study aimed to characterize opioid use disorder management in the ED.

Methods

We conducted a cross-sectional study of emergency physicians across Canada. A survey was circulated electronically to the Canadian Association of Emergency Physicians members. Participants were asked about their current management practices, satisfaction, and helpfulness of resources. SAS (version 9.4) was used for statistical analysis. We dichotomized Likert-scale responses to approximate relative risk ratios via a log binomial analysis.

Results

The survey was completed by 179 participants for a response rate of 11.1%; 143 (79.9%) physicians treated patients with opioid use disorder more than once a week. Only 7% (n = 13) of respondents always/often gave buprenorphine in the ED. Referral to an addiction clinic where patients were seen quickly was deemed the most helpful (90.5%, n = 162). Physicians who reported satisfaction with opioid use disorder management were four times more likely to prescribe buprenorphine in the ED or as an outpatient script (RR = 4.41, CI = 2.33–8.33, p < 0.01; RR = 4.51, CI = 2.21–9.22, p < 0.01).

Conclusion

This study found that buprenorphine is not frequently prescribed in the ED setting, which is incongruent with the 2018 guidelines. Care coordination and on-site support were helpful to ED physicians. Hospitals should use knowledge translation strategies to improve the care of patients with an opioid use disorder.

Résumé

Introduction

La mortalité liée à la prise d'opioïdes augmente à un taux alarmant au Canada; celui-ci a connu une hausse de 34%, de 2016 à 2017. Les patients connaissant des troubles de l'usage des opioïdes se rendent souvent au service des urgences (SU); voilà une belle occasion de les inciter à suivre une cure. Le traitement de première intention de ce type de troubles est l'association de buprénorphine et de naloxone, mais on ne connaît pas les pratiques actuelles à cet égard dans les SU. L’étude visait donc à caractériser la prise en charge des troubles de l'usage des opioïdes au SU.

Méthode

Il s'agit d'une étude transversale menée parmi les urgentologues, partout au Canada. Un questionnaire d'enquête a été envoyé, par voie électronique, aux membres de l'Association canadienne des médecins d'urgence. Les participants devaient répondre à des questions sur leurs pratiques actuelles en matière de prise en charge, leur degré de satisfaction et l'utilité de certaines ressources. L’équipe a utilisé le logiciel SAS (version 9.4) pour procéder à une analyse statistique, et dichotomisé les réponses indiquées sur l’échelle de Likert afin d'obtenir une évaluation approximative des risques relatifs (RR) fondée sur une analyse binomiale logarithmique.

Résultats

Au total, 179 participants ont rempli le questionnaire, soit un taux de réponse de 11,1%. Sur ce nombre, 143 médecins (79,9%) traitaient des patients ayant des troubles de l'usage des opioïdes plus d'une fois par semaine. Seuls 7% des répondants (n = 13) administraient toujours ou souvent de la buprénorphine au SU. Les consultations accordées rapidement aux patients dirigés vers les centres de désintoxication étaient jugées la mesure la plus utile (90,5%; n = 162). Les médecins qui se sont déclarés satisfaits de la prise en charge des troubles de l'usage des opioïdes étaient 4 fois plus susceptibles que les autres de prescrire de la buprénorphine au SU ou d'en remettre une ordonnance pour malades externes (RR = 4,41; intervalle de confiance [IC] = 2,33–8,33; p < 0,01 et RR = 4,51; IC = 2,21–9,22; p < 0,01).

Conclusion

D'après les résultats de l’étude, la buprénorphine est peu prescrite au SU, ce qui n'est pas conforme aux lignes directrices de 2018. La coordination des soins et les diverses formes de soutien sur place se sont révélées des moyens utiles aux médecins, dans les SU. Enfin, il faudrait mettre en œuvre des stratégies d'application des connaissances dans les hôpitaux afin d'améliorer les soins aux patients connaissant des troubles de l'usage des opioïdes.

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Most cited references 1

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Is Open Access

Implementation facilitation to promote emergency department-initiated buprenorphine for opioid use disorder: protocol for a hybrid type III effectiveness-implementation study (Project ED HEALTH)

Gail D’Onofrio, E. Edelman, Kathryn Hawk … (2019)

Background Patients with opioid use disorder (OUD) frequently present to the emergency department (ED) after overdose, or seeking treatment for general medical conditions, their addiction, withdrawal symptoms, or complications of injection drug use, such as soft tissue infections. ED-initiated buprenorphine has been shown to be effective in increasing patient engagement in treatment compared with brief intervention with a facilitated referral or referral alone. However, adoption into practice has lagged behind need. To address this implementation challenge, we are evaluating the impact of implementation facilitation (IF) on the adoption of ED-initiated buprenorphine for OUD into practice. Methods This protocol describes a study that is being conducted through the National Institute on Drug Abuse’s Center for the Clinical Trials Network. A hybrid type III effectiveness-implementation study design is used to evaluate the effectiveness of a standard educational dissemination strategy versus IF on implementation (primary) and effectiveness (secondary) outcomes in four urban, academic EDs. Sites start with a standard 60-min “Grand Rounds” educational intervention describing the prevalence of ED patients with OUD, the evidence for opioid agonist treatment and for innovative interventions with ED-initiated buprenorphine; followed by a 1-year baseline evaluation period. Using a modified stepped wedge design, sites are randomly assigned to the IF intervention which is guided by the Promoting Action on Research Implementation in Health Services (PARiHS) framework to assess evidence, context, and facilitation-related factors impacting the adoption of ED-initiated buprenorphine. During the 6 months of IF through the 1-year IF evaluation period, external facilitators work with local stakeholders to tailor and refine a bundle of activities to meet the site’s needs. The primary analyses compare the baseline evaluation period to the IF evaluation period (n = 120 patients with untreated OUD enrolled during each period) on (1) rates of provision of ED-initiated buprenorphine by ED providers with referral for ongoing medication (implementation outcome) and (2) rates of patient engagement in addiction treatment on the 30th day after the ED visit (effectiveness outcome). Finally, we will perform a cost-effectiveness analysis (CEA) to determine if the effectiveness benefits are worth the additional costs. Discussion Results will generate novel information regarding the impact of IF as a strategy to promote ED-initiated buprenorphine. Trial registration ClinicalTrials.gov NCT03023930 first posted 1/10/2017, https://clinicaltrials.gov/ct2/show/NCT03023930?term=0069&rank=1 Electronic supplementary material The online version of this article (10.1186/s13012-019-0891-5) contains supplementary material, which is available to authorized users.