As Opioid Epidemic Continues Unabated, EDs Mobilize to Save Lives
As the COVID-19 pandemic waxed and waned, the U.S. opioid epidemic continued apace, with death counts surpassing grim new milestones. Provisional data from the CDC indicate more than 100,000 overdose deaths occurred from April 2020 to April 2021. That is an increase of 29.5% from the preceding year.1
Although frontline providers frequently witness the medical consequences of the opioid epidemic, the opportunity to intervene with evidence-based treatment often is lost. Medications such as methadone and buprenorphine have been proven to reduce mortality rates and prevent several other outcomes related to opioid use disorder (OUD). Still, the struggle to initiate patients on these life-saving medications continues.2
However, investigators at the Perelman School of Medicine at the University of Pennsylvania have made remarkable progress in identifying patients with OUD when they present to the ED, and convincing frontline providers to initiate these patients on medication-assisted treatment (MAT). Further, they have been regularly documenting their ongoing improvement efforts to offer other EDs a potential roadmap for how to improve in this area and sustain that progress going forward.
These Philadelphia-based researchers were particularly motivated to push for improvement because the overdose death rate there has remained consistently high. Also, before starting their work in 2017, buprenorphine use was low in the three Philadelphia EDs in which they subsequently implemented their interventions.
Margaret Lowenstein, MD, MPhil, MSHP, assistant professor in the division of general internal medicine at the Perelman School of Medicine, says she and colleagues considered the barriers to initiating MAT.3 “We thought about ways ... to automate or prompt or create processes where the evidence-based practice is ... seamlessly integrated into the workflow to make it easy, attractive, and also timely so that people could get the care that they need.”
For example, Lowenstein and colleagues endeavored to automate both the identification of patients with OUD as well as the connections between these patients and peer support specialists. This approach relied on data that were in the electronic medical record (EMR), making it faster to securely prompt a peer recovery specialist to help an ED patient. Investigators found this approach made clinicians more willing to initiate patients on MAT because they knew patients would be supported and linked to the next care steps.
Other steps focused on leveraging EMR-based decision support. For instance, Lowenstein and colleagues created electronic order sets for the initiation of buprenorphine and for the discharge of patients with OUD. In addition, emergency physicians received financial incentives to undergo the required training and obtain their X-waivers. This step proved successful, increasing the percentage of physicians with X-waivers from 6% to 90% over a six-week period.
(There is an ongoing conversation about whether providers should have to obtain an X-waiver to prescribe buprenorphine. The Biden administration has staked out some middle ground, at least for now. Read more here.)
Lowenstein and colleagues took steps to change the culture and socialize the idea that treatment for OUD was important. When a patient presented to a community MAT provider for subsequent treatment following his or her ED encounter, that information would be sent to the emergency provider who initiated the treatment, along with praise for his or her efforts.
Researchers conducted a retrospective analysis of EMR data from adult patients with OUD who visited the ED from before the interventions took place (March 2017 to November 2018) to data on similar patients who visited the ED following implementation of the interventions (December 2018 to July 2020). They found the rate of OUD patients receiving buprenorphine increased from 3% to 23% by the end of the study period. Following implementation of the interventions, patients with OUD were 25% more likely to receive buprenorphine during their ED encounter. Further, researchers found the number of providers who wrote a prescription for buprenorphine at least once grew from 7% to 70%.
“We do think this is a helpful blueprint for other systems that are looking to implement these practices,” Lowenstein says. “The biggest lesson learned is that we used multiple pieces all together, all informed by different behavioral sights, such as making the process easier and providing feedback.”
Lowenstein and colleagues are working on further improvements. For example, they determined the automated process for identifying patients with OUD was missing too many patients who could benefit. Further, both physicians and nurses said nurses should be more involved in the identification and management of OUD patients. This led to the creation and implementation of a nurse-driven triage protocol that empowers nurses to initiate some aspects of care before the patient meets with their treating provider.4
Rachel McFadden, BSN, RN, CEN, an emergency nurse at the Hospital of the University of Pennsylvania, notes how nurses see the effects of the opioid crisis intensely. “They see patients cycle back, in and out, for severe withdrawal. They see the distress that this causes patients,” McFadden says. “A lot of this falls on nurses a lot of the time, and I think nurses recognized that and were looking for a way to do something about it.”
Considering triage nurses already were asking four or five high-risk screening questions, they were open to asking one more if it meant identifying patients who could benefit from MAT. Thus, under the new protocol, patients are asked in triage whether they have struggled with painkillers or have used heroin or fentanyl in the past week.
If the answer is no, then no further action is needed. However, if the patient answers yes, then the nurse asks whether the patient feels as though he or she is in withdrawal. If the patient answers yes, then a Clinical Opiate Withdrawal Scale (COWS) will immediately populate the nurse’s screen so he or she can measure the level of withdrawal.
“If a person has a COWS score at 13 or higher, he or she can receive a dose of buprenorphine right then and there,” McFadden says. However, if more than an hour elapses before the patient sees a provider, then a best practice alert will go to the primary nurse caring for the patient to conduct another COWS assessment.
After the first 10 weeks of the new screening protocol, investigators observed it added about 12 seconds to the triage process. Further, they found the approach does identify more patients with symptoms suggestive of OUD than the previous automated process.
In 10 weeks, the new process identified 860 patients, which included 273 patients who were not identified using the automated process. This represented a 47% increase in the identification of patients found to be at risk.
McFadden reports a new iteration of the protocol will roll out this spring. In the new version, the question about withdrawal will be removed from the screening protocol. Instead, triage nurses will proceed to a COWS assessment on any patient who answers yes to the initial screening question about struggles with pain pills. “Whether the COWS score is 0 or 25, something will be documented, and that score will prompt follow-up notifications,” McFadden says.
During focus group discussions with nurses, some were concerned that if patients were identified early as struggling with OUD, those patients might experience stigma later during their ED encounter. McFadden says stigma has been a longstanding barrier to treatment for patients with OUD. However, she stresses one evidence-based way to address stigma is to talk about the problem in the context of solutions that work. “All of the education I do around OUD ... is [about how] we have life-saving medicines that we can start in the ED that help people feel better rapidly,” McFadden says. “They allow people to stay and get treatment that they need. They can ultimately reduce the person’s risk of mortality by 50%. Using [the ED encounter] as an opportunity to wield these evidence-based solutions is part of what [prevents] stigma.”
- Centers for Disease Control and Prevention. Drug overdose deaths in the U.S. top 100,000 annually. Nov. 17, 2021.
- Martin A, Mitchell A, Wakeman S, et al. Emergency department treatment of opioid addiction: An opportunity to lead. Acad Emerg Med 2018;25:601-604.
- Lowenstein M, Perrone J, Xiong RA, et al. Sustained implementation of a multicomponent strategy to increase emergency department-initiated interventions for opioid use disorder. Ann Emerg Med 2022;79:237-248.
- Lowenstein M, McFadden R, Abed-Rahman D, et al. Redesign of opioid use disorder screening and treatment in the ED. NEJM Catalyst. January 2022.
Investigators have made remarkable progress in identifying patients with opioid use disorder when they present to the ED, and convincing frontline providers to initiate these patients on medication-assisted treatment. Further, they have been regularly documenting their ongoing improvement efforts to offer other EDs a potential roadmap for how to improve in this area and sustain that progress.
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