Barriers and Facilitators Associated with Establishment of Emergency Department-Initiated Buprenorphine for Opioid Use Disorder in Rural Maine

Abstract

Introduction

The opioid epidemic in the United States continues to grow and has particularly impacted rural communities served by critical access hospitals (CAH) in Maine. Buprenorphine is an effective medication for the treatment of opioid use disorder (MOUD) that can be successfully initiated in the emergency department (ED), where patients with opioid use disorder (OUD) frequently receive care. However, many EDs have not implemented programs to initiate buprenorphine. This study sought to identify barriers and facilitators to successful development of buprenorphine programs in rural CAH EDs.

Methods

Semi-structured interviews were conducted with ED directors of Maine CAHs regarding barriers and facilitators to developing programs for ED-initiated buprenorphine. Participants were recruited through a comprehensive list of Maine CAHs. Eleven of 17 Maine CAH ED directors agreed to participate and completed interviews. Interviews were audio-recorded, transcribed and analyzed using a thematic approach.

Results

Four themes and 11 sub-themes were identified including (i) Compelled to Act — Directors’ personal experiences with patients motivated and facilitated the development of buprenorphine programs in their EDs; (ii) Leadership and Mentorship — Peer mentorship from other CAH ED directors facilitated buprenorphine program development, and senior hospital administrators facilitated, in some cases, directors’ efforts to initiate buprenorphine programs, but created a barrier in other instances; (iii) Stigma — Fear that EDs would be overcrowded by drug-seeking patients was a common barrier to buprenorphine program initiation; (iv) Follow-up — Finding appropriate outpatient follow-up for OUD patients created the greatest logistical barrier buprenorphine program initiation.

Discussion

The personal experiences ED directors had working with their own patients, supportive hospital leadership and peer mentorship were important facilitators to successful ED-initiated buprenorphine programs in rural Maine CAH EDs. Overcoming stigma and developing community outreach and appropriate follow-up were the greatest barriers. Future research should focus methods for improved implementation of buprenorphine programs at CAH EDs through enhancing peer mentorship and administrative support, community outreach and staff education.

Introduction

The opioid epidemic in the United States continues to grow.¹ Rural areas in northern New England have been particularly effected, with over 14.3 deaths per 100,000 population annually, the highest outside of central Appalachia.^2,3 In Maine, over 40% of the population lives in a rural area and the total number of quarterly opioid overdose deaths has continued to trend upward since 2011, reaching the highest count on record in 2020.^4,5

Patients with opioid use disorder (OUD) seek care at emergency departments (ED) as a direct consequence of OUD, due to comorbidities related to OUD and due to lack of adequate access to primary care, making the ED well positioned for the treatment of OUD.^6,7 Buprenorphine, a long-acting opioid partial agonist, is a highly effective medication for opioid use disorder (MOUD) and has been shown to retain patients in treatment and suppress illicit drug use.^8,9 ED-initiated buprenorphine treatment with referral to ongoing treatment has also been shown to be effective at reducing relapse, and is feasible and cost-effective.^10–12

Despite compelling evidence, adoption of ED-initiated buprenorphine treatment has been limited.¹³ A study of 4 urban academic medical centers found that only 20.9% of ED clinicians reported high readiness to initiate buprenorphine.¹⁴ Stigma toward patients with OUD, clinician concern over regulation of buprenorphine prescriptions and lack of clear protocols for ED initiation of buprenorphine have been identified as potential barriers at larger medical centers.^14,15 In rural areas, similar barriers to OUD treatment with buprenorphine have been identified at family medicine clinics.^16,17

Long-term, outpatient follow-up has been identified as a barrier to ED-initiated buprenorphine at urban centers. Models for follow-up care have been developed, including the ED Bridge model in which there is a ‘warm handoff’ from the ED provider to an outpatient clinic for follow-up within 72 hours.¹⁷ A warm handoff from the ED requires existing outpatient resources to receive the patient, which makes outpatient provision of buprenorphine in rural areas particularly challenging. In addition, special authorization, known as the DEA Addiction Treatment Act (DATA) waiver, or X waiver, is required to prescribe buprenorphine. Over half of rural counties in the United States lack a buprenorphine provider, as compared to 2% of urban counties.¹⁸ Models for rural provision of outpatient buprenorphine such as telemedicine and the ‘hub and spoke’ model have been described.^19,20 The hub and spoke model is intended to increase rural access to MOUD by designating generalist rural providers to receive training and support from specialists at larger regional medical centers.

Data regarding barriers specific to ED-initiated buprenorphine treatment in the rural setting is currently lacking and no study, to our knowledge, has identified which barriers and facilitators are common to rural and urban sites alike and which may be rural-specific. This study sought to identify barriers and facilitators to successful establishment of ED-initiated buprenorphine programs at rural CAH EDs in Maine.

Methods

Study design and setting

This investigation consisted of semi-structured interviews of ED directors at CAHs in Maine regarding barriers and facilitators to successful establishment of ED-initiated buprenorphine programs at their departments. The Miriam Hospital Institutional Review Board approved the study.

Study population

Participants for this study were identified from a comprehensive list of all CAHs in Maine using data from the Maine Hospital Association and Maine Department of Health and Human Services.^23,24 Contact information for the ED director at each of these sites was obtained from the American College of Emergency Physicians, Maine Chapter. Each director was contacted via email and invited to participate in the study. For those who did not respond to the initial request, a second follow-up email was sent. Potential participants who did not respond after two emails to a verified address were presumed to have declined to participate. ED directors willing to participate were scheduled for interviews between February and September 2020. Participants were given a $20 Amazon gift card as compensation for their time.

Instrument development and content

A semi-structured interview guide was developed by the research team based upon review of research studies on the perceived barriers and facilitators to ED-initiated buprenorphine.^13,15,21,22 Two ED directors who had successfully started ED-initiated buprenorphine programs in Maine, and had experience in rural health, reviewed the interview guide and provided feedback on completeness, redundancy, ambiguity and understandability. Neither of these two directors were current ED directors at CAHs in Maine and thus not included as study participants. Adjustments were made accordingly to the final interview guide. The completed interview guide contained orienting questions that probed for reasons for starting or not starting a buprenorphine program and potential barriers and facilitators, and follow-up questions that further specified potential barriers and facilitators (Supplement). This approach was intended to focus discussion on content relevant to the study aims while allowing for flexibility during the interview.

Data collection

Interviews were conducted and audio-recorded using Zoom (Zoom Video Communications, Inc. Version: 5.4.4) according to the interview guide. All interviews were conducted by the study principal investigator, who is a practicing emergency physician with graduate training in qualitative research methodology. There were no non-participants present on the call. The interviewer operated under the assumption that ED-initiated buprenorphine is beneficial. Prior to the interview participants were informed that the goal of the study was to better understand barriers and facilitators to ED-initiated buprenorphine. Interview time allotment was approximately 30 minutes, or until completion of the interview guide and any spontaneous discussion. Verbal consent was obtained prior to each interview. All interview recordings were transcribed verbatim by a professional medical transcriptionist and deidentified prior to analysis. Additional brief field notes were generated by the interviewer to add context where necessary. Data saturation was not assessed as the goal was to interview as close as possible to all Maine CAH ED directors. Cited quotations from interviews were reviewed by participants for comment or correction.

Data analysis

Data from the transcripts were coded and analyzed using a previously described thematic analysis approach.²³ NVivo (version 12) was used for data organization. The 4 coding authors began the analysis by reviewing the entire set of transcripts. Transcripts were randomly divided into three groups and each group was independently coded by one coding author. An initial set of deductive codes were used, generated a priori from subject knowledge and review of studies that address buprenorphine program development in other settings. Inductive codes, established during the coding process itself, were added during coding. The resultant codes were reviewed by all four coding authors; redundant codes were combined, ambiguous codes were further specified, and codes that encompassed more than one potential theme were subdivided. A consensus codebook was developed based on several iterations of this process. All transcripts were recoded using the finalized code book. Codes were organized into themes and sub-themes and representative quotations were chosen. A summary of preliminary findings was shared with participants and their feedback was solicited.

Results

Of the 17 ED directors contacted, 11 agreed to participate and all 11 completed interviews in full. The remaining 6 did not respond to our request. All of the ED directors were male, as was the interviewer. Four of the ED directors were previously known to the interviewer professionally. None of the responding directors declined to participate. Interviews varied in length from 15 to 35 minutes. No interview was truncated by the participant or interviewer and no interviews were repeated. Each participant was asked whether or not their department offered buprenorphine induction. Buprenorphine had been prescribed or administered at least once in all EDs, though the extent to which a routine, protocolized method for buprenorphine induction existed varied substantially from once or twice by a single individual to routinely in by all providers. The extent was not further quantified. Key themes and sub-themes are summarized in Table 1 and described in detail below.

Table 1.

Themes and sub-themes of barriers and facilitators to development of ED initiated buprenorphine programs

Theme	Description	Sub-Themes
Compelled to act	Experiences that motivated participants to develop an ED initiated buprenorphine program at their hospital	Personal experience
		Peer example
Leadership and Mentorship	People in leadership positions were key to the success of a program	Supportive senior hospital leadership
		Obstructive senior hospital leadership
		Peer mentorship and collaboration
Stigma and outreach	The role of stigma as an initial barrier, which was later overcome	Fear of overcrowding
		Reality of low utilization
		Need for outreach
		Stigma overturned
Follow-up	Follow-up was the single greatest logistical barrier and require creative problem solving.	Lack of follow-up
		Creative solutions

1. Compelled to act

ED directors stated that they felt motivated to act against the opioid epidemic. They identified specific patient encounters in their own practice in which an opioid death brought home the gravity of the crisis or highlighted their own responsibility. One participant noted personal experience with SUD had allowed him/her to more fully empathize with patients experiencing OUD. These experiences served as internal motivation, leading them to support and, in some cases, champion ED-initiated buprenorphine programs in their EDs. Participants also noted that ED-initiated buprenorphine has become the standard of care for the treatment of OUD. Accordingly, they expressed a desire to stay current with best practices, and that this desire was a major motivating factor in establishing a program. The sense that ED peers elsewhere were establishing programs, and perhaps a competitive desire not to be left behind, also influenced their efforts.

1. Personal experience:

   “I had a patient one day, a woman, she was in her 40s or so . . . I walked into the room to see her for, I don’t remember what it was, but she saw my name badge and she just broke down and started crying. I was like, ‘What is that?’ I let her collect herself and then asked her what the deal was with that, because I’d never met this person before. Apparently her 20-something year old son had just been found dead of an overdose in his car, and . . . in his car he had a bottle of Vicodin that had my name on it [as the prescribing physician]. That’s not what he overdosed on, but it was certainly an eye opener for me.” [DR10]

   “I was on a shift in the evening and received a patient from rescue squad who had overdosed and was in cardiac arrest . . . He went to the ICU and then ended up dying the next day. It turns out that his wife died at the scene in the same [overdose] episode, and they had three children. I was just devastated. I could no longer just say, ‘Oh, it’s someone else’s problem’ That case put it as my problem.” [DR7]

   “I got in personal recovery in 2008, so that was a while ago. Up until that point, I’m not sure I would have had the same perspective on [buprenorphine] in general.” [DR5]

2. Peer example:

   “It’s the standard of care now. No doubt about it. If you’re not doing it, then you’re behind” [DR8]

   “Well, it was a big push because as you know in [ED location] County. There’s such a large problem with opioids” [DR9]

Leadership and Mentorship

Advocacy from senior hospital leadership was identified by participants as key factor for ED-initiated buprenorphine practices to be established. Hospital leadership could act as either a barrier or a facilitator, depending on the ED. As one participant noted, such conflicting influences might be especially pronounced at rural hospitals where a small number of key people can have a large impact on the group. Participants at some CAHs had benefited directly from the experience of another ED director via professional networks in establishing programs. Participants had borrowed and adapted buprenorphine-initiation protocols that had been previously developed at other small hospitals, and they expressed eagerness to pass on this knowledge and assistance to others. They noted that it was sometimes possible to trace a lineage from one ED to another as protocols and expertise were shared. One ED director in particular was identified multiple times as a key peer influencer and facilitator in this area.

1. Supportive senior hospital leadership

   “The program was developed by the hospital’s chief medical officer as his thing. This is a passionate issue for him. . . . He’s the CMO and he was really personally motivated. It was a perfect combination.” [DR4]

2. Obstructive senior hospital leadership

   “The biggest barrier I’ve had really is administration not having any interest in it. I would like to make it really a standard protocol. Right now, I think that if I left, [ED-initiated buprenorphine] would just go away.” [DR7]

   “Fewer voices have a louder say . . . It’s going to be highly dependent on the makeup of the few people who are responsible for approving initiations like this, or initiatives like this.” [DR2]

3. Peer mentorship and collaboration

   He [other ED director] was awesome and he sent me some emails and talked it over and that was helpful . . . I think that was really helpful to have a big hospital already doing it and succeeding. [DR6]

Stigma and outreach

One of the most pervasive barriers to establishing an ED-initiated buprenorphine program was the concern that doing so would attract a large number of OUD patients, which were considered to be undesirable. ED directors noted that other physicians in their group, nursing staff and hospital administrators had voiced concerns about overcrowding and attracting patients that they found difficult to care for in the ED. Participants reported that people in these groups had also expressed concern that buprenorphine would be obtained in the ED and sold in the community for illicit purposes.

None of the participants reported any problems with overcrowding after the practice of ED-initiated buprenorphine program was established. Several ED directors expressed disappointment that more patients had not utilized the service and believed that community outreach to raise awareness had been insufficient. One ED director had been prohibited by their hospital administration from developing any kind of advertising or community outreach for the ED-initiated buprenorphine practice. Multiple ED directors noted that the same individuals within the hospital who had initially been skeptical about the value of ED-initiated buprenorphine became advocates after starting a patient on buprenorphine themselves.

1. Fear of overcrowding

   “There’s the concern that: ‘Okay, we’re going to get overrun with people coming in asking for this.’ Or ‘Why would we want to make work for ourselves with these trashy people?’ or whatever” [DR5]

   “The entire group was like, ‘You’re absolutely nuts to invite this group of patients into the hospital and advertise that we’re doing this.’” [DR4]

2. Reality of low utilization

   “None of the fears that people had came true in terms of volume or diversion or abuse or anything” [DR2]

   “It’s never, ever been an issue. Unfortunately, it’s never been an issue. We’ve never been overwhelmed. . . We had a couple of points in history where we had peaks, but we were never stretched beyond where it’s a problem.” [DR7]

3. Need for outreach

   “We use local newspapers. [We] partnered with one of the independent film festivals . . . They helped sponsor this roadshow where they showed Recovery Boys [A documentary about OUD]. . . Despite being a blizzard, it was pretty well-attended and a lot of good question and answer at the end. Afterward we had a panel with myself, with our local police chief, a patient who had actually been through it” [DR10]

   “I think if you want to get access to the people in the community that need it, they need to know about it. We felt restricted as an ED group in not being able to get that word out there. . . We had very few patients enroll or be enrolled in the program that we had set up.” [DR1]

   “We know that there are actually more people out in the community that need the help, but it takes a while to get the numbers up, to provide the help and then get the education out to. [DR9].

4. Stigma overturned

   “I had one guy [ED staff physician] even say, ‘If we do that [ED-initiated buprenorphine program], I’m going to quit.’ He was one of the first people to do an induction, and it was super satisfying for him. I’ve noticed that too, that some of the most satisfying cases of my EM career have been an induction case where you do it successfully on one person, and then they bring their significant other in the next day because they had such a positive experience with it and they’ve stayed clean for months.” [DR10]

Follow-up

One of the most consistent barriers identified across almost all EDs involved finding outpatient follow-up for patients once they had received their initial doses of buprenorphine in the ED. Most directors had attempted to create variations of the Bridge model, in which ED clinicians provide up to a three-day prescription for buprenorphine, or repeat ED visits for buprenorphine administration for clinicians lacking a DEA “X waiver,” and refer patients to an MOUD clinic. One emergency medicine trained physician became so frustrated that he could never find outpatient follow-up within 72 hours, as is recommended, that he began offering outpatient follow-up visits to patients, free of charge, in order to bridge them for the two weeks that were often required to obtain a long-term buprenorphine provider. One participant noted that economic and sociodemographic factors limit the availability of outpatient follow-up. Other ED directors had better success establishing close follow-up for their patients and many relied heavily on outpatient follow-up via telehealth services or clinicians who visited the area periodically from urban centers.

1. Lack of follow-up

   “If you have outpatient follow-up, the ER part is easy. If you can get your primary care providers on board and interested, then I think that’s the key.” [DR7]

   “Our issue was not with our emergency medicine clinicians. Our issue became what do we do with them afterwards because we had no problem with initiation. . . There is a lot of rural poverty and an elderly population. There is not a lot of suitors wanting to come up here and provide programming and support the community.” [DR4]

2. Creative solutions

   What we started doing was when someone would start a patient on [buprenorphine in the ED], they would email me the patient’s identification number. I would call them at home and do an interview in their home. . . If I felt it was appropriate, I would give them a prescription for about two weeks of suboxone until they could get into [a long-term provider]. It actually worked out really well. . . It just seemed that there was no way to do it without doing it this way. I could get no interest from the hospital administration [DR7].

Discussion

This study’s findings characterize important barriers and facilitators to successfully developing an ED-initiated buprenorphine program in rural Maine CAH EDs as described by ED directors. These data suggest that individual motivation from personal experiences and supportive hospital leadership plays an important role in a program’s success. Mentorship and knowledge-sharing between ED directors was considered valuable. Overcoming stigma among hospital staff and developing a plan for community outreach was also found to be necessary. One of the most persistent barriers noted was in obtaining appropriate follow-up for long-term buprenorphine.

Studies of barriers and facilitators to ED-initiated buprenorphine in an urban setting have demonstrated some similar barriers. A mixed methods study of 4 academic, urban EDs found identified concerns about obtaining long-term care for patients as a barrier and facilitators included access to a clinical protocol and ability to obtain feedback from successful patient experiences, which shares elements in common with the importance of peer mentorship and collaboration demonstrated in our results¹⁴. Care standardization and follow-up has been echoed in two recent qualitative analysis of ED-initiated buprenorphine, including a study with 3 out of 32 physicians from a rural setting.²⁴ The importance of highlighting peer example has also been suggested in the urban context as an important facilitator.^22,25 Stigma has been identified as a barrier in the urban context as well as in our findings.^14,15

The requirement of an X-waiver for buprenorphine prescribing is often cited as a barrier to ED-initiated buprenorphine,^14,25,26 however this was not a theme in our findings. The number of physicians with an X-waiver has increased in recent years, although still insufficient in rural areas.²⁷ The importance of the X-waiver as a barrier may be on the decline, and it is likely to further decrease with new guidelines from the Department of Health and Human Services that have removed the training requirement to obtain an X-waiver.²⁸ We found that buprenorphine had been prescribed or dispensed at least once from all of the EDs studied. This finding may also indicate a trend toward better access to buprenorphine from rural EDs, however it should be interpreted with caution. We did not attempt to quantify extent of access to buprenorphine at each ED and multiple participants noted how access was highly dependent on the individual physician working on any given day or would be unlikely to continue without a key physician-champion of the practice.

Our results contrast with prior research in urban centers in the extent to which individual experiences and relationships impacted ED-initiated buprenorphine programs. We identified how personal experiences compelled many ED directors to act and played a direct role in motivating program development. It is likely that physicians at urban centers also have compelling personal experiences, but these to not appear to impact patient care to the same extent, likely due to the larger size of these organizations. Enhancement of this facilitator might be achieved by helping key hospital personnel identify motivating personal experiences and make the connection between these experiences and action on a hospital policy level. Likewise, direct peer mentorship and creative solutions to follow-up problems appear to have played a larger role in the rural setting than has been reported in urban departments.

There are several limitations to these findings. Sixty-five percent of all ED directors at Maine CAHs were interviewed, but a bias toward participants who were motivated to start a buprenorphine program likely exists. ED directors not supportive of ED-initiated buprenorphine programs or who have tried but failed to develop a program might have been less willing to respond to requests to participate in an interview. We were not able to assess reasons for not participating. In addition, this study did not quantify the relative impact of the identified barriers and facilitators on the success of the ED-initiated buprenorphine program. Finally, because only ED directors were interviewed, the perceptions of staff physicians, nurses, administrators and other staff were not directly evaluated.

These findings primarily identify barriers and facilitators to development of ED-initiated buprenorphine programs at CAHs where programs were ultimately successful. Further research should focus on rural EDs where ED-initiated buprenorphine programs have been unsuccessful or were never attempted as barriers identified at these sites may be particularly important. In addition, barriers and facilitators as perceived by other clinical and administrative staff should be evaluated. A quantitative survey to assess the relative impact of identified barriers and facilitators will help to guide efforts to efficiently target and overcome barriers and enhance facilitators. Based on the current findings, strategies to implement ED-initiated buprenorphine programs in rural settings should focus on enhancing peer mentorship, adapting protocols from similar sites, staff education to reduce stigma, community outreach and establishing outpatient follow-up.