The Impact of an Educational Intervention to Improve Emergency Medicine Resident Treatment of Individuals With Opioid Use Disorder

Abstract

Objectives

Introducing evidence-based treatment strategies into education for emergency medicine (EM) residents might improve treatment for people with opioid use disorder (OUD). Our objective was to evaluate the impact of an educational initiative in treating OUD with emergency department (ED)-initiated buprenorphine.

Methods

This was a retrospective analysis of an educational initiative using case-based discussions to train EM residents in the treatment of OUD, including ED-initiated buprenorphine, at a single EM residency program. Patients at the corresponding ED who were given an OUD-related diagnosis were screened for the initiation of buprenorphine. We calculated the odds of receiving ED-initiated buprenorphine among eligible patients 6 months before and 6 months after the educational initiative. Patients currently treated with buprenorphine or methadone were excluded from the analysis.

Results

Before the educational initiative, 14% (26/186) of patients with OUD eligible for buprenorphine underwent a novel buprenorphine induction in the ED, which increased to 18% (33/183) after the educational initiative. Following the educational initiative, the odds of receiving ED-initiated buprenorphine compared with the pre-educational initiative was 1.35 (95% CI, 0.77-2.24).

Conclusion

The total number of people with OUD treated with buprenorphine increased after our educational initiative, but the odds ratio was not statistically significant. Complementing educational initiatives, other factors are likely needed to significantly increase the likelihood that a person with OUD is treated with buprenorphine.

The Bottom Line.

This retrospective analysis sought to evaluate if an educational initiative for treating opioid use disorder (OUD) increased the odds that a person would receive a novel emergency department (ED)-initiated buprenorphine induction by a resident. Although we found no increased odds that people with OUD underwent novel buprenorphine inductions, there was a slight increase in people initiated on buprenorphine by residents. Our results highlight an unmet need to treat OUD in the ED, which will likely require a multifaceted approach. Further research is needed to evaluate the impact of education in treating OUD in the ED.

1. Introduction

1.1. Background

Emergency medicine (EM) physicians have been on the frontlines treating individuals with opioid use disorder (OUD) throughout the entirety of the ongoing US opioid epidemic. The use of buprenorphine in the treatment of patients with OUD in the emergency department (ED) has been associated with a reduction in opioid overdoses, a reduction in opioid-related morbidity and mortality, and an increase in treatment retention.1, 2, 3 Establishing a unified effort to combat this persistent epidemic will require educating current and future EM physicians on how to implement evidence-based practices for treating individuals with OUD.

Previous literature describing curricular interventions for EM residents reported increased positive perception toward treating individuals with OUD and knowledge about ED-initiated buprenorphine.^4,5 A national survey of EM residents found that most respondents, 57.3% (165/288), believed that learning how to initiate OUD treatment in the ED was very important.⁶ However, the average resident readiness to provide ED-initiated buprenorphine was 5.7 on a scale from 1 to 10.⁶ A prior educational intervention included all ED clinicians who had never initiated buprenorphine and evaluated enhanced didactics vs a basic didactic intervention.⁷ Khatri et al⁷ reported that a third of their cohort had initiated buprenorphine for the first time after an intervention, with no difference between the enhanced vs basic didactic intervention.

1.2. Importance

With the changes in federal legislation having eliminated the need for an X-waiver to prescribe buprenorphine, a unique opportunity exists in the ED setting to provide significant positive interventions for individuals with OUD. It is, therefore, essential that we educate current and future EM residents on how to utilize this lifesaving medication for OUD (MOUD).

1.3. Goals of This Investigation

Our goal was to evaluate if an educational initiative for EM residents in the treatment of OUD, including ED-initiated buprenorphine, would increase the odds that a patient who was considered eligible to receive ED-initiated buprenorphine would receive induction with buprenorphine in the ED. We hypothesized that this educational initiative would lead to an increase in ED-initiated buprenorphine.

2. Methods

2.1. Study Design

This was a retrospective study examining the impact of an educational initiative on novel buprenorphine initiation in the ED. A retrospective chart review was conducted to evaluate the number of patients with OUD who underwent novel buprenorphine inductions while being treated in the ED by a resident before and after the educational initiative. Data were collected from the electronic medical record for encounters with OUD-related diagnoses from June 21, 2022, to June 21, 2023, to capture patient encounters 6 months prior to the educational initiative and 6 months following the educational initiative. Extending the study beyond 6 months following the educational intervention would begin to include new residents who did not receive the educational intervention. The specific OUD diagnoses used for the chart review included opioid abuse, OUD, opioid overdose, opioid dependence, opioid withdrawal, opioid abuse unspecified, and opioid intoxication. The study protocol was approved by the institutional review board at NYC Health + Hospitals/Lincoln, Bronx, NY.

2.2. Educational Initiative

Four cases of treating people with OUD in the ED were created to be used as case-based discussions for teaching EM residents how to treat OUD (Files S1 and S2). The cases were created to provide learners with different situations of treating a diverse set of people with OUD. Additionally, one case focused on teaching learners about transitioning people from methadone to buprenorphine using microdose protocols. Lastly, one case included fentanyl adulterated with xylazine to help learners understand the complexity in potency of various opioid agonists and regional adulterants. The educational materials were developed by a faculty member who is board-certified in medical toxicology and addiction medicine in collaboration with a Society of Academic Emergency Medicine Foundation-National Institute on Drug Abuse grant recipient. The small groups were facilitated by the general faculty. Evidence-based preparation material was created and disseminated on a free open-access medical education platform, emDocs.net, titled ED-Initiated Buprenorphine: Basics, Barriers, and Beyond the ED.⁸

2.3. Setting

On December 21, 2022, residents at a single 4-year Accreditation Council for Graduate Medical Eduation-accredited EM residency program participated in case-based discussions using the evidence-based preparation material. The residency program staffs a single public, urban, academic hospital located in South Bronx, New York (>150,000 annual visits).

2.4. Data Extraction

Data extracted from the medical records included indications for ED-initiated buprenorphine (defined below), whether a patient was already being treated with MOUD, confirmation of enrollment in an opioid treatment program, if a patient was offered buprenorphine, if a patient accepted buprenorphine, and if a patient declined buprenorphine. Indications for ED-initiated buprenorphine were determined based on a documented Clinical Opioid Withdrawal Scale (COWS) score. In this specific ED, COWS scores are not regularly calculated in triage or by nurses, and it is typically documented in the “History of Present Illness,” “Physical Exam,” or “Medical Decision Making” portions of the electronic medical record by the treating clinician. If a patient had a COWS score of ≥8, then they were considered eligible for ED-initiated buprenorphine. Patients who had documentation of methadone use within 72 hours of presentation to the ED, current treatment with methadone, or current treatment with buprenorphine were excluded from the analysis. The patients included in the analysis were cared for by residents who attended the educational intervention. Patients cared for by other residents, mid-levels, internal medicine residents, or transitional-year residents were excluded from the analysis. If a single patient had multiple encounters, the first chronologic encounter for that patient was analyzed. The chart review was performed by the recipient of the Society of Academic Emergency Medicine Foundation-National Institute on Drug Abuse Mentor Facilitated Training award (CSH), who was not blinded to the study.

2.5. Intervention

We used the educational initiative described above as our intervention. Each case was designed to address a different and unique aspect of treating people with OUD, as described above. Residents were instructed to read the free open-access medical education preparation material prior to participation in the case-based discussions.

2.6. Exposure

Thirty-eight residents were in attendance during the educational initiative, which was used as our exposure.

2.7. Measurement

We measured the odds of a patient undergoing a novel initiation of buprenorphine while being treated in the ED by a resident who participated in the educational initiative.

2.8. Outcome

The primary outcome was the novel initiation of buprenorphine by a resident who participated in the educational initiative.

2.9. Data Analysis

Descriptive statistics were used to analyze data on demographics. Odds ratios (ORs) were calculated using cross-tabulation. Results were reported in percentages and ORs with associated 95% CIs. The exposure of the ORs was the educational initiative, and the outcome was novel buprenorphine induction in the ED, meaning they were not being actively treated with buprenorphine. We did not control for potential confounding factors. All data were analyzed using SPSS version 29 (IBM SPSS Statistics).

3. Results

From June 21, 2022, to June 21, 2023, 1405 encounters were identified in which a patient was given an OUD-related ED diagnosis. Four encounters were missing relevant data and were excluded, leaving 1401 cases in the analysis. The median age was 49 years (IQR, 39-58), and 74.4% of the encounters included a male patient. The chart review of these encounters identified 383 (27%) patients who could have been treated with buprenorphine from June 1, 2022, to June 1, 2023, 3.7% (14/383) of whom were already prescribed buprenorphine. Of the remaining 369 eligible patients, 16% (59/368) were initiated on buprenorphine in the ED. In total, 26 patients declined ED-initiated buprenorphine during the 12 months analyzed.

In the 6 months prior to the educational initiative (June 21, 2022, to December 21, 2022), 14% (26/186) of people with OUD who could have received buprenorphine underwent novel inductions by a resident (Table). In the 6-month period following the initiative, the percentage of people with OUD who could have received buprenorphine who underwent a novel induction by a resident increased to 18% (33/183) (Table). Following the educational initiative, we found no increased odds of buprenorphine initiation (OR, 1.35 [95% CI, 0.77-2.24]) (Table).

Table.

Novel buprenorphine inductions by a resident physician before and after educational intervention.

Period of data extraction	People with OUD in which ED-initiated buprenorphine was indicated	% (n) of people with OUD who underwent novel ED-initiated buprenorphine	OR (95% CI)
Before educational intervention: June 21, 2022, to December 21, 2022	186	14 (26)	1.35 (0.77-2.4)
After educational intervention: December 22, 2022, to June 21, 2023	183	18 (33)

ED, emergency department; OR, odds ratio; OUD, opioid use disorder.

Based on the chart review, 10% of people were being treated with methadone (138/1386), 26% (368/1386) were given methadone in the ED, 6% (87/1386) were offered buprenorphine per the documentation, and 2% declined treatment with buprenorphine (26/1386).

4. Limitations

This project was completed at a single EM residency program at an urban safety net hospital, and the results may not be generalizable to other cities and institutions. Additionally, the retrospective search for patients eligible for ED buprenorphine may not have captured all eligible patients. This study did not use multiple data abstractors for chart review. Another limitation is the lack of routine COWS scores within the department where the intervention took place, which likely limited the identification of all potentially eligible patients. There was no sample size calculation performed, which is needed in future studies. Our sample size was small, and the timeframe was brief, making it difficult to draw conclusions from this data. Finally, we did not adjust for confounders, and there may have been other factors preventing a person with OUD from being treated with buprenorphine other than the educational initiative.

5. Discussion

The practice of EM has now expanded to include the treatment of OUD. As such, our workforce should be trained in how to use evidence-based treatment to help people with OUD. After an educational initiative on OUD treatment with buprenorphine for EM residents, there was a slight increase in the number of people with OUD who underwent novel buprenorphine inductions by residents (Table). However, the odds that a person with OUD was treated with buprenorphine after the initiative compared with before the initiative did not increase significantly (Table).

Results from this study build on prior implementation studies meant to increase ED-initiated buprenorphine.^9,10 A recent study analyzed how implementation facilitation might increase ED-initiated buprenorphine, which resulted in an increase from 0.5% to 14.6% of eligible patients being initiated on buprenorphine in the ED in the implementation facilitation group.⁹ Melnick et al¹⁰ attempted to increase the rate of ED-initiated buprenorphine by utilizing an electronic clinical decision support tool, which resulted in an increase of patients initiated on buprenorphine from 12% to 12.5%. Prior interventions targeting residents specifically found improved knowledge and attitudes toward treating individuals with OUD in the ED; however, none had quantitatively analyzed the number of patients initiated on buprenorphine following the intervention.^4,5 Education alone is likely insufficient to overcome systematic barriers to buprenorphine induction.

Although ongoing efforts have made progress, substantially increasing the number of patients with OUD who receive buprenorphine in the ED will require additional resources. These may include local clinical champions, strong partnerships with community-based organizations, department-supported clinical guidelines, and robust systems for linkage to follow-up care. As frontline physicians, residents often serve as the first point of contact for patients with OUD, and their comfort, knowledge, and attitudes toward initiating buprenorphine can directly influence patient access to evidence-based care. Incorporating targeted addiction medicine education, clinical decision support, and structured mentorship into residency training may address current gaps and foster a new generation of emergency physicians equipped and empowered to lead in the treatment of OUD. Collectively, these findings highlight a continued unmet need and underscore the significant potential to increase ED-based initiation of MOUD through focused educational interventions.

Included in File S1 is a template for small group cased-based discussions or flipped classrooms that residency programs can utilize in formal training sessions. ED-Initiated Buprenorphine: Basics, Barriers, and Beyond the ED on EMdocs.net is meant to serve as preparation material for this case-based discussion. File S2 includes the discussion points for each case. These resources were created to be generalizable, and discussion points should be modified to include hospital-specific protocols or local resources so that residency programs can use them to educate residents on how to appropriately initiate buprenorphine in the ED.

We believe the data presented here are hypothesis-generating. It is also possible that increasing the treatment of OUD with buprenorphine will increase as more departments endorse protocols for ED-initiated buprenorphine and health care staff become more comfortable with prescribing buprenorphine now that the X-waiver has been eliminated. Further study is needed to evaluate education for ED-initiated buprenorphine that is generalizable and leads to a sustained increase in the use of buprenorphine to treat OUD over time.

Author Contributions

CSH, BPC, and DLS contributed to the initial application for the 2022 National Institute on Drug Abuse Mentor Facilitated Training Award, with CSH serving as mentee, DLS serving as mentor, and BPC serving as comentor. The conceptualization of this project was initiated by CSH with guidance and mentorship from BPC, ADS, JRW, and DLS. Drafting, reviewing, and final approval of this manuscript were performed by all authors.

Funding and Support

This manuscript highlights work from the 2022 National Institute on Drug Abuse (NIDA) Mentor-Facilitated Training Award, supported by the NIDA and sponsored by the Society for Academic Emergency Medicine (SAEM) Foundation.

Conflict of Interest

All authors have affirmed they have no conflicts of interest to declare.