Barriers and Facilitators for Emergency Department Initiation of Buprenorphine: A physician survey

Implementation of evidence-based pharmacotherapy for individuals with opioid use disorder (OUD) is cornerstone of the response to the opioid crisis [1]. ED-initiated OUD treatment with buprenorphine has been shown to increase treatment engagement at 30 days [2], but this practice has not been widely adopted [3]. To better develop strategies for implementation, we sought to 1) describe ED physician preparedness to treat OUD and 2) rank physician-perceived barriers and facilitators of ED administration of buprenorphine and obtaining a Drug Addiction Treatment Act of 2000 waiver to prescribe buprenorphine (X-waiver).

To do this, we conducted a cross-sectional survey of physicians in two urban, academic EDs assessing two domains. First, we measured self-rated levels of preparation for various aspects of OUD treatment using a 5-point Likert scale. Second, we assessed barriers and facilitators to buprenorphine administration in the ED and obtaining and X-waiver. Barriers were based on those identified in prior literature from other settings [4–9]. Barriers and facilitators were rated individually on a continuous 10-point scale, with 1 indicating “not at all a barrier” and 10 indicating “the most significant barrier.” We also collected demographic and other physician characteristics. The survey was administered via the REDCap version 8.9.0 secure web platform [10], and participants received a $10 incentive. Data were analyzed using descriptive statistics, and we compared responses by X-waiver status using chi-squared tests for categorical variables and the Mann-Whitney test for continuous variables (Stata, version 15.1; StataCorp, College Station, TX). The Institutional Review Board from the University of Pennsylvania approved this study.

84 participants completed the survey (response rate 78%). Participant characteristics are shown in Table 1. Participants were primarily male (62%), white (74%), and attending physicians (55%). Characteristics were similar for the 21% who had completed X-waiver training and those who had not. 39% of physicians reported they had ordered naloxone upon discharge from the ED in the past 3 months, and 33% had ordered buprenorphine in the past 3 months, either in the ED or at discharge. Figure 1 shows physician self-rated preparation for OUD care. While physicians felt prepared for some aspects of care, a minority felt prepared to determine the level of care for patients with OUD (39%), connect patients to outpatient treatment (29%) or initiate buprenorphine (27%). Levels of preparation did not differ significantly by X-waiver status, with the exception of initiating buprenorphine treatment (56% of waiver trained physicians vs 20% of non-waiver trained, p=0.002). Preparation also did not differ by level of training.

Table 1:

Participant Characteristics

	Number	X-waiver	No X-waiver	p-value
PHYSICIAN CHARACTERSTICS
Age
Less than 30	24 (29%)	2	22
30–39	35 (42%)	9	26
40–49	15 (18%)	6	9
50–59	7 (8%)	1	6
Over 60	3 (4%)	0	3	p=0.149
Sex
Female	32 (38%)	5	27
Male	52 (62%)	13	39	p=0.309
Ethnicity
Hispanic/Latino	4 (5%)	0	4
Non-Hispanic/Latino	80 (95%)	18	62	p=0.573
Race
White	62 (74%)	13	49
Black/African American	0 (0%)	0	0
Asian	13 (15%)	4	9
Other	9 (11%)	1	8	p= 0.561
Level of Training
Intern	8 (10%)	0	8
Resident	29 (35%)	4	25
Attending	47 (56%)	14	33	p=0.077
PGY5–9	18 (21%)
PGY10–14	9 (11%)
PGY15+	20 (24%)
Percent Time in Clinical Care
Less than 20%	2 (2%)	1	2
20–50%	10 (12%_	1	9
51–75%	10 (12%_	3	7
Greater than 75%	61 (73%)	13	48	p=0.690
Close friend/family with SUD
Yes	24 (29%)	6	18	p= 0.668
PRACTICE CHARACTERISTICS
X-waiver training completed
Yes	18 (21%)	n/a	n/a	n/a
Ordered Naloxone in past 3 months
Yes	39 (46%)	12	27	p=0.052
Ordered Buprenorphine for a patient in past 3 months
Yes	28 (33%)	8	20	p=0.259

^*Includes physicians who had an X-waiver (X-waiver) and those who had recently completed training but had not yet obtained an X-waiver (No X-waiver)

^**p-value for comparison of X-waivered vs non X-waivered physicians done using chi² tests (p<0.05)

Figure 1: Level of preparation for treatment of OUD in the emergency department.

Displayed are the percentage of physicians who rated that they were either “somewhat prepared” or “very prepared” to address each of the aspects of OUD care in the emergency department. The asterisk indicate those responses that significantly differed by X-waiver status. OUD: opioid use disorder; COWS: Clinical Opioid Withdrawal Scale.

Figure 2 shows physician-rated barriers and facilitators to prescribing buprenorphine. Many of the highest-rated concerns related to perceived patient factors, including patient social barriers, lack of patient interest in treatment, availability of referrals for substance use treatment, and patient preference for alternative treatments (e.g. non-medication based). Other highly rated barriers related to buprenorphine – comfort in counseling, ordering, or navigating regulatory barriers – differed significantly between those who had completed the waiver training and those who had not, with a mean rating 4.9 vs 6.3 (p=0.030); 3.1 vs 6.4 (p=0.001); and 3.4 vs 6.4, (p<0.001), respectively. The highest-rated facilitators for buprenorphine prescribing related to longitudinal treatment, including access to ongoing treatment services after discharge and access to a care coordinator/social worker for patients with OUD. Other highly rated facilitators related to support for ED-based treatment, including electronic medical record order sets, pharmacist consultation and availability of peer counselors.

Figure 2: Barriers and Facilitators to Prescribing Buprenorphine in the Emergency Department.

Panel A shows survey results for physician-rated barriers on a scale from 1–10 (10 being the most significant barrier). Panel B shows physician-rated facilitators for prescribing of buprenorphine in the emergency department. The asterisks indicate those responses that significantly differed by X-waiver status (p < 0.05). OUD: opioid use disorder; EMR: electronic medical record.

Finally, we asked the 66 physicians who had not yet completed X-waiver training about barriers and facilitators to obtaining an X-waiver (Figure 3). The highest rated barriers to obtaining an X-waiver were the inconvenience of the process and uncompensated time outside work. Top-rated facilitators included substituting training for a shift and financial incentives.

Figure 3: Barriers and Facilitators to obtaining an X-waiver for emergency department physicians.

Panel A shows survey results for physician-rated barriers to obtaining an X-waiver among those who had not completed a waiver training on a scale from 1–10 (10 being the most significant barrier). Panel B shows physician-rated facilitators for obtaining an X-wavier. OUD: opioid use disorder.

Our results contribute to translation of evidence into practice for ED-initiated addiction treatment in several key ways. First, while most physicians felt unprepared for referral and treatment with buprenorphine in the ED, X-waiver training was associated with higher self-rated preparation, suggesting that interventions to address knowledge or confidence gaps may increase buprenorphine implementation. However, the most significant physician-reported barriers to prescribing buprenorphine related to perceived patient, logistical or systemic factors. These barriers did not differ by X-waiver status, suggesting that they may not be mitigated by waiver training or other educational interventions alone. Promising strategies to address these barriers and increase treatment include multidisciplinary teams with social workers and peer specialists, development of treatment and referral protocols, and other supports that address patient or system-level barriers [11]. Finally, our findings demonstrate that the burden of X-waiver training poses challenges. Incentives may be one effective strategy for overcoming barriers, but they may need to be further reduced through regulatory changes to ease the burden of the X-waiver training [12]. As ED-initiated treatment expands, it will be critical to develop interventions that address not only provider knowledge but also patient and system-level challenges.