Models for implementing ED-initiated buprenorphine with referral for ongoing medication treatment at ED discharge in diverse academic centers

Abstract

There has been a substantial rise in publications and training opportunities on the care and treatment of Emergency Department patients with opioid use disorder over the past several years. The American College of Emergency Physicians recently published recommendations on providing buprenorphine to patients with OUD, but barriers to implementing this clinical practice remain. We describe the models for implementing ED-initiated buprenorphine at four diverse urban, academic medical centers across the country as part of a federally funded effort termed ‘Project ED Health’. These four sites successfully implemented unique ED-initiated buprenorphine programs as part of a comparison of Implementation Facilitation to traditional educational dissemination on uptake of ED-initiated buprenorphine. Each site describes elements central to the ED process including screening, treatment initiation, referral and follow- up while harnessing organizational characteristics including ED culture. Finally, we discuss common facilitators to program success, including information technology and electronic medical record integration, hospital-level support, strong connection to outpatient partners and quality improvement processes.

INTRODUCTION

Morbidity and mortality from opioid use disorder (OUD) and opioid overdose continue to rise.^1,2 People with OUD who receive medications for Opioid Use Disorder (MOUD) have decreased mortality, overdose and ED visits compared to those that do not receive MOUD.^3–9 Buprenorphine, a partial opioid agonist can be administered in the ED for patients in acute opioid withdrawal^10–12 and administered and prescribed for patients with OUD.^13,14 Initiation of buprenorphine can be directly observed (e.g. administered to the patient while they are in the ED) or unobserved which includes a prescription to be started at a later time. There is improved 30-day treatment retention and decreased days of illicit opioid use for patients discharged from the ED receiving ED-initiated buprenorphine compared to those receiving a standard referral.^{15,16 16–18} Several barriers to implementing buprenorphine initiation in the ED have been described, including lack of training and experience, concerns about linkage to care and competing ED priorities.^19–21 Facilitators to ED-initiated buprenorphine include development of local protocols or pathways, providing patient feedback to clinicians, quality improvement as well as education and training.¹⁹ While prior work on ED-initiated buprenorphine has described retrospective quantitative outcomes,^22–26 attention to program specifics is lacking.

Recently, the American College of Emergency Physicians (ACEP) published consensus guidelines, recommending that emergency physicians offer buprenorphine initiation with linkage to ongoing medications for OUD as an outpatient.²⁷ Our aim is to provide four specific examples of ED-initiated buprenorphine programs (Table 1) developed as part of the National Institute on Drug Abuse Clinical Trials Network study ‘Project ED Health.’²⁸ Four U.S. urban, academic, geographically disparate EDs were provided Implementation Facilitation (IF) as an implementation strategy²⁹ to develop ED-initiated buprenorphine programs. All sites were provided with an example program (Appendix A) and based on local context and resources, each site developed a unique and successful ED-initiated buprenorphine clinical process with a referral to outpatient OUD treatment. We describe elements central to the ED-initiated buprenorphine process at each site including screening, treatment initiation, referral and follow-up while harnessing organizational characteristics of hospital support, identification of clinical champions and ED culture. Common facilitators to clinical program success are also discussed.

Table 1.

Site Characteristics and ED-buprenorphine Program Details

	Site A	Site B	Site C	Site D
City, State	Baltimore, MD	New York City, NY	Cincinnati, OH	Seattle, WA
Approximate annual ED census	>70,000	>90,000	>75,000	66,000
Program Launch Date	April 1, 2018	July 1, 2018	October 1, 2018	January 1, 2019
Protocol for ED-initiated buprenorphine in place?	Yes	Yes	Yes	Yes
Buprenorphine in automated medication dispensing system in the ED for rapid dispensing?	Yes	Yes	Yes	Yes
Outpatient pharmacy on site that can fill buprenorphine	Yes	No, but several pharmacies close by that routinely fill medications from the ED	Yes	Yes
Clinical Champion	Yes, medical director	Yes, physician	Yes, physician	Yes, physician
Electronic Medical Record (EMR) supports	EMR screening, physician referral to Care Manger and Peer Recovery Coach through EMR	EMR screening by triage nurse, Clinical Protocol on Epic, specific trackboard for the Health Educator	Automated query assists with patient identification and notification of ancillary staff and OUD order set integrated into EMR	None
Screening question(s) in EMR	Bedside nurse asks about ‘current drug use’ and if patient answers ‘yes’ they are asked to name the drug and frequency of use/week.	Triage nurse asks ‘How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?’ A non-zero response moves patient info to health educator track board for engagement.	Triage nurse prompted to ask about ‘non-medical use of opioids’	None
Pharmacist in the ED	Yes	Yes	Yes	Yes
ED Social Work involved in program	Yes	No	Yes, in ED to assist with care coordination	Yes, Social Work assists with care coordination
Peer Navigator in the ED	Yes	No	Yes	No
Other allied-health professionals (e.g. health advocates, recovery coaches)	Care Manager	Health Educator	Health Promotion Advocate, Addiction Counselors,	No
Funding for peer navigators or other allied health professionals	Program grant and hospital	Program grant and hospital	Program grant and hospital	n/a
EMR instructions for unobserved treatment initiation	Yes	Yes	Printed and available, not in EMR	Printed and available, not in the EMR
What is the usual referral process for outpatient care	Care Manager or Peer Recovery Coach work with patient and tailor outpatient referral to patient needs	Health Educator evaluates patient, provides brief intervention, communicates with provider and coordinates outpatient care	Health Promotion Advocate, Peer, Addiction Counselor or provider can refer to several walk-in clinics for next day care	Referred to clinic with OUD care integrated into primary care on hospital campus. Able to make appointment from the ED 24/7
Average turn-around time for follow-up appointment	1–4 days	1–4 days	1–4 days	1–4 days
Quality Improvement process in the ED	Dashboard used to show metrics e.g. screens, referrals, etc. Patient outcomes tracked by Peer Recovery Coaches	Monthly report of ICD10 codes for OUD and overdose and systematic chart review to give providers feedback	Monthly email with department metrics diagnoses of OUD, buprenorphine dispensed, prescriptions and 1–2 good cases	Monthly email from clinical champion with department metrics on buprenorphine dispensed, prescriptions and 1–2 good cases
Quality Improvement process from referral site	Monthly opioid steering committee meeting with CM, PRCs and other stakeholders to discuss logistics and operations	Frequent and ongoing email and phone conversations about referral process with each referral site	Monitoring of linkage success on individual basis with continuous case by case troubleshooting	Monthly meeting with top referral site to discuss issues and operations.

FOUR DIVERSE ED-INITIATED BUPRENORPHINE PROGRAMS:

Site A:

ED Process

All patients are screened for OUD using standard questions for drug use by a nurse in the ED. Additionally, ED providers may identify OUD by history. When OUD is suspected or identified, an order is placed in the Electronic Medical Record (EMR) for a substance use consultation³⁰ by a care coordination team including trained Peer Recovery Coaches, Case Managers, and Social Workers. Peer Recovery Coaches are members of the community with lived experience with substance use disorders (SUDs) who are familiar with the evolving network of local community OUD resources. Successful integration of Peer Recovery Coaches requires attentive training including a robust understanding and philosophical alignment with MOUD regardless of the individual’s specific treatment history. Buprenorphine is routinely dispensed in this ED as treatment for patients in acute opioid withdrawal for Clinical Opioid Withdrawal Scale (COWS)³⁷ score > 7 in conjunction with a consideration of last opioid use.¹⁰ The care coordination team identifies a referral site based on patient clinical circumstances, needs and preferences, with attention to streamlining clinical work-up, appointment scheduling, and often, immediate transportation. Buprenorphine prescriptions are provided by ED clinicians. Four frequently used referral sites from the ED include a hospital-based After Care Clinic with embedded addiction care expertise in a primary care setting, a university-based office based opioid treatment (OBOT) program, a community-based OBOT and a federally regulated Opioid Treatment Program (OTP).

Organizational Characteristics

A detailed clinical pathway for OUD management including buprenorphine administration and prescription was integrated into the EMR which aids with all phases of OUD treatment from identification to referral. Site A stakeholders attribute the Peer Recovery Coaches as key to program success. They are employed by the hospital through a contract mechanism with a nationally recognized community-based organization that provides services associated with SUDs³⁰ with oversight by both the organization and the ED Medical Director. After ED care, Peer Recovery Coaches contact referral sites to see if the patient followed up for treatment.

The Medical Director is a key clinical champion, working closely with the Peer Recovery Coaches, as well as with Emergency Medicine (EM) faculty, Advance Practice Providers, residents, and nurses to provide regular education, opportunities for training and data on key metrics. The clinical champion provides a variety of formal educational sessions for EM residents regarding OUD. A variety of standing educational sessions (e.g. daily medical minutes for clinical staff, nursing sessions/meetings) were utilized to provide education and commentary on best practices for the use of buprenorphine for a variety of clinical staff. Additionally, the clinical champion provides operational direction and directs the monthly ED Opioid Steering Committee which reviews data and provides guidelines for evidence-based opioid dispensing and prescribing. These efforts changed the culture of OUD care in the ED resulting in increased buprenorphine dispensing and prescribing.

At the time of the study,²⁸ Site A had core group of attending physicians in the ED that had received a Drug Addiction Treatment Act of 2000 waiver (e.g. X-waiver). Initially, three members of this group were available to assist with prescriptions during most hours of most days if no waivered physician was on-site. The group of waivered providers has steadily increased since implementation of the protocol. While many referrals from the ED for patients with OUD are for appointments on the same day or next day, clinical leadership encourages prescribing sufficient buprenorphine to ensure an appropriate supply and eliminate known patient-level barriers^31,32 to medication access.

Site B

ED Process

All patients seen in the ED are screened for substance use by a triage nurse using single question screens for alcohol and drug use.^33,34 A positive screen moves the patient’s ED visit information to a separate EMR dashboard visible to Health Educators embedded in the ED who work with clinicians to improve patient health and wellness. They are knowledgeable about community resources and local healthcare access. After a positive screen for drugs, patients are administered the 10-item Drug Abuse Screening Test (DAST-10)³⁵ for opioids. Patients with scores consistent with moderate/severe OUD, receive a brief intervention using motivational interviewing techniques to asses patient readiness for treatment.³⁶

The Health Educator, ED clinical team and/or the site OUD clinical champion collaboratively provide buprenorphine when appropriate. If indicated, the health educator, or clinician, performs a COWS³⁷ assessment to quantify the amount of opioid withdrawal and buprenorphine is administered in the ED via an algorithm.¹⁰ Patients receive a prescription for buprenorphine at discharge and those without substantial withdrawal (as determined by a low COWS score) receive instructions for unobserved treatment initiation at discharge. The OUD clinical champion provides technical assistance for clinicians needing help prescribing buprenorphine in real time and is available to be contacted by phone if they are not working clinically.

The Health Educator works with patients and clinicians to identify the most appropriate of three commonly used referral clinics. One referral site is a hospital-affiliated clinic with addiction care embedded within primary care and is the primary referral site for patients with complex comorbidities such as underlying pain, or Hepatitis C virus (HCV). Additional referral sites included a comprehensive addiction medicine center run by Addiction Psychiatry and an outpatient primary care clinic utilizing a nurse care management model³⁸ for patients receiving buprenorphine.

Organizational Characteristics:

At Site B, a clinical pathway was adapted from public resources with the support of ED and hospital pharmacy.³⁹ Pharmacists ensured hospital-level buy-in of this work through the hospital Pharmacy and Therapeutics (P&T) committee and buprenorphine was subsequently stored in the automated medication dispensing machine (e.g. Pyxis) to facilitate rapid medication access. Pre-existing universal EMR-based screening for drug use³³ allowed for a natural EMR integration of the ED-initiated buprenorphine pathway utilizing clinician decision support.

The Health Educators are grant funded with an overall public health mission that integrates the care and treatment of patients with SUDs into comprehensive services including HIV and HCV testing,⁴⁰ sexual health education, pre-exposure prophylaxis, post-exposure prophylaxis and naloxone education and distribution. Oversight is provided by the ED clinical champion who conducts research and quality improvement on substance use and related topics from the ED, in addition to clinical work. Prior to pathway development, the OUD clinical champion developed relationships with all three referral sites to understand the clinic treatment infrastructure, capacity and associated services. Ongoing communication is important to facilitate discussion of specific cases, share success stories or address systems issues. Health Educators review a daily report from the EMR on buprenorphine administration and prescriptions and a monthly report that includes ICD-10 codes on opioid-related diagnosis to perform program quality improvement. Input and buy-in from ED leadership and administration was critical to enhancing buprenorphine prescribing capacity. The ED Medical Director was one of the first X-waivered providers and in the beginning, provided technical assistance to other providers on-shift. Currently, the Chair of the Department of Emergency Medicine at Site #2 requires an X-waiver for all full-time academic faculty.

Site C

ED Process:

At Site C, patients with OUD are identified through a variety of parallel processes. A single question about non-medical opioid use is integrated into the EMR triage nurse assessment while an automated EMR query based on prior diagnosis and medications displays a banner to visually alert providers of possible OUD. Alternatively, providers often make the diagnosis after obtaining a history and physical and then have the option to engage ancillary staff which include Health Promotion Advocates, certified Addiction Counselors, or Peer Support Specialists based on staffing and patient characteristics. Health Promotion Advocates are ED- based and focus on patient engagement, follow-up for a variety of public health needs including HIV and HCV screening and longitudinal assistance with linkage to care. The Peer Support Specialists come from the local community and have a lived SUD experience. They initially engage patients in the ED but also extend into the hospital or community to assist with care linkage. Separate from the decision to engage ancillary staff, the provider works with the patient to determine appropriateness for buprenorphine treatment. The ED-initiated buprenorphine pathway provides guidance for buprenorphine administration in the ED as well as prescribing for an unobserved treatment initiation.

Site C has a robust substance use treatment network that has been in place for several years. The major referral sites include a university-affiliated Addiction Psychiatry Clinic, a branch of a large outpatient treatment center and a publicly funded treatment center, and many offer walk-in or next-day follow-up.

Organizational Characteristics:

This ED harnessed a long-standing commitment to and partnership with local public health experts developed through the ED-based HIV^41,42 and HCV⁴³ screening “Early Intervention Program”. Additionally, Site C had recently initiated a SUD screening and linkage to care program which is staffed by publicly funded health promotion advocates. The pathway for ED-initiated buprenorphine was developed in partnership with Department of EM researchers and the Vice Chair of Operations. The presence of the Health Promotion Advocates working in the Early Intervention Program allowed for integration of ED-initiated buprenorphine and OUD program priorities into usual care systems. This created a culture of substance use care in the ED where support staff worked closely with clinicians to encourage treatment initiation including buprenorphine administration for acute opioid withdrawal and OUD treatment.

Clinical champions at Site C have a strong relationship with the University affiliated addiction treatment unit which operates a hospital-affiliated opioid treatment program (OTP) providing buprenorphine and methadone with a comprehensive substance use treatment intake available within 24 hours. Initially, there was a small cadre of attending physicians with an X-waiver to provide prescriptions for patients being cared for by non-waivered providers. EM residents were extremely interested in incorporating buprenorphine into their clinical practice and sought out a waivered provider if they did not have an X-waiver.

Site D

ED Process

Patients in the ED with OUD at Site D are identified by the treating clinician who also initiates treatment with buprenorphine as appropriate. The ED Social Worker performs additional screening as well as brief intervention using motivational interviewing⁴⁴ for substance use. Social Workers get involved early in the visit to allow for simultaneous medical care from the clinical team so they can address substance use and other social determinants of health. On weekdays during the day shift, the ED Social Worker contacts the hospital-based Outpatient Based Opioid Treatment (OBOT) team which is funded thorough state grants and consists of a program manager and Peer Support Specialist. A member of this team comes immediately to the ED to meet the patient at the bedside, describe the program and discuss patient priorities and experience with treatment. After hours or on weekends, the ED Social Work staff will take on these tasks.

Buprenorphine is routinely provided to ED patients with acute opioid withdrawal based on a clinical diagnosis¹⁰ as part of an observed initiation of buprenorphine. Patients that are not in moderate or severe withdrawal receive a prescription for buprenorphine, instructions for an unobserved initiation and an appointment for follow up. Due to the strong connection of the ED to the OBOT team, most outpatient referrals are made to the on-site After Care Clinic, a hospital-based transitional primary care clinic designed to provide easy and rapid access to short-term follow up for ED patients with a wide variety of conditions⁴⁵ and can serve as a transition between the ED and primary care and/or specialty care including addiction treatment. Thus, this clinic has the expertise and organizational structure to provide rapid low-barrier follow up for ED patients receiving buprenorphine. Clinic appointments can be scheduled by OBOT staff or ED registration staff during the ED visit within 1–3 days with a nurse practitioner experienced with buprenorphine and addiction care.

Organizational Characteristics:

The ED-initiated buprenorphine pathway at Site D was developed with multidisciplinary input from emergency physicians, pharmacists, ED social work, ED nursing and primary care addiction providers. Therefore, the document and pathway provide a shared mental model for the treatment of OUD from the ED including linkage and transition to outpatient care. The document is published in a peer-reviewed repository for hospital clinical guidelines accessible to all hospital employees. The protocol was adapted from existing resources^39,46 for the local environment. Within Site D, the OBOT team has a strong presence in the outpatient clinics and uses a nurse care manager model to improve reach and decrease barriers to treatment with buprenorphine in the outpatient settings.⁴⁷

The clinical champion at Site D works clinically in the ED and is also a substance use researcher with an interest in care linkage and implementation science. Through research, the connection to OBOT was strengthened and the ED-initiated buprenorphine program was developed. Monthly reports of the number of patients administered and prescribed buprenorphine are reviewed, and specific cases are discussed to highlight success stories or to improve care. These cases are often shared with the treating provider to provide feedback and improve practice. Monthly emails are sent to all providers in the ED with an update on the program including the number of patients administered and prescribed buprenorphine. This provides an opportunity to share success stories to encourage practice change. Educational opportunities are provided to all ED clinicians to improve knowledge around evidence-based treatment for OUD. Initially, formal presentations were made to physicians, ED Social Work and nurses and clinical champions were identified within each group (e.g., nursing, social work, resident) so information about OUD and buprenorphine could be tailored.

Input and buy-in from clinical leadership at all levels improved buprenorphine prescribing capacity. The ED Medical Director, Department Chair, Residency Director and lead advanced practice provider (APP) were among the first to get an X-waiver. At the beginning these faculty with an X-waiver were available on-shift to provide buprenorphine for patients. Additionally, EM residents were active in getting X-waivered which created a push for faculty to improve knowledge and get waivered. The APP group was also active in obtaining X-waivers which was key for seeing patients in the ‘Fast Track’ area which generally sees low acuity complaints including skin and soft tissue infections and patients requesting substance use treatment. After program launch, X-waivers became required for clinical work in the ED for full-time academic faculty. It is now expected that all new full-time faculty will have an X-waiver upon starting clinical work. Similarly, all residents are provided with resources to apply for an X-waiver prior to graduation.

KEY COMMON FACILITATORS

Information Technology (IT) and EMR integration:

Leveraging the EMR to assist with case finding, workflow and clinician support was common to three sites. Minimizing barriers to prescribe buprenorphine by integrating clinical decision support, IT pathways and order sets into the EMR has been previously identified as an effective strategy to enhance provider prescription of buprenorphine.^48,49 Site A uses clinical pathways to enhance evidence-based care for a variety of common ED problems, and developed a clinical pathway for the use of buprenorphine in the ED. This pathway included templated order sets, prescriptions, naloxone distribution, referral information and discharge instructions. Site C used machine learning methods integrated into the EMR to improve case finding using historical ICD-10 codes and medication lists to identify patients with possible OUD at the beginning of the visit.

Clinical Champions and ED Culture

Every site noted the importance of an emergency physician “Clinical Champion” that had a strong and frequent clinical presence and could disseminate program information to residents, nurses and other clinical staff. At several sites, this clinical champion was someone that could provide consultation for clinicians seeing patients and provide just-in-time education on the pathway as well as assist with dispensing and prescribing buprenorphine. Department Chairs at all four sites were supportive of this work and made time for discussion of the clinical process at department meetings. Sites leveraged support of the Chair and/or the Medical Director to develop a culture where obtaining an X-waiver is viewed as important. Having a cadre of waivered Emergency providers eliminates the need for non-ED clinicians or consultants who may be unfamiliar with ED workflow and/or unavailable after-hours or on weekends and gives the ED autonomy. At many sites, EM residents were eager to incorporate OUD care into their practice including prescribing buprenorphine. Similar to the broad dissemination of point of care ultrasound in EDs, resident enthusiasm and education alongside a few local champions propelled culture and practice change for faculty. Several sites noted that waivered APPs took a leadership role in caring for this population. APPs noted that patients with OUD who were seeking treatment were easily cared for in the fast track or urgent care areas of the ED as they do not require IV access and can usually be dispositioned quickly. Additionally, nursing buy-in was key for sites that leveraged EMR-based screening at triage. A culture of screening and treatment for public health issues including interpersonal violence, suicide, and alcohol use are important scaffolding for incorporating screening for drug use that can be done universally. This culture also elevated efforts at Site D which did not utilize any EMR-based screening tools but leveraged a culture of public health efforts within the ED.

Importantly, at all sites there was tension between a desire for a perfect process and “protocol” prior to official roll-out and a reasonable roadmap or pathway that could be iteratively refined as time progressed and needs became more apparent or changed. This tension was often navigated by the clinical champion who was an early adopter of ED-initiated buprenorphine. Early adopter activities included buprenorphine prescribing, working with colleagues to carve out paths for follow-up and bringing data and personal stories back to leadership to showcase need. The combination of local early adopters, ongoing increases in opioid-related fatalities and support from ACEP and American College of Clinical Toxicology on the use of buprenorphine in the ED nurtured the growth and development of these programs.^27,50

Hospital-Level Support

All four sites noted significant support from hospital administration and leadership for the program, financial support and support within existing job roles within the ED. At Site B, screening and referral for SUD is mandated by law⁵¹ thus, the health system has dedicated substantial resources to this process. All sites had different roles doing care coordination tasks, which off-loaded tasks from ED clinicians and served an important role to improve engagement and assist with logistics. Several ED clinical champions had a significant role in hospital or health system opioid response committees. Many sites noted the importance of collaboration with pharmacy. ED Pharmacists were key partners for working with hospital P&T committees to ensure hospital guidelines and processes acknowledge the ED as a place that can administer and prescribe buprenorphine. The ED chair at many sites was helpful in understanding how support of the program can improve operations. Several sites had on-line repositories of clinical guidelines where site-specific processes related to ED-initiated buprenorphine were published for internal reference. All these activities required time and effort and all sites were committed to improving care across a wide range of job roles.

Strong Connection to An Active Outpatient Partner for Follow-Up

All sites noted the importance of an engaged and proximal outpatient partner or partners who were available to see patients in follow-up for ongoing addiction treatment after the ED visit. The types of outpatient partners at each site varied and included substance use treatment centers, addiction psychiatry and primary care clinics that provided addiction care. Each clinical champion noted the importance of visiting outpatient sites to understand workflow and process and to facilitate close collaboration. Clinics with walk-in hours and/or on-demand availability were important. Clinics associated with the hospital took advantage of a shared workforce between the clinic and the ED. At Sites B and D staff from the clinic routinely met patients in the ED for a “warm hand-off”.¹³

Quality Improvement Process

Quality Improvement (QI) processes have been recognized as a critical component to program development⁵² as it highlights opportunities to improve quality of care, identify missed opportunities, and highlight clinical successes on an individual and group level. Uncertainty about whether the patient will be able to access and reliably attend follow-up appointments was a common clinician concern before program implementation and clinicians noted that receiving feedback about successful follow-up appointments for patients who experienced ED-initiated buprenorphine enhanced practice change.^19,21 QI processes varied across sites and in general were performed by a local champion rather than as part of the regular departmental QI process. Across all sites, success stories of patients who were successfully linked to outpatient treatment after receiving buprenorphine in the ED were shared.

IMPLICATIONS FOR FUTURE PRACTICE:

Opioid overdose and ED visits related to substance use continue to rise across the country.^7,53,54 The ED is a critical health care location for continued in-person treatment including initiating buprenorphine for patients with OUD. We acknowledge that the sites included were urban, academic EDs with Emergency Medicine residencies. Clinical champions utilized non- clinical time and effort as academic emergency physicians to grow the program. Given the urban environment, linkage to care was proximal to all sites but the facilitators described including ED culture, and hospital-level support are generalizable to any site interested in improving or initiating processes for ED-initiated buprenorphine. Improved access to treatment is especially important in the midst of the COVID-19 pandemic⁵⁵ for patients experiencing homelessness, with limited phone access or with limited prior interactions with healthcare. All sites noted that simultaneously addressing the COVID-19 pandemic and the needs of patients with OUD required adapted workflow, and longer buprenorphine prescriptions to allow for variable follow-up access. Initially, support staff that conduct screening, brief intervention and care coordination were limited in their ability to come to the ED in-person. However, all sites reported that support staff are now back in the ED and currently working with patients in-person now that vaccines are available, and they have received appropriate training in personal protective equipment. Recent ACEP recommendations are that ED clinicians treat opioid withdrawal and provide buprenorphine with direct linkages to ongoing treatment with medications.²⁷ New Department of Health and Human Services Guidelines functionally eliminated the X-waiver training requirement for ED clinicians, who are extremely unlikely to prescribe buprenorphine to 30 or more patients at one time during routine ED care.⁵⁶ Optimizing training for administration and prescribing buprenorphine specifically for emergency providers has been done. Medical directors should consider local context and follow-up networks as part of the education process. Non-pharmaceutical fentanyl use is on the rise which contributes heavily to fatal opioid overdose.² All EDs can respond to this epidemic by understanding local trends and providing treatment for OUD. Novel buprenorphine administration practices from the ED^57–59 may expand treatment options. These programs provide a framework which will allow EDs to adopt new evidence for OUD treatment into practice.

SUMMARY AND CONCLUSIONS:

Overall, implementation of ED-initiated buprenorphine is possible and the models at these four ED’s showcase the variations in process and implementation. Each site uses different local resources, however, there were several common facilitators to implementation success. Importantly, all sites describe an ED culture that is passionate about improving public health and the care of patients with SUD. Physician champions within the ED cultivated relationships with existing clinics for transition of care and QI efforts that helped highlight site accomplishments, showcase successful stories and track important implementation metrics that supported practice uptake. Finally, these programs highlight the successful multidisciplinary nature of this work.