Abstract
Opioid overdose deaths are increasing, and improving access to evidence-based treatment is necessary. Emergency department (ED) initiation of treatment for opioid use disorder (OUD) via medications and referral to treatment is one approach that leverages a critical health care entry point for individuals with OUD. Efforts to engage patients in treatment through the ED are growing, but systematic analysis of program features as implemented and challenges across different models remains limited. Lessons from early adopter programs may benefit clinicians and others looking to offer ED-initiated treatment for OUD.
We conducted case studies of five ED-based efforts to address OUD across the United States, selected for diversity in structure, approach, and geography. We conducted telephone interviews with 37 individuals (ED physicians, ED nurses, navigators, hospital administrators, community providers, and state policymakers) affiliated with the five programs. Interviews were transcribed, coded, and analyzed using a framework analysis approach, identifying relevant lessons for replication.
These five programs (an academic medical center, two large urban hospitals, a rural community hospital, and a community-based program) successfully implemented ED-initiated MOUD. Often a champion with knowledge of OUD treatment and a reliable connection with outpatient treatment began the program. The approach to patient identification varied from universal screening to relying on patient self-identification. Substance use treatment navigators provide crucial services but can be difficult to pay for within current reimbursement frameworks. Barriers to implementation include lack of knowledge about treatment options and effectiveness, stigma, community treatment capacity limits, and health insurance and reimbursement policies. Facilitators of success include taking a patient-centered, low-barrier approach, having a passionate champion, a strong structure with health system support, and a relationship with community partners. Metrics for success vary across programs. Some programs are expanding to include treating the use of other substances such as alcohol and stimulants.
ED-initiated MOUD is feasible across different settings. Research and real world efforts need to promote programs that include OUD treatment as standard in ED treatment.
•ED-based OUD efforts are motivated by ED champions, rewarding work, and funding.•Barriers include lack of information, stigma, outpatient capacity.•Facilitators: a person-centered low-barrier approach and tracking performance.•Established ED programs are expanding to treat other substance use disorders.•Efforts are needed to make patient-centered OUD treatment standard in all EDs.