Date: August 23rd, 2022
Reference: Schoenfeld et al. “Just give them a choice”: Patients’ perspectives regarding starting medications for opioid use disorder in the ED. AEM August 2022
Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM.
Case: A 24-year-old male presents to the emergency department (ED) after a fentanyl overdose. He is successfully resuscitated using naloxone and is stable after an observation period. You are interested in seizing this opportunity to offer some type of help to this patient to prevent another opioid overdose in his future.
Background: We have done a few shows on opioids over the past decade:
- Incidence of opioid use disorder (SGEM#264)
- Observing patients after giving naloxone (SGEM#241)
- Department guideline to prevent opioid use disorder (SGEM#55)
Drug overdose deaths continue to rise in the United States with opioids being the number one cause (1). There are several medications available to treat Opioid Use Disorder, including methadone and buprenorphine, which are the most effective means to decrease future illicit opioid use and death (2-5). The ED has been identified as a low barrier environment where medications for OUD (MOUD) can be initiated, even in resource-constrained settings (3,6,7).
Despite the relatively easy availability of buprenorphine, less than 5% of patients discharged from the ED after a non-fatal opioid overdose fill a prescription for buprenorphine in the next 90 days (8-11). Past studies have focused on clinician-reported barriers to administering or prescribing buprenorphine in the ED (11-19).
However, the perspectives and preferences of patients have not been so thoroughly explored. Shared decision making (SDM) puts patients at the center of clinical decisions and has been shown to increase knowledge, trust, and adherence in other clinical decisions (20-23).
An SDM framework that fosters conversations and addresses common misconceptions around MOUD initiation may improve the patient-provider interaction and ultimately increased ED-based MOUD administration.
Clinical Question: What are patient’s perspectives regarding the initiation of medications for opioid use disorder in the ED?
Reference: Schoenfeld et al. “Just give them a choice”: Patients’ perspectives regarding starting medications for opioid use disorder in the ED. AEM August 2022
As this is a qualitative study, we will use a modified PICO question
- Population: Patients with opioid use disorder
- Interest: Exploring patient perspectives and experiences with OUD and using medications for OUD
- Context: Improving the initiation and adherence to treatment with medications for OUD from the ED
This is an SGEMHOP episode and it is my pleasure to introduce Dr. Elizabeth Schoenfeld. She is an Emergency Physician and researcher, and the Vice Chair for research in the Department of Emergency Medicine at UMass – Baystate. Her research focuses on Shared Decision-Making (SDM) in the setting of Emergency Department care.
Dr. Schoenfeld and her co-authors used the Ottawa Decision Support Framework for their study. Listen to the podcast to hear her describe this tool in more detail.
Authors’ Conclusions: “Although participants were supportive of offering buprenorphine in the ED, many felt methadone should also be offered. They felt that treatment should be tailored to an individual’s needs and circumstances, and clarified what factors might be important considerations for people with OUD.”
CASP Checklist for Qualitative Research
- Was there a clear statement of the aims of the research? Yes
- Is a qualitative methodology appropriate? Yes
- Was the research design appropriate to address the aims of the research? Yes
- Was the recruitment strategy appropriate to the aims of the research? Yes
- Was the data collected in a way that addressed the research issue? Yes
- Has the relationship between researcher and participants been adequately considered? Yes
- Have ethical issues been taken into consideration? Yes
- Was the data analysis sufficiently rigorous? Yes
- Is there a clear statement of findings? Yes
- How valuable is the research? Valuable
Results: There were 26 participants interviewed, seven of whom were recruited and interviewed in the ED and 19 who were recruited and interviewed via video conferencing.
The mean age of study participants was 36 and the majority had used an unprescribed opioid within the past two years. The majority had also tried both buprenorphine and methadone. Nearly all participants had ED visits related to opioid use and the goals for participant heterogeneity outlined in the methods were met.
There are three themes we pulled out of the results section. Elizabeth added her own comments on the podcast after each theme was discussed.
1. Decisional Needs and Factors Relevant for Decision-Making
Factors for decision making generally fell into either social, pharmacological, or emotional categories.
Focusing on pharmacological factors, participants noted the logistical ease of using buprenorphine (at home dosing vs. methadone’s observed dosing at a pharmacy) and that it was effective in helping with withdrawal and avoiding street drugs.
Disadvantages of buprenorphine were the ability to sell it and buy illicit opioids, the need to be in severe withdrawal to initiate it and that it could trigger precipitated withdrawal. It was also noted that with methadone you could continue using opioids as needed whereas this wasn’t an option with buprenorphine.
Nearly all patients were unaware that buprenorphine could be initiated in the ED and thought it should be offered. Whether it was initiated on that ED visit or not, even offering it helped to “open the door” for future use and lessen stigma surrounding MOUD.
Many patients also thought that any conversation surrounding MOUD should include both buprenorphine and methadone.
2. Informing Decisional Support
Participants identified that it was important for clinicians to avoid appearing judgmental and hoped clinicians had additional training in discussing the pros and cons of MOUD. They also recognized that clinicians were not experts in MOUD and should be honest about their knowledge of MOUD.
Several noted a “peer recovery” coach in the ED with lived experience would be more beneficial than a physician.
“Readiness” was also described as an important factor and patients noted that they would often be at different stages of readiness to change on each visit to the ED. They further identified it was important to offer MOUD at each visit because of this.
Coordination with outpatient care was also identified as important, eg. OUD clinic and outpatient resource list, psychiatric care, naloxone kit training, peer recovery coach contacts and comfort medications such as clonidine or acetaminophen would all be useful.
3. Additional relevant themes identified by researchers
“Recovery” has a different meaning to different people. For example, it can mean complete abstinence from opioids and MOUD to one person, use of MOUD and no illicit opioids to another person, and even use of MOUD with reduced use of illicit opioids to a third.
Relapse was a part of every single story and getting to the point of non-use always took multiple attempts and different methods.
Participants felt psychiatric care should be integrated into OUD care as opioid use was frequently in response to their mental health problems such as depression or PTSD.
Listen to the podcast to hear Elizabeth answer our five nerdy questions.
1. External Validity: Two thirds of your patients were recruited from urban MOUD clinics. How do you think this may have affected your results and do you think they have external validity to rural or resource low environments?
2. Shared Decision Making: You mention that you did not specifically ask patients about shared decision making but that it was brought up by many of them. Why wasn’t this asked specifically?
3. Participant Heterogeneity: How did you determine the seven groups that you used as goals for establishing participant heterogeneity and what were the seven groups?
4. Non-English: One of the inclusion criteria was the ability to speak conversational English. How do you address this significant limitation for discussing cultural barriers to MOUD in non-English speaking populations?
5. Contextual Factors: You had a figure in your manuscript to help understand decisional needs in the context of the whole patient, salient themes of participants’ recovery stories, organized via the socioecological model of addiction. Can you briefly explain this and we will put Figure 3 in the show notes?
Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.
SGEM Bottom Line: Consider offering MOUD to patients in the ED and tailor treatment to the individual needs and circumstances of each patient.
Case Resolution: You discuss the availability of buprenorphine which can be prescribed from the ED and methadone from clinics within your city. You discuss the pros and cons of each treatment as best you understand them, and he is interested in trying buprenorphine at home. You also provide him with a list of outpatient clinics that can help with the multifactorial interventions needed to address his OUD.
Clinical Application: The patient agrees to take home four doses of buprenorphine-naloxone as well as instructions on when to take the first dose with respect to the development of significant withdrawal symptoms. He will try to follow up at a local clinic tomorrow.
What Do I Tell the Patient? I (Elizabeth) tell them they have to wait as long as they can – the worse they feel, the more it will help. They can take acetaminophen, clonidine, etc., to get them as far as they possibly can past their first use before they take it. We also give them instructions to let them escalate their dose – don’t be stingy, 4mg is probably not enough – start with 8mg and let them go to 16mg or 32mg on the first day if needed.
Keener Kontest: There was no winner to Dr. Kirsty Challen’s super hard question. The use of imaging to support the diagnosis of postoperative ileus was first reported in the Journal of the Michigan Medical Society 1920 by JT Case.
Listen to the podcast this week to hear the keener contest question. If you are the first person to email the correct answer to TheSGEM@gmail.com with “keener” in the subject line you will receive a cool skeptical prize.
SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on patient perspectives regarding initiation of medications for OUD in the ED? Tweet your comments using #SGEMHOP. What questions do you have for Elizabeth and her team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.
Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article.
REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.
- Drug overdose deaths in the U.S. top 100,000 annually. Centers for Disease Control and Prevention. 2021. Accessed December 2, 2021. https://www.cdc.gov/nchs/pressroom/nchs_press_relea ses/2021/20211117.htm
- Sordo L, Barrio G, Bravo MJ, et al. Mortality Risk during and after Opioid Substitution Treatment: Systematic Review and Meta-Analysis of Cohort Studies. BMJ. 2017;357:j1550. doi:10.1136/bmj.j1550
- D’OnofrioG,O’ConnorPG,PantalonMV,etal.Emergencydepartment– initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.
- Kinsky S, Houck PR, Mayes K, Loveland D, Daley D, Schuster JM. A comparison of adherence, outcomes, and costs among opioid use disorder Medicaid patients treated with buprenorphine and methadone: a view from the payer perspective. J Subst Abuse Treat. 2019;104:15-21.
- Connery HS. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harv Rev Psychiatry. 2015;23(2):63-75.
- Kelly T, Hoppe JA, Zuckerman M, Khoshnoud A, Sholl B, Heard K. A novel social work approach to emergency department buprenor- phine induction and warm hand-off to community providers. Am J Emerg Med. 2020;38(6):1286-1290.
- Edwards FJ, Wicelinski R, Gallagher N, McKinzie A, White R, Domingos A. Treating opioid withdrawal with buprenorphine in a community hospital emergency department: an outreach program. Ann Emerg Med. 2020;75(1):49-56.
- Houry D, Adams J. Emergency physicians and opioid overdoses: a call to aid. Ann Emerg Med. 2019;74(3):436-438.
- Chua K-P, Dahlem CHY, Nguyen TD, et al. Naloxone and buprenor- phine prescribing following US emergency department visits for suspected opioid overdose: august 2019 to April 2021. Ann Emerg Med. 2021;79:225-236. doi:10.1016/j.annemergmed.2021.10.005
- Kilaru AS, Xiong A, Lowenstein M, et al. Incidence of treatment for opioid use disorder following nonfatal overdose in commercially in- sured patients. JAMA Network Open. 2020;3(5):e205852-e205813. doi:10.1001/jamanetworkopen.2020.5852
- Schoenfeld EM, Westafer LM, Soares WE. Missed opportuni- ties to save lives-treatments for opioid use disorder after over- dose. JAMA Network Open. 2020;3(5):e206369. doi:10.1001/ jamanetworkopen.2020.6369
- Collins AB, Beaudoin FL, Samuels EA, Wightman R, Baird J. Facilitators and barriers to post-overdose service delivery in Rhode Island emergency departments: a qualitative evaluation. J Subst Abuse Treat. 2021;130:108411. doi:10.1016/j.jsat.2021.108411
- Sokol R, Tammaro E, Kim JY, Stopka TJ. Linking MATTERS: Barriers and facilitators to implementing emergency department-initiated buprenorphine-naloxone in patients with opioid use disorder and linkage to long-term care. Subst Use Misuse. 2021;56(7):1045-1053. doi:10.1080/10826084.2021.1906280
- Hawk KF, D’Onofrio G, Chawarski MC, et al. Barriers and facili- tators to clinician readiness to provide emergency department- initiated buprenorphine. JAMA Network Open. 2020;3(5):e204561. doi:10.1001/jamanetworkopen.2020.4561
- Schoenfeld EM, Soares WE, Schaeffer EM, Gitlin J, Burke K, Westafer LM. “This is part of emergency medicine now”: A qualita- tive assessment of emergency clinicians’ facilitators of and barriers to initiating buprenorphine. Acad Emerg Med. 2021;29(1):28-40. doi:10.1111/acem.14369
- Fox L, Nelson LS. Emergency department initiation of bu- prenorphine for opioid use disorder: current status, and future potential. CNS Drugs. 2019;33(12):1147-1154. doi:10.1007/ s40263-019-00667-7
- Lowenstein M, Kilaru A, Perrone J, et al. Barriers and facilitators for emergency department initiation of buprenorphine: a physician sur- vey. The American Journal of Emergency Medicine. 2019;37(9):1787- 1790. doi:10.1016/j.ajem.2019.02.025
- Dong KA, Lavergne KJ, Salvalaggio G, et al. Emergency physician
perspectives on initiating buprenorphine/naloxone in the emer- gency department: a qualitative study. J Am Coll Emerg Physicians Open. 2021;2(2):e12409. doi:10.1002/emp2.12409
- Im D, Chary A, Condella A, et al. Emergency department Clinicians’ atti- tudes toward opioid use disorder and emergency department-initiated buprenorphine treatment: a mixed-methods study. West J Emerg Med. 2020;21(2):261-271. doi:10.5811/westjem.2019.11.44382
- Probst MA, Kanzaria HK, Schoenfeld EM, et al. Shared Decisionmaking in the emergency department: a guiding framework for clinicians. Ann Emerg Med. 2017;70(5):688-695. doi:10.1016/j. annemergmed.2017.03.063
- Schoenfeld EM, Mader S, Houghton C, et al. The effect of shared decisionmaking on patients’ likelihood of filing a complaint or law- suit: a simulation study. Ann Emerg Med. 2019;74:126-136.
- Hess EP, Knoedler MA, Shah ND, et al. The chest pain choice decision aid. Circ Cardiovasc Qual Outcomes. 2012;5(3):251-259. doi:10.1161/circoutcomes.111.964791
- Wilson SR, Strub P, Buist AS, et al. Shared treatment decision mak- ing improves adherence and outcomes in poorly controlled asthma. Am J Resp Crit Care Med. 2010;181(6):566-577. doi:10.1164/ rccm.200906-0907oc