Harm Reduction
Loren Bonner
Emergency department pharmacists at Boston Medical Center (BMC) led an opioid use disorder (OUD) initiative that not only contributed to a decrease in OUD ED visits, but it also changed the culture at BMC for clinicians to promote harm reduction strategies and offer treatment with follow-up to patients with OUD.
The program began in 2018 and won the best practice award poster at ASHP 2021 Midyear Clinical Meeting and Exhibition, which was held virtually.
“While we didn’t look at outpatient addiction medicine service utilization for all patients, the reduction in ED visits for ICD-10 specific to opioid use disorder suggests that the provision of medications for opioid use disorder in the ED helps facilitate engagement in outpatient addiction medicine services,” said Natalija Farrell, PharmD, BCPS, who was part of the team and helped lead the research.
Clinicians know that methadone and buprenorphine-naloxone are effective for combating the opioid epidemic for a variety of reasons. Several studies have demonstrated ED-initiated buprenorphine has increased patient engagement in outpatient addiction medicine services and reduced self-reported illicit opioid use. Studies have also demonstrated that patients receiving medications for OUD have lower rates of ED visits and higher rates of using ambulatory care services.
However, patients encounter multiple barriers accessing medications for OUD.
Like many other harm reduction experts, the team that led this initiative at BMC believed the ED represented an appropriate setting to engage patients in OUD treatment options because patients frequently use EDs for overdose treatment or when they experience secondary complications from opioid use.
The program
The initiative at BMC was led by a multidisciplinary work group consisting of ED pharmacists, ED nurses, ED physicians, addiction medicine physicians, and licensed alcohol and drug counselors.
The team created ED-specific guidelines for the management of opioid withdrawal, added methadone and buprenorphine-naloxone to ED automated dispensing cabinets, and provided education to physicians, pharmacists, and nurses on the team. ED health care providers also received incentives to obtain Drug Addiction Treatment Act (DATA) waiver numbers, sometimes referred to as X-waivers. Buprenorphine prescriptions require a provider to have this X-waiver.
The research team found that medications for OUD administered in the ED increased significantly and have been sustained since January 2019. No patients received rescue naloxone after being given medications for OUD, which Farrell said reaffirmed the safety of their protocols, and helped reassure staff that treating opioid withdrawal with methadone or buprenorphine-naloxone was not harmful to patients.
“Our protocol used a higher initial buprenorphine-naloxone of 8 mg, which infrequently required subsequent redosing,” said Farrell, who is also an assistant professor of medicine at Boston University School of Medicine. “Our protocol supports the newer literature, which has found higher doses of buprenorphine-naloxone to be safe and effective.”
The research team also found that no patients discharged from the ED after receiving medications for OUD returned to the ED within 24 hours for an opioid overdose.
Farrell said that eventually they add-ed buprenorphine-naloxone take-home
kits to address the lack of local 24/7 pharmacies to fill buprenorphine-naloxone prescriptions during off hours.
In total, buprenorphine-naloxone discharge prescribing increased from a mean of 0 to 2.3 prescriptions/month starting in September 2018, which further increased to a new average of 8 prescriptions/month beginning in January 2019.
“We’ve also created an ED/inpatient order set to help guide providers in selecting methadone or buprenorphine-naloxone for patients,” said Farrell. “Most recently, we expanded naloxone take home kit ordering privileges to include pharmacists.”
Pathway to opioid treatment
The initiative improved patient access to OUD treatment and naloxone in addition to increasing follow-up at one of BMC’s substance abuse disorder bridge clinics, Faster Paths.
“Our Faster Paths bridge clinic has since applied the ED’s utilization of opioid withdrawal treatment methadone in accordance with the ‘72-hour rule’ to its patients, and has established pathways with local opioid treatment programs to link patients within 48 hours,” Farrell said. ■
The BMC OUD initiative
- ED-specific guidelines for the management of opioid withdrawal
- Methadone and buprenorphine-naloxone in ED automated dispensing cabinets
- Related education to physicians, pharmacists, and nurses on the team
- Incentives for ED health care providers to obtain DATA waiver number
- Buprenorphine-naloxone take home kits (to address lack of local 24/7 pharmacies to fill buprenorphine-naloxone prescriptions during off hours)