Program Profile

Medications for Opioid Use Disorder Program in a VA Emergency Department

Publish date: October 20, 2022

References

2. Bohnert ASB, Ilgen MA, Galea S, McCarthy JF, Blow FC. Accidental poisoning mortality among patients in the Department of Veterans Affairs health system. Med Care. 2011;49(4):393-396. doi:10.1097/MLR.0b013e318202aa27

3. Ma J, Bao Y-P, Wang R-J, et al. Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis. Mol Psychiatry. 2019;24(12):1968-1983. doi:10.1038/s41380-018-0094-5

4. The Management of Substance Use Disorders Work Group. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Version 2.0. US Department of Veterans Affairs; 2009.

5. The Management of Substance Use Disorders Work Group. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Version 3.0. US Department of Veterans Affairs. 2015. Accessed July 1, 2022. https://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPGRevised22216.pdf

6. Hulsey J, Mellis A, Kelly B. COVID-19 pandemic impact on patients, families and individuals in recovery from substance use disorder. Accessed July 7, 2021. https://www.addictionpolicy.org/covid19-report

7. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opiod dependence. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474

8. Weiner SG, Baker O, Bernson D, Schuur JD. One-year mortality of patients after emergency department treatment for non-fatal opioid overdose. Ann Emerg Med. 2020;75(1):13-17. doi:10.1016/j.annemergmed.2019.04.020

9. CA Bridge. Updated 2021. Accessed July 1, 2022. https://cabridge.org

10. Penney L, Miake-Lye I, Lewis D, et al. Proceedings from the 11th annual conference on the science of dissemination and implementation: S72 spreading VA’s emergency department-rapid access clinics (ED-RAC) intervention: key factors for success. Implementation Sci. 2019;14(suppl 1). doi:10.1186/s13012-019-0878-2

11. Hu T, Snider-Alder M, Nijmeh L, Pyle A. Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers. CJEM. 2019;21(4):492-498. doi:10.1017/cem.2019.24

12. US Department of Health and Human Services. Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. Federal Register. Accessed July 1, 2022. https://www.federalregister.gov/documents/2021/04/28/2021-08961/practice-guidelines-for-the-administration-of-buprenorphine-for-treating-opioid-use-disorder

13. D’Onofrio G, Melnick ER, Hawk KF. Improve access to care for opioid use disorder: a call to eliminate the x-waiver requirement now. Ann Emerg Med. 2021;78(2):220-222. doi:10.1016/j.annemergmed.2021.03.023

14. Dieujuste N, Johnson-Koenke R, Celedon M, et al. Provider perceptions of opioid safety measures in VHA emergency department and urgent care centers. Fed Pract. 2021;38(9):412-419. doi:10.12788/fp.0179

15. Hawk KF, D’Onofrio G, Chawarski MC, et al. Barriers and faciliatators to clinician readiness to provide emergency department-initiated buprenorphine. JAMA Netw Open. 2020;3(5):e204561. doi:10.1001/jamanetworkopen.2020.4561

16. Lowenstein M, Kilaru A, Perrone J, et al. Barriers and facilitators for emergency department initiation of buprenorphine: a physician survey. Am J Emerg Med. 2019;37(9):1787-1790. doi:10.1016/j.ajem.2019.02.025

17. Srivastava A, Kahan M, Leece P, McAndrew A. Buprenorphine unobserved “home” induction: a survey of Ontario’s addiction physicians. Addic Sci Clin Pract. 2019;14(1):18. doi:10.1186/s13722-019-0146-4

18. The Management of Substance Use Disorders Work Group. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Version 4.0. US Department of Veterans Affairs. 2021. Accessed July 1, 2022. https://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPG.pdf

19. Patnode CD, Perdue LA, Rushkin M, et al. Screening for unhealthy drug use updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2020;323(22):2310-2338. doi:10.1001/jama.2019.21381

20. Coles S, Vosooney A. Evidence lacking to support universal unhealthy drug use screening. Am Fam Physician. 2021;103(2):72-73.

21. Sahota PK, Sharstry S, Mukamel DB, et al. Screening emergency department patients for opioid drug use: a qualitative systematic review. Addict Behav. 2018;85:139-146. doi:10.1016/j.addbeh.2018.05.022

Future Directions

More than half of our patients did not receive ED buprenorphine initiation because they were not in moderate or severe withdrawal (COWS ≥ 8) similar to 57% of patients cited in the D’Onofrio and colleagues study.⁷ Teaching veterans how to start buprenorphine at home could greatly expand enrollment. However, this requires a prescription from an X-waiver licensed clinician. In 2021, the US Department of Health and Human Services removed the 8-hour training requirement for obtaining an X-waiver.¹² However, clinicians are still required to apply for licensing. Eliminating the X-waiver requirement, as proposed by D’Onofrio and colleagues in a 2021 editorial, would have allowed all clinicians to offer home initiation.¹³

Previous studies suggest that despite the ability to provide a prescription, clinicians may be reluctant to offer home initiation.^14–17 In a national VA 2019 survey, many emergency medicine physicians believe that SUD care is not in their scope of practice, as Dieujuste and colleagues described in Federal Practitioner.¹⁴ Although it is likely some attitudes have changed with the increased visibility of ED MOUD programs, there is still much work to be done to change perceptions.

Another area for improvement is screening for OUD in the ED to better reveal MOUD candidates. Missed opportunities (neither referral nor treatment offered) occurred in 21% of our visits. D’Onofrio and colleagues identified 66% of patients by screening all ED patients.⁷ Although universal screening for SUD in routine health care settings has been recommended, 2021 VA guidelines state that there is insufficient evidence to recommend universal screening.^18-20 There are also limited data on the best screening tool for OUD in the ED.²¹ Further research on how to effectively and efficiently identify OUD patients in the ED is needed.

Conclusions

With minimal resource allocation, we started the program to offer MOUD with buprenorphine for patients with OUD at a VA ED and provided addiction treatment follow-up. This program, the first of its kind within VA, can be modeled and expanded to other VA facilities. Given increasing numbers of fatal opioid overdose, and significant adverse impacts of the COVID-19 pandemic on the OUD crisis, developing local and national strategies to treat OUD is essential. Future steps include improved screening and expanding capacity to offer home initiation by increasing the number of X-waiver ED clinicians.⁶

Acknowledgments

Thank you to Jeffrey Balsam, PharmD, BCPS, Veterans Affairs Greater Los Angeles Clinical Applications Coordinator for his contributions in creating a Computerized Patient Record System opioid use disorder screening tool. Thank you to Gracielle Tan, MD, Veterans Affairs Greater Los Angeles Health Science Specialist for her administrative assistance in manuscript preparation.

References

1. Wyse JJ, Gordon AJ, Dobscha SK, et al. Medications for opioid use disorder in the Department of Veterans Affairs (VA) health care system: historical perspective, lessons learned, and next steps. Subst Abuse. 2018;39(2):139-144. doi:10.1080/08897077.2018.1452327

2. Bohnert ASB, Ilgen MA, Galea S, McCarthy JF, Blow FC. Accidental poisoning mortality among patients in the Department of Veterans Affairs health system. Med Care. 2011;49(4):393-396. doi:10.1097/MLR.0b013e318202aa27

3. Ma J, Bao Y-P, Wang R-J, et al. Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis. Mol Psychiatry. 2019;24(12):1968-1983. doi:10.1038/s41380-018-0094-5

4. The Management of Substance Use Disorders Work Group. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Version 2.0. US Department of Veterans Affairs; 2009.

5. The Management of Substance Use Disorders Work Group. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Version 3.0. US Department of Veterans Affairs. 2015. Accessed July 1, 2022. https://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPGRevised22216.pdf

6. Hulsey J, Mellis A, Kelly B. COVID-19 pandemic impact on patients, families and individuals in recovery from substance use disorder. Accessed July 7, 2021. https://www.addictionpolicy.org/covid19-report

7. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opiod dependence. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474

8. Weiner SG, Baker O, Bernson D, Schuur JD. One-year mortality of patients after emergency department treatment for non-fatal opioid overdose. Ann Emerg Med. 2020;75(1):13-17. doi:10.1016/j.annemergmed.2019.04.020

9. CA Bridge. Updated 2021. Accessed July 1, 2022. https://cabridge.org

10. Penney L, Miake-Lye I, Lewis D, et al. Proceedings from the 11th annual conference on the science of dissemination and implementation: S72 spreading VA’s emergency department-rapid access clinics (ED-RAC) intervention: key factors for success. Implementation Sci. 2019;14(suppl 1). doi:10.1186/s13012-019-0878-2

11. Hu T, Snider-Alder M, Nijmeh L, Pyle A. Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers. CJEM. 2019;21(4):492-498. doi:10.1017/cem.2019.24

12. US Department of Health and Human Services. Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. Federal Register. Accessed July 1, 2022. https://www.federalregister.gov/documents/2021/04/28/2021-08961/practice-guidelines-for-the-administration-of-buprenorphine-for-treating-opioid-use-disorder

13. D’Onofrio G, Melnick ER, Hawk KF. Improve access to care for opioid use disorder: a call to eliminate the x-waiver requirement now. Ann Emerg Med. 2021;78(2):220-222. doi:10.1016/j.annemergmed.2021.03.023

14. Dieujuste N, Johnson-Koenke R, Celedon M, et al. Provider perceptions of opioid safety measures in VHA emergency department and urgent care centers. Fed Pract. 2021;38(9):412-419. doi:10.12788/fp.0179

15. Hawk KF, D’Onofrio G, Chawarski MC, et al. Barriers and faciliatators to clinician readiness to provide emergency department-initiated buprenorphine. JAMA Netw Open. 2020;3(5):e204561. doi:10.1001/jamanetworkopen.2020.4561

16. Lowenstein M, Kilaru A, Perrone J, et al. Barriers and facilitators for emergency department initiation of buprenorphine: a physician survey. Am J Emerg Med. 2019;37(9):1787-1790. doi:10.1016/j.ajem.2019.02.025

17. Srivastava A, Kahan M, Leece P, McAndrew A. Buprenorphine unobserved “home” induction: a survey of Ontario’s addiction physicians. Addic Sci Clin Pract. 2019;14(1):18. doi:10.1186/s13722-019-0146-4

18. The Management of Substance Use Disorders Work Group. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Version 4.0. US Department of Veterans Affairs. 2021. Accessed July 1, 2022. https://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPG.pdf

19. Patnode CD, Perdue LA, Rushkin M, et al. Screening for unhealthy drug use updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2020;323(22):2310-2338. doi:10.1001/jama.2019.21381

20. Coles S, Vosooney A. Evidence lacking to support universal unhealthy drug use screening. Am Fam Physician. 2021;103(2):72-73.

21. Sahota PK, Sharstry S, Mukamel DB, et al. Screening emergency department patients for opioid drug use: a qualitative systematic review. Addict Behav. 2018;85:139-146. doi:10.1016/j.addbeh.2018.05.022

Medications for Opioid Use Disorder Program in a VA Emergency Department

References

Future Directions

Conclusions

Acknowledgments

Pages

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