Emergency Department Residents Drive Buprenorphine Waiver Campaign

NEW YORK—Emergency department (ED) resident physicians are driving a campaign to increase the number of buprenorphine-waivered emergency physicians as part of their effort to address the opioid overdose crisis.

"We in the ED often see patients with opioid use disorder (OUD) at their very lowest points, and if we have the ability to help them then, we may get the chance that no other physicians ever will," Dr. Ali S. Raja from Massachusetts General Hospital (MGH) and Harvard Medical School, Boston, Massachusetts told Reuters Health by email.

Buprenorphine has been shown to increase retention in treatment and reduce illicit opioid use, and several hospitals have embedded medication for addiction treatment programs within their EDs. But nationwide, only about 1% of emergency physicians have obtained the Drug Enforcement Administration (DEA) X waiver needed to prescribe buprenorphine.

Dr. Raja's team organized Get Waivered, a resident-driven campaign that addressed three key behavioral barriers that stood in the way of completion of the DEA X waiver process for the faculty and residents in the MGH ED.

They targeted the lack of consistent social norms around treating OUD and getting the necessary waiver by recruiting influential faculty members to be among the first waivered, creating a Get Waivered Month, designing honorific gold lapel pins to recognize those who had completed waiver training, and inviting local media to cover the first white coat "pinning" ceremony.

The second barrier, the perceived hassle in obtaining a waiver, they addressed by coordinating all schedules for interested participants, creating an easy-to-follow website, and presenting information about the waiver process at resident and faculty conferences.

Lack of salience, which the authors describe as the lack of faculty members and residents who could easily recall stories of patients with OUD who had been treated successfully and are in recovery, was the third barrier. They targeted this barrier through nudges related to sharing in-person patient stories from individuals, including physicians with OUD, who had used medication for addiction treatment to enter into and stay in recovery.

By the end of the 3-month Get Waivered campaign, 38 of 42 attending physicians in the faculty group and 22 ED resident physicians had taken their waiver training course, and 95% of the current faculty attendings have obtained a buprenorphine waiver, according to the July 1st Annals of Emergency Medicine online report.

"From ED visits for overdose to visits for complications from long-term opioid use, patients who are not treated are just less well," Dr. Raja said. "By starting patients on treatment, we can decrease healthcare costs, which is especially important in these days of ACOs (Accountable Care Organizations) and population health management."

"This needs to be a hospital-level, not an ED-level intervention," he said. "It takes outpatient clinics, EDs, pharmacies, insurers, etc. to be able to do this - and this cannot be mandated for only a single department in a hospital."

Dr. Bradley D. Stein, director of Opioid Policies, Tools, and Information Center of Research Excellence at RAND Corporation, Pittsburgh, Pennsylvania, who has researched several aspects of buprenorphine prescribing by waivered physicians, told Reuters Health, "This is a wonderful initiative, and shows how relatively simple efforts can greatly enhance clinicians' willingness to prescribe buprenorphine to treat opioid use disorder. There really aren't many obstacles to a campaign like this - the greatest barriers in many cases are likely the stigma that still in many cases exists in treating individuals with opioid use disorder and the competing demands on time for very busy clinicians."

"It's important to note that physicians need CME credits for relicensure, and since you get CME credits for the training for the DEA X-waiver, the time spent in that training would likely need to be spent in a different training anyway," he said in an email.

Dr. Stein added, "Opioid use disorder is a chronic, episodic, relapsing disorder, and treatment in an ED is by definition for acute problems. So programs like this help to increase access. That is necessary but not sufficient - it's critical that such programs are accompanied by a range of efforts to increase not only access but also engagement in high quality treatment for opioid use disorder."

"The MGH residents had a bridge clinic they could refer patients to to be seen the next day, but not all ED physicians have that option," he said. "We need ongoing efforts not just to increase access to buprenorphine, but also to ensure we have a robust high-quality treatment system, involving both primary care and specialty care, for individuals with opioid use disorder."

SOURCE: https://bit.ly/2SuZ6g1

Ann Emerg Med 2019.

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