Physicians who prescribe opioid treatments inspire others to do the same

Buprenorphine adoption in ED for opioid disorder patients.

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Emergency rooms are essential for treating opioid addiction. However, not many doctors use a drug called buprenorphine, which helps people manage opioid addiction safely. A study from Yale University found that if emergency room doctors see their colleagues using buprenorphine, they are more likely to start using it, too.

This could be a helpful strategy to increase opioid addiction treatment in emergency rooms. In the United States, about 2 million people are affected by the opioid crisis, and more people are going to emergency rooms for opioid-related issues as overdose rates go up.

Buprenorphine is a helpful treatment for opioid use, easing withdrawal symptoms and reducing cravings. However, many emergency room doctors hesitate to use it due to a lack of training and stigma. In 2019, Yale researchers tested a tool in electronic health records to see if it could encourage more doctors in emergency rooms to use buprenorphine. The study found that, over time, more doctors started prescribing buprenorphine.

Andrew Loza, a lecturer and clinical informatics fellow at Yale School of Medicine and senior author of the new study, said, “We wanted to know what factors were driving that. There’s this adage in medicine: see one, do one, teach one. We wanted to investigate whether seeing a colleague prescribe buprenorphine contributes to an individual’s likelihood of prescribing it themselves.”

In a recent study, researchers looked at data from a November 2019 to May 2021 trial in 18 emergency departments across five healthcare systems. They found that when clinicians saw their colleagues starting buprenorphine treatment, they were more likely to do it themselves. If a clinician witnessed one initiation, they were 1.3 times more likely to prescribe it later. Seeing it happen five times increased the likelihood to 2.7 times, and catching it ten times made them 3.6 times more likely to prescribe buprenorphine later on.

Loza said, “The more you see it, the more likely you are to do it yourself.”

The study also found that people’s roles in the emergency department and their overall culture influenced how likely they were to use buprenorphine. Physician associates and nurse practitioners were more likely to use it than attending physicians.

The study also showed that in some health systems, clinicians were more likely to start using buprenorphine compared to those in other systems. This suggests that the workplace and the specific role someone has in the emergency department are significant factors in whether they choose to adopt buprenorphine, with the workplace having the most significant impact.

“A potential obstacle to using buprenorphine was the X-waiver, a process required until this year for doctors to prescribe it. The X-waiver also limited how many patients a doctor could give the treatment to. Even though we’re now past the X-waiver, there are still challenges,” explained Ted Melnick, a study co-author and associate professor of emergency medicine at Yale School of Medicine. “Removing these obstacles is essential to address the opioid crisis quickly.”

According to the study, addressing obstacles to starting buprenorphine treatment can be tackled at different levels. Healthcare systems and emergency department leaders can work on overcoming cultural and structural limitations. On an individual level, clinicians can set an example, influencing their colleagues. To encourage this, emergency departments should find ways to showcase, celebrate, recognize, and empower clinicians who adopt and promote the practice of treating opioid use disorder, as suggested by Melnick.

Loza said, “We’re at a critical crossroads between the health care system and individuals with opioid use disorder. EDs are where we can address the care gap for treatment. The potential impact of this is broad as the ED is where you can shift someone’s trajectory dramatically.”

This study emphasizes the crucial influence of physicians in shaping the adoption of opioid treatments, particularly buprenorphine, in Emergency Departments. The observed link between colleagues initiating buprenorphine treatment and subsequent prescription patterns is evident.

Additionally, the study underscores the impact of clinical roles and ED culture, stressing the need for targeted strategies to overcome existing barriers. While the removal of the X-waiver is a positive step, challenges persist. The study advocates for a holistic approach, urging healthcare systems to address cultural and structural limitations and empowering individual clinicians to drive positive change in the treatment landscape for opioid use disorder in Emergency Departments.

Journal reference:

  1. Evangeline Gao, Edward R. Melnick et al., Adoption of Emergency Department–Initiated Buprenorphine for Patients With Opioid Use Disorder. JAMA Network Open. DOI: 10.1001/jamanetworkopen.2023.42786.

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