Program Profile

Medications for Opioid Use Disorder Program in a VA Emergency Department

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Background: Opioid use disorder (OUD) is a public health crisis significantly affecting veterans. Providing medications for opioid use disorder (MOUD) can increase engagement with addiction treatment. Although emergency departments (EDs) throughout the United States are beginning to provide this life-saving treatment, little is known about how this can be applied to the US Department of Veterans Affairs (VA) health care setting.

Observations: Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) ED developed the first VA ED MOUD program in an 8-step process. Following stakeholder buy-in, we developed the protocol, determined appropriate follow-up, identified eligible veterans, developed supporting tools and resources, modified organizational policy and processes, educated clinicians about the protocol, and evaluated the results. Veterans treated with MOUD were given follow-up appointments within 2 business days in the VAGLAHS SUD clinic or referred directly to a substance use rehabilitation center.

Conclusions: This program demonstrates the feasibility of an ED bridge program at a single VA facility that could be expanded to other VA medical centers. Patients who received buprenorphine in the ED were more likely to remain engaged in addiction care; however, many patients lacked symptom severity to be initiated in the ED. Offering home initiation and increasing OUD screening may help increase enrollment. With increased OUD overdose rates during the COVID-19 pandemic, expanding access to MOUD is essential to combating this crisis.


 

References

Opioid use disorder (OUD) is a public health crisis significantly affecting veterans. A substantial increase in veterans diagnosed with OUD has occurred, nearly tripling from 25,031 in 2003 to 69,142 in 2017.1 Furthermore, compared with civilians, veterans are twice as likely to die of an accidental overdose, most often from opioids.2

For patients with active OUD, medications for opioid use disorder (MOUD) reduce the risk of overdose and all-cause mortality.3 In 2009, the US Department of Veterans Affairs (VA) and Department of Defense (DoD) published clinical practice guidelines for substance use disorders that strongly recommended MOUD with either buprenorphine or methadone as a first-line treatment. In 2015 updated guidelines encouraged buprenorphine initiation in primary care settings.4,5 This was followed by an academic detailing campaign designed to encourage VA clinicians to initiate MOUD.1 Despite this institutional support, MOUD remains underutilized within the VA, with widely variable rates of prescribing among VA sites.1

Efforts to further expand MOUD cultivated interest in administering buprenorphine in VA emergency departments (EDs). Patients with OUD often use the ED for same-day care, providing opportunities to initiate buprenorphine in the ED 24 hours, 7 days per week. This has been especially true during the COVID-19 pandemic during which reliable access to usual recovery services has been disrupted and EDs have served as a safety net.6

Buprenorphine’s safety profile and prolonged effect duration make it superior to other MOUD options for ED administration. As a partial opioid agonist, buprenorphine is unlikely to cause significant sedation or respiratory depression compared with full agonists like methadone. This is known as the ceiling effect. Additionally, at higher doses, buprenorphine’s effects can last for about 3 days, potentially obviating the need for repeat dosing. D’Onofrio and colleagues seminal 2015 paper conceptually proved the feasibility and value of initiating buprenorphine in the ED; patients who received ED initiation therapy were more likely to be engaged in addiction treatment 30 days after their visit and have reduced rates of illicit opioid drug use.7 Such ED harm-reduction strategies are increasingly recognized as essential, given that 1 in 20 patients treated for a nonfatal opioid overdose in an ED will die within 1 year of their visit, many within 2 days.8 Finally, a significant barrier faced by physicians wanting to administer or prescribe buprenorphine for patients with OUD has been the special licensing required by the Drug Enforcement Administration Drug Addiction Treatment Act of 2000, also known as an X-waiver. A notable exception to this X-waiver requirement is the 72-hour rule, which allows nonwaivered practitioners to administer (but not prescribe for home use) buprenorphine to a patient to relieve acute withdrawal symptoms for up to 72 hours while arranging for specialist referral.Under the 72-hour rule, ED clinicians have a unique opportunity to treat patients experiencing acute withdrawal symptoms and bridge them to specialty care, without the burden of an X-waiver requirement.

The VA Greater Los Angeles Healthcare System (VAGLAHS), therefore, developed and implemented a program to administer buprenorphine in the ED to bridge patients with OUD to an appointment with substance use disorder (SUD) services. We describe our development, implementation and evaluation of this program protocol as a model for other VA EDs. This project was determined to be quality improvement (nonresearch) by the VAGLAHS Institutional Review Board.

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