Medications for Opioid Use Disorder Program in a VA Emergency Department
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.
Identification of Eligible Veterans
Target patients were those primarily presenting with a request for treatment of opioid dependence or withdrawal. Patients were not actively screened for OUD. Clinicians diagnosed and assessed for OUD as per their usual practice. Patients with OUD who presented to the ED for other reasons were assessed, at clinician discretion, for their interest in receiving MOUD. If patients presented in moderate-to-severe withdrawal (eg, Clinical Opiate Withdrawal Scale [COWS] ≥ 8), buprenorphine was initiated in the ED. These patients were subsequently referred to either the local SUD clinic or to a residential treatment center. Patients presenting with a COWS score < 8 were referred to the outpatient SUD clinic or residential treatment centers without initiating buprenorphine from the ED. The SUD clinic or residential treatment centers could offer buprenorphine or other MOUD options. From the ED, prescribing buprenorphine for patients to self-initiate at home was not available as this required an X-waivered prescriber, which were limited during the program time frame.
Support Tools and Resources
To facilitate ED clinicians using the protocol, we worked with a programmer experienced with the Computerized Patient Record System, the VA electronic health record (EHR), to create electronic order menu sets that directed clinicians to the protocol and educational materials (Appendix 3). These menus are readily accessible and embedded into the ED clinician workflow. The menus highlight key elements of the protocol, including indications for initiation, contraindications, recommended dosing with quick orders, and how to obtain follow-up for the patient. Links also are provided to the protocol and patient discharge handouts, including the CA Bridge website.
Organizational Policy and Processes
Before implementing the developed protocol, we worked with stakeholders to modify organizational policies and processes. Our pharmacy agreed to stock buprenorphine in the ED to make it readily available. EHR restrictions that historically prohibited ordering buprenorphine for ED administration by nonwaivered clinicians were modified. Additionally, our chief of staff, pharmacy, and credentialing department agreed that physicians did not need to apply for additional delineated privileges.
Clinician Education
The final preparation step was educating clinicians and other protocol users. The VAGLAHS SUD chief presented a lecture and answered questions about MOUD to core ED faculty about the rising prevalence of OUD and use of buprenorphine as a recommended treatment.
Evaluation
To assess adherence to the developed protocol, we conducted a retrospective health record review of all ED visits March 1 to October 25, 2019, in which the patient had OUD and may have qualified for MOUD. To do this, we identified (1) ED visits with an OUD ICD-10 code as a primary or secondary diagnoses; (2) ED referrals to outpatient SUD treatment; and/or (3) ED visits in which buprenorphine was given or prescribed. We included the latter 2 criteria as application of ICD-10 codes for OUD care was inconsistent. Visits were excluded if patients did not have OUD, had OUD in remission, were already maintained on a stable MOUD regimen and no longer using illicit drugs or craving additional opioids, or were presenting solely for a refill or administration of a missed dose. Patients who relapsed were categorized as unstable. Visits were excluded if the patient was admitted to the hospital or left against medical advice. Patients on MOUD who had relapsed or requested a change in MOUD treatment were included. For all included visits, 2 ED physicians (MC, JH) reviewed the ED clinician and nursing notes, pharmacy and referral records, diagnostic codes, and veteran demographics.
