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.
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.
