Natalija M. Farrell, Pharm.D., BCPS, DABAT; Jessica L. Taylor, M.D.; Ludy O. Young, Med, LADC I; Jessica Kehoe, BSN; Sandy Gonzalez, M.A.; Patricia M. Mitchell, RN; David Fett, Pharm.D., BCPS; Danielle D. Margetak, Pharm.D., BCPS; Monique Payne-Cardona, Pharm.D., BCPS; Bryan J. Gendron, Pharm.D., BCPS; Danielle Kebadjian Lindale, Pharm.D., BCCCP; Elena Serpico, Pharm.D., BCCCP; Anne Marie Guthrie, Pharm.D., BCCCP; Rosa Auterio-Williams, M.Ed., LADC I, CADC; Dawn Thomas, LADC II; Sebastian Hamilton, Pharm.D., M.B.A.; Lauren M. Nentwich, M.D.
Boston Medical Center
Boston, MA
Methadone and buprenorphine-naloxone are effective for combating the opioid epidemic due to their reduction in overdose mortality, increased patient engagement in addiction treatment programs, and decreased illicit opioid use. Patients encounter multiple barriers to accessing medications for opioid use disorder (MOUD), which has resulted in less than 20% receiving these life-saving treatments. The Emergency Department (ED) represents a unique care area to engage patients in opioid use disorder (OUD) treatment options, because patients frequently utilize EDs for the treatment of overdose or secondary complications of opioid use.
At our institution, a quality improvement (QI) work group consisting of ED physicians, ED nurses, ED pharmacists, addiction medicine physicians, and licensed alcohol and drug counselors was formed to improve the treatment of patients with OUD presenting to the ED through provision of harm reduction services and initiation of MOUD. The ED pharmacist-led QI initiatives were evaluated using the Model for Improvement framework from the Institute of Healthcare Improvement, and multiple Plan-Do-Study-Act (PDSA) cycles were conducted between April 2018 and July 2021. The PDSA cycles included developing an ED-specific MOUD guideline, removing MOUD from autoverify and stocking MOUD in the ED, incentivizing ED provider X-waiver certification, pathway for linkage within 48 hours of ED discharge to our substance use disorder (SUD) bridge clinic, education to patients and healthcare team members, naloxone take home kit distribution and evolving novel reimbursement processes at no cost to the institution, and implementing a buprenorphine-naloxone take home kit transitions of care (TOC) bundle.
This QI initiative improved patient access to OUD treatment and naloxone in addition to increasing follow-up at our SUD bridge clinic. Administration of MOUD in the ED increased from a baseline of 38 to 98 administrations/month in starting in September 2018, which further increased to a new mean of 199.9 administrations/month that has been sustained since January 2019. No patients received rescue naloxone following MOUD administration. No patients discharged from the ED after receiving MOUD returned to the ED within 24 hours for an opioid overdose. Buprenorphine-naloxone discharge prescribing increased from a mean of 0 to 2.3 prescriptions/month starting in September 2018, which further increased to a new average of 8 prescriptions/month beginning in January 2019. In January 2020, we implemented buprenorphine-naloxone take home kits which consisted of buprenorphine-naloxone 8-2mg x4 films, naloxone 4mg spray, medication handouts, SUD bridge clinic brochure, and ED pharmacist discharge counseling. The ED pharmacist-led buprenorphine-naloxone TOC bundle resulted in significantly greater follow-up at the SUD bridge clinic within 7 days (76.7% vs 42.7%, p<0.001) and naloxone co-prescribing (98.7% vs 10.1%, p<0.001) when compared to traditional buprenorphine-naloxone discharge prescriptions. A significant shift change leading a reduction in ED visits for OUD was observed starting in November 2020. Naloxone take home kit dispenses increased annually and reached a new high of 397.
Our ED pharmacist-led initiatives demonstrate that a pharmacist is essential to the development and successful implementation of an ED-based MOUD and naloxone programs. Our department developed innovative strategies to reduce barriers to treatment and facilitate linkage to outpatient care.
