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Recommendations for Emergency Departments Caring for Persons with Opioid Use and Opioid Use Disorders: An Integrative Review

Open AccessPublished:January 11, 2022DOI:https://doi.org/10.1016/j.jen.2021.11.003

      Abstract

      Introduction

      The emergency department is a primary portal to care for persons after an opioid overdose and those with an opioid use disorder. The aim of this integrative review was to provide best practice recommendations for nurses caring for this highly stigmatized and often undertreated population.

      Methods

      An integrative review was conducted using studies focusing on adults treated with opioid agonist-antagonist medications in the emergency department. The integrative review method by Whittemore and Knafl was used to guide this review and enhance its rigor.

      Results

      Twelve studies were included in the review. Opioid care begins with identifying opioid use risk, followed by implementing tailored strategies including opioid agonist-antagonist treatment if indicated, referral to treatment when warranted, and follow-up opioid use monitoring when feasible. Eleven recommendations provide guidance on integrating best practices into routine emergency care.

      Discussion

      The emergency department is an ideal setting for addressing the opioid crisis. Nurses can use the recommendations from this review to lead system change and more effectively manage the care of persons with opioid use and opioid withdrawal, and those at risk for opioid overdose.

      Keywords

       Contribution to Emergency Nursing Practice

      • The main findings of this paper are the best practices for (1) Screening: identifying and assessing persons who are at risk because of opioid use, (2) Brief intervention: delivering motivationally based interventions, (3) Pharmacotherapy: providing access to buprenorphine and naloxone, (4) Referral to treatment: making a referral to specialty treatment, and (5) Follow-up and monitoring: confirming that the patient is linked to treatment and outcomes are being monitored.

      Introduction

      The results of the 2019 National Survey on Drug Use and Health

      Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 national survey on drug use and health. U.S. Department of Health & Human Services. Published 2020. Accessed December 1, 2021. https://www.samhsa.gov/data/

      reinforced that use of nonprescription opioids and heroin requires the attention of health care providers. In 2018, more than 9.7 million Americans aged 12 or older reported using a nonprescribed opioid or heroin, and 1.6 million were identified with an opioid use disorder.

      Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 national survey on drug use and health. U.S. Department of Health & Human Services. Published 2020. Accessed December 1, 2021. https://www.samhsa.gov/data/

      Concerning is that in 2019, nearly 50 000 people in the United States died from opioid-involved overdoses,

      Centers for Disease Control and Prevention. Data overview. The drug overdose epidemic: behind the numbers. Accessed December 2, 2021. https://www.cdc.gov/opioids/data/index.html

      and this number has increased during the coronavirus disease 2019 (COVID-19) pandemic.
      • Rossen L.M.
      • Hedegaard H.
      • Warner M.
      • Ahmad F.B.
      • Sutton P.D.
      Early provisional estimates of drug overdose, suicide, and transportation-related deaths: nowcasting methods to account for reporting lags. National Vital Statistics System. Published February 2021.
      The impact of the opioid epidemic on emergency departments (ED) is evident given the prevalence of opioid-related visits to US emergency departments. Specifically, there were 234 million adult visits to emergency departments in the US across 2016 and 2017; 2.88 million (1.23%) were opioid-related.
      • Langabeer J.R.
      • Stotts A.L.
      • Bobrow B.J.
      • et al.
      Prevalence and charges of opioid-related visits to US emergency departments.
      Although not nationally representative, over 3000 emergency departments across 48 states and Washington, DC, contributed data on the number of ED visits for opioid overdoses in 2019 and 2020. The number of ED visits for opioid overdoses was higher in 2020 (N = 5075; mean = 306.9) than in 2019 (N = 3940; mean = 211.1).
      • Langabeer J.R.
      • Stotts A.L.
      • Bobrow B.J.
      • et al.
      Prevalence and charges of opioid-related visits to US emergency departments.
      State-level reports confirm those multistate trends in ED visits for opioid overdose before and after the pandemic. For example, in Kentucky, there were 1133 and 1323 opioid overdose-related medical service transports in the 52-day period before the pandemic declaration in March 2020 versus the same period after, respectively, a 17% increase.
      • Slavova S.
      • Rock P.
      • Bush H.M.
      • Quesinberry D.
      • Walsh S.L.
      Signal of increased opioid overdose during COVID-19 from emergency medical services data.
      Also recorded were 12 versus 18 emergency medical service runs for suspected opioid overdose with death at the scene pre- versus intra-COVID-19, respectively, a 50% increase in fatal opioid overdose.
      • Slavova S.
      • Rock P.
      • Bush H.M.
      • Quesinberry D.
      • Walsh S.L.
      Signal of increased opioid overdose during COVID-19 from emergency medical services data.
      A reasonable speculation is that as the COVID-19 pandemic continues, there likely will be an increase in fatal opioid overdoses, and more ED use by persons with opioid use. As such, there is an opportunity for emergency departments to address the needs of persons presenting after an opioid overdose and provide universal screening to identify persons who may be at risk because of opioid use, those who exhibit opioid withdrawal while in the emergency department, and those with a suspected or actual opioid use disorder.
      The World Health Organization

      Opioid overdose. World Health Organization. Published August 4, 2021. Accessed December 1, 2021. https://www.who.int/news-room/fact-sheets/detail/opioid-overdose

      and US Surgeon General

      U.S. Surgeon General’s advisory on naloxone and opioid overdose. U.S. Department of Health & Human Services. Published August 2, 2018. Accessed December 1, 2021. https://www.hhs.gov/surgeongeneral/priorities/opioids-and-addiction/naloxone-advisory/index.html

      recommend prescribing or dispensing naloxone for persons who are at risk for opioid overdose. Among patients presenting to a US urban emergency department in March 1 to June 30, 2019 compared with those presenting during the early months of the COVID-19 pandemic (March to June 2020), the number of nonfatal overdose visits increased from 102 in 2019 to 227 in 2020; yet there was only a 2% change in patients receiving a naloxone prescription from 2019 to 2020 (54% in 2019 and 56% in 2020).
      • Ochalek T.A.
      • Cumpston K.L.
      • Wills B.K.
      • Gal T.S.
      • Moeller F.G.
      Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic.
      Rates of receipt of treatment resources (ie, telephone numbers and addresses of community treatment providers) or referral to treatment were slightly higher for the 2020 period (68%) than in 2019 (44%).
      • Ochalek T.A.
      • Cumpston K.L.
      • Wills B.K.
      • Gal T.S.
      • Moeller F.G.
      Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic.
      A comprehensive discharge plan should include naloxone access for persons at risk for opioid overdose and linkage to specialty treatment providers in the community.
      Efforts to increase treatment access for persons with opioid use disorder are critically needed, given the estimated 1 million individuals who go untreated annually.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      The emergency department is a prime point of contact for persons detected to be at risk because of opioid use, persons in opioid withdrawal, those surviving an opioid overdose, and persons with a suspected or confirmed opioid use disorder. This review was guided by the following question:Among persons presenting to the emergency department who may be taking opioids (eg, heroin, fentaNYL, opioids not prescribed to them), persons surviving an opioid overdose, those in withdrawal from opioids, and those with a suspected or confirmed opioid use disorder, what are evidence-based approaches and treatments that can be provided in the emergency department, and what are the outcomes?
      The purpose of this review is to provide emergency nurses with the evidence for a variety of opioid-care strategies that can be implemented to address the needs of this population. Best practice recommendations are provided to guide emergency nurses to act, lead practice change, and initiate evidence-based purposeful interventions for improved care in this highly stigmatized, often undertreated population.

      Methods

      The integrative review method is an approach that allows for the inclusion of experimental research and has the potential to play a greater role in evidence-based practice for nursing.
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.
      Completion of all stages of this proposed methodology, with attention to the issues specific to undertaking an integrative review, has the potential to strengthen the process and the outcomes of integrative reviews. The following stages were followed to promote the rigor of this integrative review.

       Problem Identification Stage

      A clear problem identification and review purpose are essential to provide focus and boundaries for the integrative review process.
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.
      The crisis related to opioid use and the emergency department as a primary portal for treatment led to the clinical question for this integrative review.

       Literature Search Stage

      A health sciences librarian was instrumental in developing the search strategy to ensure a comprehensive search. The search employed Medical Subject Headings terminology, truncations, and Boolean operators as applicable for the following databases: PubMed, Cumulative Index of Nursing and Allied Health Literature, and PsycINFO. The search dates spanned a decade, beginning with 2011 to capture any studies conducted before the landmark trial of ED-initiated buprenorphine treatment by D’Onofrio et al.
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      Key terms included opioid-related disorders, emergency service, hospital, delivery of health care, and model. Inclusion criteria were as follows: peer reviewed articles written in English that included adults in the ED setting and that studied interventions for persons with opioid use, opioid overdose, opioid withdrawal, or opioid use disorder. Excluded were articles that focused on substances other than opioids, settings other than emergency department, nonresearch, and samples focused on youth/children. The search strategy is provided in the Online Supplement.
      Citations were imported into Covidence,

      Covidence. Better systematic review management. Accessed December 1, 2021. www.covidence.org

      allowing the members of the team to work together on the project in real time. A total of 12 publications met the inclusion criteria. The Figure depicts the search results based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

      Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. https://doi.org/10.1136/bmj.n71

      Figure thumbnail gr1
      FigurePRISMA flow diagram. Recommendations for emergency departments caring for persons with opioid use and opioid use disorders: an integrative review. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

      Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. https://doi.org/10.1136/bmj.n71

       Data Analysis Stage

      A thorough and unbiased interpretation of primary sources is critical for the data analysis stage.
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.
      The empirical reports were evaluated using the Johns Hopkins Nursing Evidence-Based Practice Guidelines framework through which evidence was appraised and leveled. In accord with the framework, Level I evidence included studies that employed a classic experimental design/randomized control trial (RCT); an explanatory mixed-methods study that employed an RCT; or any systematic review, with or without meta-analysis, of experimental studies/RCTs. Level II evidence included studies that employed a quasi-experimental design; an explanatory mixed-methods study that employed a quasi-experimental design; or a systematic review of a combination of RCTs and quasi-experimental studies, or only quasi-experimental studies, with or without a meta-analysis. Level III evidence included nonexperimental studies; a systematic review of a combination of RCTs, quasi-experiment, and nonexperimental studies, or nonexperimental studies only, with or without meta-analysis; exploratory, convergent, or multiphasic mixed-methods studies; explanatory mixed-methods design that includes only a Level III quantitative study; qualitative studies; or metasynthesis. Level IV evidence included opinions of respected/nationally recognized expert committees/consensus panels based on scientific evidence (clinical practice guidelines, consensus panels/position statements). Level V evidence included experiential and nonresearch work, such as integrative reviews; literature reviews; quality improvement, program, or financial evaluation; case reports; or opinions of nationally recognized expert(s) based on experiential evidence.
      • Dang D.
      • Dearholt S.
      • Bissett K.
      • Ascenzi J.
      • Whalen M.
      Each team member extracted data (ie, study design, level and grade of evidence, sample, setting, measures, outcomes) from their assigned publications into matrices. Each matrix was reviewed by a second team member, and any revisions and additions were resolved in discussion with the primary reviewer. A further goal of the data analysis stage is the synthesis of the evidence.
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.
      Thus, the final step of this integrative review was the synthesis of important elements into an integrated summation of recommendations for care of the population in emergency departments.

       Presentation Stage

      The results of the integrative review capture the depth and breadth of the topic and contribute to a new understanding of the phenomenon of concern and implications for practice are emphasized.
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.
      This integrative review took into account the various scenarios of a patient being treated in the emergency department—from opioid use that puts the person at risk to persons with a suspected or confirmed opioid use disorder.

      Results

      Twelve studies were included in the review. On the basis of the Johns Hopkins Nursing Evidence-Based Practice Guidelines,
      • Dang D.
      • Dearholt S.
      • Bissett K.
      • Ascenzi J.
      • Whalen M.
      the majority of studies were Level III and only one study was a Level I. Sample sizes ranged from 18 to 2382. Across the studies reporting demographics, the samples were predominantly male, White, and for studies that reported age, participants were in their 30th year of life. Table 1 provides a summary of the studies organized in accord with each component of the continuum of care beginning with methods for screening for opioid use, assessment for opioid withdrawal and opioid overdose, and determination of opioid use disorder; approaches for a brief intervention; opioid agonist-antagonist medication provided; sources for referral to treatment; and outcomes related to follow-up monitoring. Table 2 provides an overview of medications included in this set of studies. More detailed information about those medications can be found in the Treatment Improvement Protocol from the Substance Abuse and Mental Health Services Administration.

      Substance Abuse and Mental Health Services Administration. Medications for opioid use disorder for healthcare and addiction professionals, policymakers, patients, and families. Published 2021. Accessed December 1, 2021. https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP21-02-01-002.pdf

      Provided below is a summary of the continuum of care components based on the studies included in this integrative review.
      Table 1Summary of articles included in the review
      First authorDesign, purpose, level of evidenceSampleScreening/AssessmentBrief interventionMedication/prescriberReferral to treatmentFollow-up outcomes
      Bogan
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      Retrospective cohort study

      Provide initial outcomes for 3 EDs in South Carolina for SBIRT + opioid agonist treatment

      Level III

      Grade B
      n = 727 (n = 241 buprenorphine eligible)

      Demographics:

      not reported
      Opioid use:

      “In the last 12 months have you smoked marijuana, used another street drug or used a prescription pain killer, stimulant, or sedative for non-medical reasons?”

      Opioid withdrawal:

      COWS
      COWS scores ranging from 5 to 12 = mild, 13 to 24= moderate, 25-26=moderately severe, > 36 = severe.
      >8
      Motivational interviewing

      Assessment of readiness to change

      Goal: encourage reduction or quitting use and engagement in treatment
      Buprenorphine/naloxone 8-2 mg or Buprenorphine sublingual 8 mg

      Physician with X-waiver or under 3-d rule

      Naloxone kit
      Area treatment providers (8-30 miles from ED)Initial intake:

      78% (187/241)

      Naloxone distribution:

      209 of those with OUD
      Devries
      • Devries J.
      • Rafie S.
      • Ajayi T.A.
      • Kreshak A.
      • Edmonds K.P.
      Results of a naloxone screening quality-improvement project in an academic emergency department.
      Retrospective cohort study

      To assess whether any of 6 screening questions predicted naloxone prescriptions

      Level III

      Grade B
      n = 182

      Demographics: not reported
      Opioid use and Opioid Overdose: Documentation of opioid prescription, OUD, current or past opioid use or history of opioid overdoseEducation related to (1) preventing opioid-related overdose, (2) recognizing an opioid-related overdose, and (3) using naloxone should respiratory depression occurNaloxone prescription (IM with syringe, intranasal, autoinjector)Referred to pharmacy to obtain medicationProportion treated:

      31.9% (58/182) were recommended by MD to receive naloxone

      Naloxone acceptance:

      62.1% (36/58)
      D’Onofrio
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      RCT

      Test efficacy of 3 interventions for persons with OUD

      Level I

      Grade A
      n = 104; RT (S and referral)

      n = 111 BI (S, BI, RT to community-based treatment)

      n = 114 Buprenorphine (S, BI, ED-initiated treatment, RT primary care)

      Demographics (n = 329)

      Male: 76.3%

      White: 75.4%

      Age: 31.4 (SD 10.6)

      Opioid overdose: 8.8%
      OUD:

      Mini-International Neuropsychiatic Interview score ≥ 3 with positive toxicology for opiates or oxyCODONE

      Opioid withdrawal:

      COWS- moderate to severe withdrawal
      COWS scores ranging from 5 to 12 = mild, 13 to 24= moderate, 25-26=moderately severe, > 36 = severe.
      Brief Negotiated Interview 10-15 minute conversation based on structured framework. Tailored based on patient insurance, residence, and preference.Buprenorphine/naloxone (dosage not reported)

      Home induction dosage: 8 mg on day 1, 16 mg on days 2 and 3)

      All physicians held X- waiver
      Area treatment providers for those not receiving buprenorphine

      Buprenorphine group – 10 wk in office-based clinic per research protocol then referred for ongoing care to community provider
      Initial intake (30-d post randomization):

      Buprenorphine group: 78% (89/114)

      BI group:

      45% (50/111)

      RT group:

      37% (38/102):

      Opioid use in past 7 d:

      Buprenorphine group: 5.4 to 0.9 days (93/114)

      BI group: 5.6 to 2.4 d (93/111)

      RT group:

      5.4 to 2.3 d (69/104):
      Dunkley
      • Dunkley C.A.
      • Carpenter J.E.
      • Murray B.P.
      • et al.
      Retrospective review of a novel approach to buprenorphine induction in the emergency department.
      Retrospective cohort study

      Describe management of persons with OUD

      Level III

      Grade C
      n = 18 (19 data points as 1 patient presented twice)

      Demographics:

      Male: 74%

      Race: not reported

      Age: 36 (IQR 29-52)

      Opioid overdose: 26%
      OUD: diagnosis based on DSM documented by Medical Toxicology Fellow

      Opioid withdrawal:

      COWS ≥ 10
      Education:

      After assessing for withdrawal, Medical Toxicology Fellow provides information about buprenorphine, the opioid antagonist treatment clinic, and alterative treatment options.
      Buprenorphine/naloxone (2 mg-0.5 mg)

      Prescribers with X-waiver
      Referral to hospital associated opioid antagonist treatment clinicInitial intake:

      64% (12/19)
      Dwyer
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      Retrospective cohort study

      Post discharge survey assessing overdose risk

      Level III

      Grade B
      n = 415

      Demographics:

      Male: 73%

      Age: 36 (SD 10.6)

      White: 62%
      Opioid use: self-reported use in the past 30 d

      Opioid overdose: self-reported overdose since discharge from ED
      Education r/t opioids provided by ED-based LDAC.

      Content included:
      • overdose risks
      • how to recognize and respond to a witnessed overdose
      Naloxone kit 2 atomized 2 mg vials

      Receipt depended on LDAC availability and patient preference.

      13.5% (56/415) received naloxone kit
      Not includedSurvey completion rate:

      12% (51/415)

      Past 30-d use: 35%

      Survived OD: 22%

      Witnessed OD: 52.9%
      • Called 911: 63%
      • Rescue breathing: 26%
      • Administered naloxone: 22%
      • Stayed with: 93%
      Edwards
      • Edwards F.J.
      • Wicelinski R.
      • Gallagher N.
      • McKinzie A.
      • White R.
      • Domingos A.
      Treating opioid withdrawal with buprenorphine in a community hospital emergency department: an outreach program.
      Prospective cohort study

      Describe outcomes for ED-based buprenorphine administration.

      Level III

      Grade C
      n = 62

      Demographics:

      Male: 45%

      Race: not reported

      Age: 34 (median)
      Opioid withdrawal:

      COWS ≥5
      Not addressedBuprenorphine / naloxone 4 mg

      85% (53/62) met criteria for buprenorphine induction in ED

      Physician administered (not specified if X-waiver or 3-day rule)
      Agreement with local clinic to reserve 80 intake appointments. Staff scheduled appointment during open hours (M-F, 9 am to 5 pm) or, if closed, directed patient to present the next morning.Initial intake:

      81% (50/62)
      Hu
      • Hu T.
      • Snider-Adler M.
      • Nijmeh L.
      • Pyle A.
      Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.
      Retrospective cohort study

      Determine retention in treatment after ED-initiated buprenorphine

      Level III

      Quality C
      n = 49

      Demographics:

      Male: 57%

      Race: not reported

      Age: 37 (SD 12.3)
      Opioid withdrawal:

      COWS >5
      Educational materials:
      • Information on withdrawal symptoms
      • Options for managing withdrawal
      • Contact information for outpatient clinics and case management programs
      Buprenorphine 2 to 4 mg sublingually

      88% (43/49) induced in ED

      Buprenorphine prescription provided with up to 3 daily observed doses (Canadian pharmacy)
      ED staff advised patient to go next day to rapid access treatment clinic accessible in communityInitial intake:

      54% (23/43)
      Kaucher
      • Kaucher K.A.
      • Caruso E.H.
      • Sungar G.
      • et al.
      Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program.
      Retrospective cohort study

      Opioid withdrawal

      Evaluate outcomes following ED-initiated buprenorphine

      Level III

      Quality B
      n = 219

      Demographics:

      Male: 56.2%

      White: 86%

      Age: 35 (SD 10.3)
      Opioid withdrawal:

      COWS 6 to 12 (Buprenorphine SL 2-4 mg)

      COWS ≥ 13 (Buprenorphine SL 4-6 mg)
      Not includedBuprenorphine sublingual 2 mg up to 6 mg initial dose

      Physician assistants or nurse practitioners (X-waivered) conducted 58% of inductions.

      Narcan Rescue Kit
      Opioid agonist treatment clinic, located on health center campus, served as “Hub” in “Hub-and-Spoke” model. If X-waivered prescribe Buprenorphine 16 mg maximum if >24 h delay in intakeInitial intake:

      74%
      Kelly
      • Kelly T.
      • Hoppe J.A.
      • Zuckerman M.
      • Khoshnoud A.
      • Sholl B.
      • Heard K.
      A novel social work approach to emergency department buprenorphine induction and warm hand-off to community providers.
      Retrospective cohort study

      Evaluate protocol driven treatment with warm handoff.

      Level III

      Quality B
      n = 120

      Demographics:

      Male: 62.5%

      White: 69.1%

      Non-Hispanic: 77.5%

      Age: not reported
      Opioid use:

      “How often in the past 3 months have you used an illegal drug or use a prescription medication for non-medical reasons?” query by RN.

      Provider documentation of cellulitis or abscess.

      OUD:

      2 or more criteria met with DSM 5 OUD Checklist completed by social worker.

      Opioid withdrawal:

      COWS (by RN) ≥8
      Motivational interviewing techniques used by social worker with assessment readiness/stage of change.Suboxone 4 mg

      Suboxone provided when provider was available (7 AM-11 AM each day of wk)

      Buprenorphine prescription provided to bridge to intake appointment
      ED social worker worked with community clinics to determine most appropriate, then discussed with patient to schedule follow-up appointment (ie, warm handoff). Call back number for social worker was provided to patient in event further assistance was needed.Initial intake:

      61% (70/120)
      McLane
      • McLane P.
      • Scott K.
      • Suleman Z.
      • et al.
      Multi-site intervention to improve emergency department care for patients who live with opioid use disorder: a quantitative evaluation.
      Quality improvement

      To evaluate change in buprenorphine initiation rates over time when processes are put in place to increase uptake.

      Level V

      Quality B
      n = 427 (n = 51 received buprenorphine)

      Demographics n = 51 receiving buprenorphine):

      Male: 48.9%

      Race: not reported

      Age (median): 34 (21-66)
      Opioid withdrawal:

      COWS ≥ 12 (buprenorphine eligible)

      COWS < 12 (home induction eligible)
      Not includedBuprenorphine/naloxone (dose not specified)

      Naloxone kit
      Participating clinicsInitial intake:

      43% (16/37)

      Filled prescription after first ED visit:

      74.4% (35/47)
      Monico
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      Retrospective cohort study

      To examine the scalability of SBIRT across 23 hospital EDs

      Level III

      Quality A
      n = 950 with opioid withdrawal

      Demographics:

      not reported
      Opioid use:

      “In the last 12 months have you smoked marijuana, used another street drug or used a prescription pain killer, stimulant, or sedative for a non-medical reason?”

      Opioid withdrawal:

      COWS ≥ 7

      Opioid overdose:

      Unable to conduct screening due to altered mental state
      Motivational interviewing based BI including assessing for motivation for treatment (trained by experts)Buprenorphine/naloxone 8 mg sublingual

      Naloxone kit
      Established rapid referral network in which programs would accept ED patients within 24 h of dischargeInitial intake:

      Buprenorphine administered:

      64.6% (430/630)

      Opioid overdose:

      74.2% (244/329)
      Samuels
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.
      Retrospective cohort study

      To determine practice changes from pre- to post-implementation of LOOP program

      Level III

      Quality A
      n = 555

      Demographics:

      Male: 63.6%

      White: 82%

      Age:
      • 18-29: 40%
      • 30-50: 43.4%
      • 51+: 16.6%
      Opioid use:

      Documentation of diagnosis in medical record

      Opioid overdose:

      Opioid use resulting in decreased mental status or respiratory depression necessitating the use of naloxone before or during the ED visit
      Education

      Pictorial and verbal instructions on assembly of naloxone for administration and administration instructions in English and Spanish
      Naloxone kit: two doses of 2 mg intranasal naloxone, a mucosal atomizer device, and instructionsDocumentation of one or both:
      • discussion with an outpatient treatment provider
      • specific treatment program follow-up details
      Naloxone distribution:

      Total sample (n = 555): increased from none to 35.4%. (P < .001)

      Admitted with OD (n = 249): increased from none to 56.5%

      Received peer recovery coach consult when available:

      Total sample (n-555): 33.1%

      Admitted with OD (n = 249): 49.1%

      RT:

      Total sample (n = 555): increased from 9.16% to 20.74%. (P = .003)

      Admitted with OD (n = 249): D/C with RT increased from 1.9% to 14.9% (P = .01)
      Under the “three-day rule” a practitioner in the emergency department can administer buprenorphine for the treatment of acute opioid withdrawal without a Drug Enforcement Agency (DEA) waiver, for no more than 3 consecutive days.

      Substance Use-disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act, Pub L No. 115-271, STAT 3894, 115th Cong (2018). Accessed December 1, 2021. https://www.govinfo.gov/content/pkg/PLAW-115publ271/html/PLAW-115publ271.htm

      SBIRT, Screening, Brief Intervention, Referral to Treatment; COWS, Clinical Opioid Withdrawal Scale; OUD, opioid use disorder; MD, medical doctor; IM, intramuscular; RCT, randomized control trial; RT, Referral to Treatment; S, screening; BI, brief intervention; IQR, interquartile range; DSM, Diagnostic and Statistical Manual; LADC, licensed alcohol and drug counselors; OD, overdose; LOOP, lifespan opioid overdose prevention; D/C, discharge; RN, registered nurse.
      COWS scores ranging from 5 to 12 = mild, 13 to 24= moderate, 25-26=moderately severe, > 36 = severe.
      Table 2Medications for the treatment of OUD and opioid overdose
      MedicationIndicationDescription
      BuprenorphineTreatment for OUD
      • Partial opioid-agonist – activates mu receptors
      • Displaces morphine, methadone, and other full opioid agonists from receptors and therefore can precipitate withdrawal; thus, assessing with COWS is essential
      • Long half-life (24 to 60 h) leading to prolonged suppression of opioid withdrawal and blockade of exogenous opioids
      NaloxoneReverses the CNS effects of opioid intoxication and overdose
      • Opioid antagonist – blocks mu receptors
      • Rapid onset of action; short (approximately 4-h half-life)
      • May require higher doses when potent opioids (eg, fentaNYL) have been taken
      • Extended-release formulation is indicated for treatment of OUD; requires stopping use of any opioids for a period of 7 to 10 d before treatment initiation
      OUD, opioid use disorder; CNS, central nervous system; COWS, Clinical Opioid Withdrawal Scale.

       Screening, Assessment, And Diagnosis

       Opioid Use and Opioid Use Disorder

      Two studies described integrating a single screening question into the electronic medical record, “In the last 12 months have you smoked marijuana, used another street drug or used a prescription pain killer, stimulant, or sedative for non-medical reasons?” to identify opioid use.
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      ,
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      Kelly et al
      • Kelly T.
      • Hoppe J.A.
      • Zuckerman M.
      • Khoshnoud A.
      • Sholl B.
      • Heard K.
      A novel social work approach to emergency department buprenorphine induction and warm hand-off to community providers.
      asked, “How often in the past 3 months have you used an illegal drug or used a prescription medication for non-medical reasons?” while others relied on documentation in the electronic medical record on self-reported use in the past 30 days,
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      an opioid diagnosis,
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.
      or documentation of cellulitis or abscess suggestive of intravenous drug use.
      • Kelly T.
      • Hoppe J.A.
      • Zuckerman M.
      • Khoshnoud A.
      • Sholl B.
      • Heard K.
      A novel social work approach to emergency department buprenorphine induction and warm hand-off to community providers.
      Opioid use disorder (OUD) diagnoses were given by a researcher,
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      physician,
      • Dunkley C.A.
      • Carpenter J.E.
      • Murray B.P.
      • et al.
      Retrospective review of a novel approach to buprenorphine induction in the emergency department.
      or licensed social worker
      • Kelly T.
      • Hoppe J.A.
      • Zuckerman M.
      • Khoshnoud A.
      • Sholl B.
      • Heard K.
      A novel social work approach to emergency department buprenorphine induction and warm hand-off to community providers.
      ; 2 studies used criteria from the Diagnostic and Statistical Manual of Mental Disorders
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
      in diagnosing OUD. Retrospective studies relied on documentation of OUD in the medical record.
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      ,
      • Dunkley C.A.
      • Carpenter J.E.
      • Murray B.P.
      • et al.
      Retrospective review of a novel approach to buprenorphine induction in the emergency department.
      ,
      • McLane P.
      • Scott K.
      • Suleman Z.
      • et al.
      Multi-site intervention to improve emergency department care for patients who live with opioid use disorder: a quantitative evaluation.

       Opioid Withdrawal

      Nine studies in which buprenorphine was administered in the emergency department measured symptom severity via the Clinical Opiate Withdrawal Scale (COWS).
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      ,
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      ,
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      ,
      • Dunkley C.A.
      • Carpenter J.E.
      • Murray B.P.
      • et al.
      Retrospective review of a novel approach to buprenorphine induction in the emergency department.
      ,
      • McLane P.
      • Scott K.
      • Suleman Z.
      • et al.
      Multi-site intervention to improve emergency department care for patients who live with opioid use disorder: a quantitative evaluation.
      • Edwards F.J.
      • Wicelinski R.
      • Gallagher N.
      • McKinzie A.
      • White R.
      • Domingos A.
      Treating opioid withdrawal with buprenorphine in a community hospital emergency department: an outreach program.
      • Hu T.
      • Snider-Adler M.
      • Nijmeh L.
      • Pyle A.
      Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.
      • Kaucher K.A.
      • Caruso E.H.
      • Sungar G.
      • et al.
      Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program.
      COWS cut scores for buprenorphine induction ranged from ≥5
      • Edwards F.J.
      • Wicelinski R.
      • Gallagher N.
      • McKinzie A.
      • White R.
      • Domingos A.
      Treating opioid withdrawal with buprenorphine in a community hospital emergency department: an outreach program.
      ,
      • Hu T.
      • Snider-Adler M.
      • Nijmeh L.
      • Pyle A.
      Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.
      to a score of ≥36 corresponding to severe opioid withdrawal.
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.

       Opioid Overdose

      Studies focusing on opioid overdose included patients with a documented history of opioid overdose
      • Devries J.
      • Rafie S.
      • Ajayi T.A.
      • Kreshak A.
      • Edmonds K.P.
      Results of a naloxone screening quality-improvement project in an academic emergency department.
      or those with a self-report of overdose since previous ED discharge.
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      Others assessed opioid overdose on the basis of the inability to conduct screening because of altered mental state
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      and decreased mental status or respiratory depression necessitating the use of naloxone before or during the ED visit.
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.

       Brief Intervention and Education

      Motivational interviewing, assessment of readiness to change, and level of motivation were components of the brief intervention (BI).
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      ,
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      • Kelly T.
      • Hoppe J.A.
      • Zuckerman M.
      • Khoshnoud A.
      • Sholl B.
      • Heard K.
      A novel social work approach to emergency department buprenorphine induction and warm hand-off to community providers.
      D’Onofrio et al
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      provided the most detailed description of BI and cited the manual and associated materials that were used to deliver it. The BI delivered in D’Onofrio et al
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      was a structured 10- to 15-minute conversation. Their BI also focused on suggested treatment options based on insurance coverage, residence, and preferences.
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      Educational interventions focused on opioid overdose prevention, including use of naloxone,
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      ,
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.
      ,
      • Devries J.
      • Rafie S.
      • Ajayi T.A.
      • Kreshak A.
      • Edmonds K.P.
      Results of a naloxone screening quality-improvement project in an academic emergency department.
      or on buprenorphine.
      • Dunkley C.A.
      • Carpenter J.E.
      • Murray B.P.
      • et al.
      Retrospective review of a novel approach to buprenorphine induction in the emergency department.
      ,
      • Hu T.
      • Snider-Adler M.
      • Nijmeh L.
      • Pyle A.
      Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.
      Dwyer et al
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      employed ED-based licensed alcohol and drug counselors to deliver a 5-minute overdose educational intervention, composed of overdose risks, how to recognize and respond to a witnessed overdose by calling 911, delivering rescue breaths, and staying with the individual until the emergency response team arrived.
      • Kelly T.
      • Hoppe J.A.
      • Zuckerman M.
      • Khoshnoud A.
      • Sholl B.
      • Heard K.
      A novel social work approach to emergency department buprenorphine induction and warm hand-off to community providers.
      Of the 415 people who underwent overdose education, 56 (13%) received a naloxone kit with verbal and written instructions for its use, as well as the telephone numbers for poison control and the hospital pharmacy.
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      Samuels et al
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.
      provided naloxone kits and used a video to educate participants on overdose prevention, response, and naloxone administration for overdose reversal; bilingual printed instructions were included with the naloxone kit. With a focus on buprenorphine, Hu et al
      • Hu T.
      • Snider-Adler M.
      • Nijmeh L.
      • Pyle A.
      Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.
      provided print educational materials explaining opioid withdrawal symptoms, options for managing withdrawal, and contact information for outpatient clinics and case management programs.

       Buprenorphine Induction

      Buprenorphine induction dosages ranged from 2 mg
      • Hu T.
      • Snider-Adler M.
      • Nijmeh L.
      • Pyle A.
      Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.
      ,
      • Kaucher K.A.
      • Caruso E.H.
      • Sungar G.
      • et al.
      Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program.
      to 8 mg
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      ,
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      ,
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      and varied across studies in response to a participant’s COWS score. For example, participants whose COWS score was greater than 5 received 2 mg buprenorphine,
      • Hu T.
      • Snider-Adler M.
      • Nijmeh L.
      • Pyle A.
      Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.
      whereas Kaucher et al
      • Kaucher K.A.
      • Caruso E.H.
      • Sungar G.
      • et al.
      Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program.
      used a COWS cut score of 6 to 12. Most buprenorphine prescribers were physicians; 2 studies
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      ,
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      ,
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      reported that these providers were federally waivered to prescribe buprenorphine. The only study reporting specific details about the provider involved in the induction was by Kaucher et al,
      • Kaucher K.A.
      • Caruso E.H.
      • Sungar G.
      • et al.
      Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program.
      who reported that advanced practice providers conducted most of the buprenorphine induction (58%).

       Naloxone Prescription

      Four studies in which naloxone was provided at discharge from the emergency department reported that it was either prescribed
      • Devries J.
      • Rafie S.
      • Ajayi T.A.
      • Kreshak A.
      • Edmonds K.P.
      Results of a naloxone screening quality-improvement project in an academic emergency department.
      or freely provided.
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      ,
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.
      The contents of the naloxone kits varied and included either 2 mg naloxone vials
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      or 2 doses of 2 mg of intranasal naloxone, a mucosal atomizer device, and pictorial with written assembly and administration instructions in English and Spanish.
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.

       Referral to Treatment

      Referral to treatment was used as a stand-alone intervention or to augment ED buprenorphine induction. D’Onofrio et al
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      employed a stepped approach to care. That is, participants assigned to ED buprenorphine induction underwent 10 weeks of protocol treatment then community-based ongoing treatment; those assigned to the screening and referral to treatment arm were provided a handout that listed addiction treatment services of varied intensity and duration that included their names and contact information and were categorized according to the participating insurance plans. Participants in the screening, BI, and referral to treatment arm of the study were directly linked with the referral, considering participant’s eligibility for services, ensuring insurance clearance, and arranging transportation.
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      Other studies employed continuity of care approaches after ED buprenorphine induction. Dunkley et al
      • Dunkley C.A.
      • Carpenter J.E.
      • Murray B.P.
      • et al.
      Retrospective review of a novel approach to buprenorphine induction in the emergency department.
      provided follow-up treatment at the hospital’s associated clinic, in which the providers who evaluated study participants in the emergency department were those who provided care in the clinic. Kaucher et al
      • Kaucher K.A.
      • Caruso E.H.
      • Sungar G.
      • et al.
      Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program.
      employed a hub-and-spoke model in which the emergency department and the health center’s outpatient center served as the hub, and the community health providers were the poststabilization spokes. Others relied on community resources, such as the rapid access outpatient community-based clinics for participants
      • Hu T.
      • Snider-Adler M.
      • Nijmeh L.
      • Pyle A.
      Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.
      and bridge-building or established relationships with community clinics.
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      • Kelly T.
      • Hoppe J.A.
      • Zuckerman M.
      • Khoshnoud A.
      • Sholl B.
      • Heard K.
      A novel social work approach to emergency department buprenorphine induction and warm hand-off to community providers.
      ,
      • McLane P.
      • Scott K.
      • Suleman Z.
      • et al.
      Multi-site intervention to improve emergency department care for patients who live with opioid use disorder: a quantitative evaluation.

       Follow-Up Buprenorphine-Focused Studies

       Initial Appointment

      Participant follow-up with the first appointment after ED or home-based buprenorphine induction ranged from 53.4%
      • Hu T.
      • Snider-Adler M.
      • Nijmeh L.
      • Pyle A.
      Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.
      to 81%.
      • Edwards F.J.
      • Wicelinski R.
      • Gallagher N.
      • McKinzie A.
      • White R.
      • Domingos A.
      Treating opioid withdrawal with buprenorphine in a community hospital emergency department: an outreach program.
      Participants referred to their hospital’s associated clinic
      • Dunkley C.A.
      • Carpenter J.E.
      • Murray B.P.
      • et al.
      Retrospective review of a novel approach to buprenorphine induction in the emergency department.
      ,
      • Kaucher K.A.
      • Caruso E.H.
      • Sungar G.
      • et al.
      Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program.
      reported that 63% and 74% attended their initial appointment, respectively. Provider-facilitated referral to treatment reported rates for keeping the initial appointment of 77.5%,
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      61%,
      • Kelly T.
      • Hoppe J.A.
      • Zuckerman M.
      • Khoshnoud A.
      • Sholl B.
      • Heard K.
      A novel social work approach to emergency department buprenorphine induction and warm hand-off to community providers.
      and 64.4%.
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      Among studies in which community treatment referral was accomplished without active involvement, rates for attending the initial appointment were 81%
      • Edwards F.J.
      • Wicelinski R.
      • Gallagher N.
      • McKinzie A.
      • White R.
      • Domingos A.
      Treating opioid withdrawal with buprenorphine in a community hospital emergency department: an outreach program.
      and 53.4%.
      • Hu T.
      • Snider-Adler M.
      • Nijmeh L.
      • Pyle A.
      Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.

       Opioid Use

      Using self-reported data for opioid use in the past 7 days and urine toxicology testing, D’Onofrio et al
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      obtained data for 244 of 329 patients (74%), representative of all 3 study arms: buprenorphine group, brief intervention group, and referral group. Although participants in all 3 study arms reported reduced opioid use, there were statistically significant between-group differences and group-by-time interactions. The buprenorphine group (n = 93 of 114) reported greater reductions in the mean number of days of illicit opioid use per week, from 5.4 days to 0.9 days than the referral group (n = 69 of 104) from 5.4 days to 2.3 days or the BI group (n = 93 of 114) from 5.6 days to 2.4 days.
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      In addition, of 339 participants, 220 (66.9%) provided a urine sample for toxicology. There were no significant differences in rates of opioid-negative test results, with 57.6%, 42.9%, and 53.8% opioid-negative urine tests reported for the buprenorphine, the BI, and the referral study arms, respectively.
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.

       Naloxone Education and/or Prescription/Kit Distribution

       Distribution Rates

      Rates of naloxone distribution varied from a low of 13.5%,
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      to 35.4%,
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.
      to a high of 62.1%.
      • Devries J.
      • Rafie S.
      • Ajayi T.A.
      • Kreshak A.
      • Edmonds K.P.
      Results of a naloxone screening quality-improvement project in an academic emergency department.
      Of 58 participants, 22 (37%) declined the offered naloxone prescription
      • Devries J.
      • Rafie S.
      • Ajayi T.A.
      • Kreshak A.
      • Edmonds K.P.
      Results of a naloxone screening quality-improvement project in an academic emergency department.
      ; among those participants who accepted naloxone, only 32.8% received a prescription at discharge.

       Knowledge Retention, Opioid Use, Overdose Response

      Dwyer et al
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      explored sustained overdose risk knowledge, opioid use, and overdose response for 51 respondents at 30-day follow-up. With respect to overdose risk, 73% identified the risk of mixing opioids with other substances, 31% identified risks related to opioid use after periods of abstinence, 22% identified the risk of using drugs alone, and 4% identified higher risk when chronic medical conditions were present.
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      Among these participants, 35% endorsed drug use, 22% reported opioid overdose survival, and 53% endorsed witnessing an overdose.
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.
      Among the 27 participants who witnessed an overdose, 93% stayed with the victim, 63% called 911, 26% performed rescue breathing, and 22% administered nasal naloxone. There was a trend for participants with those who received naloxone compared which those who received opioid overdose education to endorse overdose support interventions, but the difference was not significant.
      • Dwyer K.
      • Walley A.Y.
      • Langlois B.K.
      • et al.
      Opioid education and nasal naloxone rescue kits in the emergency department.

       Peer Recovery Support Services

      Across the set of studies, the peer recovery coach (PRC) worked directly with the person who could benefit from intervention, treatment, and recovery support. Whether employed by the emergency department
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      or hired by a partnering treatment program,
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      ,
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.
      the PRC was an integral member of the health care team, Table 3 provides the requirements for the PRC position and their responsibilities across the set of studies.
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      ,
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      ,
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.
      Table 3PRC: Requirements and responsibilities
      First authorRequirementsResponsibilities
      Bogan
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      • Hired and supervised by local treatment program
      • Majority with 3-y of recovery
      • General Equivalency Diploma
      • Screening
      • BI
      • Assess readiness for Buprenorphine
      • Referral to treatment
      Monico
      • Monico L.B.
      • Oros M.
      • Smith S.
      • Mitchell S.G.
      • Gryczynski J.
      • Schwartz R.
      One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.
      At least 3 PRCs in each emergency department
      • Respond to alert to see patient
      • For suspected opioid overdose: provide timely interventions focused on rapid harm reduction education, provision of naloxone kit, recording patient locator and contact information, refer to community PRC who would follow up in next day or 2 to offer additional support
      • Use motivational interviewing in delivering BI
      • Assess treatment motivation
      • Develop plan with patient
      • Make referral arrangements
      • Obtain consent to contact treatment program to confirm attendance
      • Contact provider to confirm follow-up
      • Document in electronic health record whether appointment was kept
      • Follow up to provide support and inquire about satisfaction with linkages
      Samuels
      • Samuels E.A.
      • Baird J.
      • Yang E.S.
      • Mello M.J.
      Adoption and utilization of an emergency department naloxone distribution and peer recovery coach consultation program.
      • In addiction treatment for ≥2 y
      • Completed 36 h PRC training
      • Employed by the partnering clinic
      • Completed HIPAA training
      • Available Friday 8 PM to Monday 8 AM (due to limited funding)
      • Respond to page within 30 min
      • Provide BI
      • Identify risk factors for recurrent overdose
      • Provide teaching on use of naloxone kit
      • Provide individualized support and addiction treatment navigation at the time of and after the ED visit
      PRC, peer recovery coach; BI, Brief Intervention; HIPAA, health insurance portability and accountability act.

      Discussion

      The purpose of this review was to provide nurses with evidence specific to a variety of opioid care strategies that can be integrated into routine ED care. Care of patients affected by opioid use begins with identifying opioid use risk, followed by implementing tailored strategies including opioid agonist-antagonist treatment if indicated, referral to treatment when warranted, and follow-up opioid use monitoring when feasible. The purpose of screening for opioid use is to identify risk, and when that risk is present, there is a need for further assessment and evaluation for an opioid use disorder. Persons who screen positive for opioid risk may not necessarily meet criteria for an OUD. Thus, there are opportunities in the ED setting for preventing the progression of opioid use to an OUD. The following recommendations for emergency nurses are made on the basis of this integrative review.
      • 1.
        Screen all patients presenting to the emergency department for opioid-related risk using the single question, “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons, for instance, ‘because of the experience or feeling it causes?’ ” A response of 1 or more is considered a positive screen and, thus, triggers the need for further assessment.
      • 2.
        Assess patients with a positive screen for type and amount of opioid used, frequency and duration of use, and route of administration. Be alert to signs of opiate withdrawal. Complete the COWS when symptoms first appear and subsequently to track opioid withdrawal and effectiveness of opioid agonist treatment. The technical assistance publication from SAMHSA
        U.S. Department of Health and Human Services
        Buprenorphine: A Guide for Nurses.
        is a valuable resource for emergency nurses seeking further information about opioid withdrawal, particularly in the context of buprenorphine treatment.
      • 3.
        Assess patients who present after a suspected or confirmed opioid overdose and administer naloxone as indicated. Document information from the person or emergency responder about the number of naloxone doses administered and the elapsed time since rescued. Such information is important because multiple sequential doses of naloxone are indicative of potent synthetic opioids such as fentaNYL.
        • Moss R.B.
        • Carlo D.J.
        Higher doses of naloxone are needed in the synthetic opiod era.
        Opioid overdose risk is increased when there is a lifetime history of overdose,
        • Britton P.C.
        • Wines Jr., J.D.
        • Conner K.R.
        Non-fatal overdose in the 12 months following treatment for substance use disorders.
        and thus, it is important to assess and document any previous opioid overdose.
      • 4.
        Defer diagnosis of an OUD to the qualified evaluator on the health care team or consultant to the emergency department (ie, physician, advanced practice nurse, physician assistant, licensed social work). In the absence of a formal diagnosis, the emergency nurse may suspect an OUD when there are signs and symptoms that reflect compulsive, prolonged use of opioids without medical purpose or opioid use greatly in excess of the amount prescribed.
      • 5.
        Engage in a conversation with the patient about the recommendations and options after consulting with the health care team on the treatment plan. The emergency nurse can structure this discussion on the basis of the Brief Negotiated Interview format.
        • D’Onofrio G.
        • Pantalon M.V.
        • Degutis L.C.
        • Larkin G.L.
        • O’Connor P.G.
        • Fiellin D.
        BNI Training Manual: Opioid Dependent Patients in the Emergency Department.
        That is, the emergency nurse would begin by (1) raising the subject of opioid use, for example, “I’d like to talk with you about your use of oxyCODONE which is not prescribed for you.”; (2) providing feedback by reviewing the screening and assessment data and connecting opioid use and the ED visit; (3) enhancing motivation by asking the patient to identify the benefits and risks of opioid use and asking how ready they are to change their opioid use; and (4) presenting the proposed treatment plan.
      • 6.
        Provide patient education related to any opioid agonist and opioid antagonist medication provided/prescribed, symptoms of withdrawal, and how to prevent opioid overdose. This patient education can be supplemented by published written materials such as those published by Wistanley et al.
        • Winstanley E.L.
        • Mashni R.
        • Schnee S.
        • Miller N.
        • Mashni S.M.
        The development and feasibility of a pharmacy-delivered opioid intervention in the emergency department.
        Emergency nurses and advanced practice providers can advance their knowledge about OUD and medication treatment through free online courses, such as offered by the American Psychiatric Nurses Association,

        American Psychiatric Nurses Association. MAT training. Medication for addictions treatment training for nurses. Accessed December 1, 2021. https://www.apna.org/i4a/pages/index.cfm?pageid=6197

        and access a variety of educational materials at the Providers Clinical Support System website.

        Providers Clinical Support System. Education & training. Accessed December 1, 2021. https://pcssnow.org/education-training/

        In addition, the emergency nurse should also anticipate needing to educate patients who will be referred to specialty treatment about what that entails.
      • 7.
        Know which providers on the ED team or consultants can administer, prescribe, and dispense buprenorphine. A DEA X-waiver allows qualified physicians, nurse practitioners, and physician assistants to administer, dispense, and prescribe buprenorphine in any setting.

        Drug Addiction Treatment Act, HR 2634, 106th Cong (2000). Accessed December 1, 2021. https://www.congress.gov/bill/106th-congress/house-bill/2634/actions

        ,

        Substance Use-disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act, Pub L No. 115-271, STAT 3894, 115th Cong (2018). Accessed December 1, 2021. https://www.govinfo.gov/content/pkg/PLAW-115publ271/html/PLAW-115publ271.htm

        However, under the “three-day rule,” an ED practitioner can administer buprenorphine for the treatment of acute opioid withdrawal without a DEA X-waiver, up to 3 consecutive days.

        Substance Use-disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act, Pub L No. 115-271, STAT 3894, 115th Cong (2018). Accessed December 1, 2021. https://www.govinfo.gov/content/pkg/PLAW-115publ271/html/PLAW-115publ271.htm

        If a clinical protocol is not in place to guide the implementation of buprenorphine treatment, the emergency nurse can lead the process to ensure that is in effect and disseminated to all ED health care team members. Emergency nurses can encourage their physician, physician assistant, and advanced practice nurse colleagues to become buprenorphine-waivered providers, directing them to the Substance Abuse and Mental Health Services Administration website.

        Substance Abuse and Mental Health Services Administration. Become a buprenorphine waivered practitioner. Accessed December 1, 2021. https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner

      • 8.
        Implement a process for naloxone distribution for patients at high risk of overdose. That process would include ensuring that these patients are discharged with a prescription or a naloxone kit. Patient education should be provided on the indications for use, summoning emergency help, and how to acquire naloxone in the future.
      • 9.
        Engage patients in the referral to treatment process as this entails more than identification of the need for more extensive treatment. That is, advising patients to seek treatment after discharge from the emergency department does not translate into them following through with the referral.
      It is important to know what treatment resources are in the region served by the emergency department. Emergency nurses can advocate for establishing partnerships between their facility and treatment programs to improve care coordination and linkages to care. Emergency nurses can lead the development of innovative models of care, working in the emergency department and the specialty treatment setting in their facility, and evaluate outcomes of that care coordination model such as increased rates of engagement in specialty treatment after discharge from the emergency department.
      Emergency nurses can engage patients in discussing and problem-solving potential barriers to acceptance of a referral, such as insurance, transportation, job, and family responsibilities. Emergency nurses can engage with other members of the health care team, such as social workers and PRCs, to assist in removing those barriers.
      Emergency nurses can employ the warm handoff approach by engaging in communication with the prospective treatment provider and the patient. In this manner, the patient is included in the referral process, which helps reinforce the reason for the referral and allows them to correct or clarify the information exchanged.
      • 10.
        Lead quality initiatives, such as calling patients to ensure that they are being followed-up on and monitored after discharge from the emergency department. This follow-up call provides the opportunity to ask whether the patient is experiencing any symptoms, and if so, triage to the most appropriate level of care. Such interventions could prevent complications that lead to costlier care and support timely access to care in the most appropriate setting.
      • 11.
        Appeal for hiring PRCs as members of the health care team. As persons with lived experience in substance use recovery, PRCs are experientially qualified to support others who are at risk because of opioid use. The PRC whose role extends beyond the emergency department to the community is in a unique position to provide care across the treatment continuum, help link the patient to treatment, provide support for ongoing engagement in treatment, help remove structural barriers to treatment and recovery, and collect data for ongoing follow-up. In a freely accessible video https://www.youtube.com/watch?v=DcE3NJb5uD4, 4 PRCs discuss how they applied for and were hired into the position, how their experiences prepared them to help others, their ability to be credible and authentic because of that experience, their engagement with the person from the first encounter, and their advocacy and support throughout the recovery process.

        What is a peer recovery coach? YouTube page. Accessed December 1, 2021. https://www.youtube.com/watch?v=DcE3NJb5uD4&feature=youtu.be

      Implications for Emergency Clinical Care

      Emergency nurses are in key positions to lead system change. Practice changes should focus on the continuum of care for persons presenting to the emergency department with opioid use, in opioid withdrawal, or after an opioid overdose. Implementing the recommendations based on this integrative review would advance the quality of care for this population within the emergency department and extend support for the person after discharge and foster linkage to ongoing treatment.

      Conclusions

      Emergency departments are key settings in which interventions and treatments can be initiated for persons with or suspected of opioid use. All articles in this review demonstrated some aspect of the care continuum that can feasibly be provided within the emergency department. Despite variable approaches to linking individuals to community-based opioid-related treatment, the majority who were referred kept the initial appointment. As more emergency departments use SBIRT and provide opioid agonist-antagonist treatment, they will serve as exemplars for other emergency departments and ultimately lead to widespread adoption of these lifesaving measures.

      Author Disclosures

      Conflicts of interest: none to report.
      The work presented herein was supported by a grant from the Substance Abuse and Mental Health Services Administration (1 H79 TI081678-03; PI: T. Slater). All authors received federal funding support at the time this work was conducted.

      Supplementary Data

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      Biography

      Tammy Slater is an Assistant Professor and Track Coordinator, Adult-Gerontology Acute Care Nurse Practitioner Track, Johns Hopkins School of Nursing, Baltimore, MD. Twitter: @tmslaterACNP. ORCID identifier: 0000-0002-5612-1050.
      Tamar Rodney is an Assistant Professor, Track Coordinator, Post-Master’s Psychiatric Mental Health Nurse Practitioner Certificate, Johns Hopkins School of Nursing, Baltimore, MD. Twitter: @TamarRodney. ORCID identifier: https://orcid.org/0000-0002-0187-985X.
      Sharon L. Kozachik is an Associate Professor and Associate Dean for Academics, Medical University of South Carolina, College of Nursing, Charleston, SC. Twitter: @SkozResearch. ORCID identifier: https://orcid.org/0000-0002-4070-8009.
      Deborah S. Finnell is a Professor Emerita, Johns Hopkins School of Nursing, Baltimore, MD. Twitter: @dsfinnell. ORCID identifier: https://orcid.org/0000-0001-7678-96.