Opioid Withdrawal Doubles With Automated Prompt

A program encouraging emergency department clinicians to identify and treat opioid use disorder was shown to double assessment for opioid withdrawal and improve commencement of evidence-based treatment, according to a recent study from the University of Pennsylvania’s Perelman School of Medicine.

To raise clinicians’ awareness of patients with opioid use disorder and improve the possibility of patients receiving more comprehensive care in the emergency department, a triage screening question to be asked by nurses was used in conjunction with an automated nudge in the electronic health record. Aside from an increase in withdrawal assessments, the prompts were also linked to an increase in prescriptions for life-saving drugs used to treat opioid use disorder. The findings were published in the Annals of Emergency Medicine this week.

“The big picture context is that treatment with medications for opioid use disorder is highly effective, lowers mortality from overdoses by more than half, and doubles engagement with treatment after discharge from the emergency department,” said the study’s first author, Margaret Lowenstein, MD, an assistant professor of Medicine and the research director of the Penn Center for Addiction Medicine and Policy (CAMP). “Our findings indicate that the screening and prompts help clinicians to recognize patients and increasingly initiate important care for them.”

Lowenstein and senior author M. Kit Delgado, MD, an assistant professor of Emergency Medicine and director of the Penn Medicine Nudge Unit, had previously demonstrated that automation in the electronic health record alone was insufficient for identifying opioid use disorder patients. Involving nurses on the front end, advising patients in triage, proved to be a critical step in the process.

Historically, people with opioid use disorder were often discharged from emergency departments after their other pressing issues were addressed, according to Lowenstein. Patients would be given information on where to get treatment, but many would struggle to navigate the complex substance abuse treatment system on their own.

However, for many patients, the emergency room is the primary, if not the only, point of contact with medical personnel. It is now widely acknowledged as a critical opportunity to deliver lifesaving care to a large number of people.

The current study by Lowenstein and Delgado shows findings from applying this technique at three hospitals and comparing insights to two hospitals used as controls for the study. The researchers discovered that after activating the intervention, the number of individuals with opioid use disorder who were identified and screened for withdrawal increased from 26% to 48%. This increase coincided with a 12% increase in prescriptions for naloxone, an overdose-reversing nasal spray, and a 5% increase in prescriptions for buprenorphine, a medication that stabilizes opioid withdrawal, reduces cravings, and reduces the risk of death in people with opioid use disorder.

This is the latest in a series of studies undertaken by Lowenstein and Delgado to persuade emergency medicine professionals to identify opioid use disorder patients and initiate recovery-focused therapy. They previously investigated how financial incentives could improve training for prescribing buprenorphine, as well as the launch of initiatives that assist emergency physicians in prescribing buprenorphine and linking patients with recovery specialist teams.

All of these efforts aim to steer more patients toward medication-assisted opioid use disorder treatment rather than the traditional non-medication-assisted ways of treatment. In Lowenstein and Delgado’s recent study, buprenorphine numbers increased less than withdrawal assessment, but any increase can have a significant influence. For example, they discovered that screening added little time to the triage process and resulted in one additional buprenorphine prescription for every 20 individuals tested.

Earlier research found that more than half of patients who participated in an outreach program and got a buprenorphine prescription stayed on treatment for at least a month. The naloxone numbers could also make a significant difference in averting overdoses.

The electronic health record prompt is simple to adopt for any hospital wishing to urge their personnel toward improved opioid use disorder care.

Rachel McFadden, BSN, RN, CEN, a Penn emergency department nurse who is also an opioid stewardship fellow at the Penn Center for Addiction Medicine and Policy, is one of the paper’s co-authors. She and the paper’s co-authors agreed that it was critical to understand that emergency department nurses’ plates are already full and to ensure that there was enough capacity to add these triage activities to their responsibilities. McFadden stated that in focus groups used to influence the triage program, many nurses expressed a wish to identify more opioid use disorder patients who may have previously gone untreated.

“Everyone likes to know why they’re being asked to change practice, and I saw some real ‘ah-ha’ moments in nurses once they understood the downstream benefits of screening,” McFadden said. “Training also helped uncover many questions about opioid use disorder and treatment options among my peers, and these opportunities for education and engagement added considerable value to the care provided.”

Since the study, there has been a push to make it easier for those suffering from opiate addiction to obtain treatment. Earlier in 2023, the particular training required to administer buprenorphine was dropped, allowing any doctor with a Drug Enforcement Agency license—that is, any doctor who can already prescribe medications—to prescribe the medicine.

“There is a huge group now eligible to prescribe buprenorphine, which could really expand access to treatment,” Lowenstein said. “However, this can only happen if people recognize and treat opioid use disorder.” This is where our findings come into play.”

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