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The opioid epidemic has disproportionately impacted areas in the Appalachian region of the United States. Characterized by persistent Medicaid nonexpansion, higher poverty rates, and health care access challenges, populations residing in these areas of the United States have experienced higher opioid overdose death rates than those in other parts of the country. Jefferson County, Alabama, located in Southern Appalachia, has been especially affected, with overdose rates over 2 times greater than the statewide average (48.8 vs 19.9 overdoses per 10,000 persons). Emergency departments (EDs) have been recognized as a major health care source for persons with opioid use disorder (OUD). A program to initiate medications for OUD in the ED has been shown to be effective in treatment retention. Likewise, continued patient engagement in a recovery or treatment program after ED discharge has been shown to be efficient for long-term treatment success.
This protocol outlines a framework for ED-initiated medications for OUD in a resource-limited region of the United States; the study will be made possible through community partnerships with referral resources for definitive OUD care.
When a patient presents to the ED with symptoms of opioid withdrawal, nonfatal opioid overdose, or requesting opioid detoxification, clinicians will consider the diagnosis of OUD using the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) criteria. All patients meeting the diagnostic criteria for moderate to severe OUD will be further engaged and assessed for study eligibility. Recruited subjects will be evaluated for signs and symptoms of withdrawal, treated with buprenorphine-naloxone as appropriate, and given a prescription for take-home induction along with an intranasal naloxone kit. At the time of ED discharge, a peer navigator from a local substance use coordinating center will be engaged to facilitate patient referral to a regional substance abuse coordinating center for longitudinal addiction treatment.
This project is currently ongoing; it received funding in February 2019 and was approved by the institutional review board of the University of Alabama at Birmingham in June 2019. Data collection began on July 7, 2019, with a projected end date in February 2022. In total, 79 subjects have been enrolled to date. Results will be published in the summer of 2022.
ED recognition of OUD accompanied by buprenorphine-naloxone induction and referral for subsequent long-term treatment engagement have been shown to be components of an effective strategy for addressing the ongoing opioid crisis. Establishing community and local partnerships, particularly in resource-limited areas, is crucial for the continuity of addiction care and rehabilitation outcomes.
DERR1-10.2196/18734
The Appalachian region of the Eastern United States has been disproportionately affected by the opioid epidemic. In 2017, the death rate for opioid overdoses in Appalachian counties was 72% higher than that in non-Appalachian counties [
Patients with OUD often present to emergency departments (EDs) to treat opioid-related conditions, including nonfatal opioid overdose [
Similarly, although the ED has long been recognized as the health care system’s “front door,” providing critical access and referral to primary care and specialty services, it often does not translate to effective linkage to substance use disorder (SUD) treatment. In Appalachia, an insufficient supply of behavioral and public health services targeting opioid misuse contributes to higher rates of opioid misuse and mortality in the region [
The overall objective of this implementation project is to increase the number of persons with OUD who present to either of 2 academic EDs in Jefferson County to receive MOUD and community treatment referral, thereby improving OUD outcomes in this region. We will accomplish this objective by initiating buprenorphine-naloxone in the ED, activating bedside referral services, and linking patients to longitudinal addiction care.
Goals and objectives for the Emergency Department-Medication for Opioid Use Disorder Therapy Demonstration Project in Jefferson County, Alabama.
Goals for Jefferson County, Alabama | Measurable objectives |
Increase the number of clinicians with DATAa 2000 training to identify and treat patients with OUDb | Obtain DATA 2000 waiver training in at least 75% of EDc attending and licensed resident physicians by February 28, 2020. (25 UAB-EDd MDse by July 2, 2019; an additional 30 MDs by February 28, 2020). |
Develop and implement an electronic evidence-based induction and referral to treatment protocol initiated in the ED | Implement an electronic evidence-based order set to standardize OUD diagnosis, determine the need for buprenorphine induction, activate bedside referral services, and initiate outpatient MOUDf in the University and Highlands EDs by July 2, 2019. |
Operationalize the protocol to increase the number of individuals with OUD referred for MOUD | Treat and refer 272 individuals with OUD for MOUD over the 3-year project period (56 in year 1+108 in year 2+108 in year 3). |
Improve retention in care for individuals who have been diagnosed with OUD | Increase treatment completion rates by individuals with OUD throughout the program by 5%-10% each year (year 1=baseline). |
Decrease opioid overdose–related deaths | In collaboration with other community-based initiatives and public health interventions, decrease opioid overdose–related deaths in Jefferson County by 30% over 3 years. |
aDATA: Drug Addiction Treatment Act.
bOUD: opioid use disorder.
cED: emergency department.
dUAB-ED: University of Alabama at Birmingham Hospital Emergency Department.
eMD: Medicine Doctor.
fMOUD: medications for opioid use disorder.
The population for this project includes patients seeking treatment for OUD who present to either of 2 University of Alabama at Birmingham (UAB) Hospital EDs located in Jefferson County. The University Hospital ED is a tertiary care academic ED with >70,000 annual patient visits in 2018, and the Highlands Hospital ED is an urban community ED with 30,000 annual patient visits in the same year. To estimate the number of persons potentially impacted by this public health intervention, we conducted an
Baseline characteristics of emergency department patients seen for opioid overdose, opioid withdrawal, or seeking detoxification in 2018 (n=2395).
Characteristic | Value | |
Age, mean (SD) | 39.8 (12.4) | |
Male sex, n (%) | 1433 (59.83) | |
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White or Caucasian | 1860 (77.66) |
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Black or African American | 485 (20.25) |
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Other | 50 (2.09) |
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Privately insured | 380 (15.87) |
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Publicly insured (Medicare or Medicaid) | 817 (34.11) |
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Self-pay or uninsured | 1198 (50.02) |
The geographic catchment area for this initiative, Jefferson County, is the largest and most populous county in the state of Alabama, encompassing the city of Birmingham and 29 additional municipalities. Jefferson County has a total area of 1124 square miles and a population of 659,300, of which 44% are African American, 53% Caucasian, and 17% live below the federal poverty level [
Admitted patients will be excluded from this study. Variability in inpatient treatment plans and logistical inability to consistently provide a
Enrollment will occur in the ED 24 hours per day, 7 days per week. To be feasible in our context, the protocol developed by D’Onofrio et al [
It must be noted that the prescription drug monitoring program (PDMP), a statewide controlled substance prescription database, is seamlessly integrated into the EHR at UAB and is now the standard of care in our hospitals. The PDMP for each patient is visible to all providers registered with the Alabama PDMP without the need to access an external website. A review of PDMP records before initiation of MOUD is an approach recommended by a recent American College of Emergency Physicians policy statement [
To alert research staff to potential study participants, we developed a custom OUD order set in Cerner that delivers automated, real-time, electronic notifications to research personnel when activated by an emergency physician (
Custom opioid use disorder electronic health record order set.
UEDa opiate use disorder (initiated pending) | Order | ||||
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Communication order nursing |
Complete COWSb assessment |
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Communication order nursing |
Verify the patient’s contact information for follow-up purposes |
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Buprenorphine-naloxone (buprenorphine [dosed with naloxone]) |
4 mg, Tab-SLc, sublingual, every 1 hour; now, PRNd, other (see comment below regarding observation prior to second dose), 2 doses Administer 4 mg now. Observe patient for 45-60 min. If no adverse events, administer second dose |
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Buprenorphine-naloxone (buprenorphine [dosed with naloxone]) |
8 mg, Tab-SL, sublingual, once, now 0.5 mg naloxone per each 2 mg buprenorphine |
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Buprenorphine-naloxone (buprenorphine-naloxone 8 mg-2 mg sublingual tablet) |
=1 tablet, sublingual, BIDe, #14 tablets, refill 0 |
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Naloxone intranasal (take-home supply) | ||||
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Buprenorphine-naloxone (buprenorphine-naloxone 8 mg-2 mg sublingual tablet) |
=1 tablet, sublingual, BID, #20 tablets, refill 0 |
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Drugs of abuse profile (urine drug screen) |
Urine |
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Comprehensive metabolic panel |
Blood |
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Order urine pregnancy test for females aged 15-55 years |
Urine |
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Consult to social services |
Other (use special instructions); evaluate opioid use disorder, treatment, and referral in the emergency department |
aUED: university emergency department.
bCOWS: Clinical Opioid Withdrawal Scale.
cTab-SL: tablet-sublingual.
dPRN: pro re nata (as needed).
eBID: bis in die (twice daily).
Concomitantly, prompted by a nursing order in the OUD order set, the nursing staff will assess the presence and severity of opioid withdrawal symptoms using the Clinical Opioid Withdrawal Scale (COWS) [
Before buprenorphine-naloxone induction and activation of bedside referral services, patients will undergo routine medical screening and clearance consisting of a comprehensive metabolic panel, urine drug test (UDT), and a urine pregnancy test in female patients with childbearing potential. Although the only true contraindication to buprenorphine is a hypersensitivity reaction to the medication, dose modification in the setting of hepatic dysfunction will be considered. Urine drug screening will allow clinicians to detect patients who are malingering and/or seeking to divert buprenorphine-naloxone. Pregnant patients with OUD in active withdrawal or seeking addiction care receive a consultation for psychiatric addiction services in the ED. Preexisting institution-specific services offer focused monitoring and intervention for this specific population to minimize the risk of neonatal abstinence syndrome and miscarriage and optimize pregnancy outcomes [
Only buprenorphine-naloxone, which has a lower risk of diversion than methadone, will be administered by ED staff per DATA 2000 waiver training regulations [
ADMH-certified facilities that receive OUD patients are required to independently develop, maintain, and implement diversion control plans. We will also limit the duration of the buprenorphine-naloxone prescription to 10 days, with an option for a subsequent
Despite linkage support and efforts, there may be occasions when a patient fails to link to outpatient MOUD. In these circumstances, the patient may return to the ED seeking reengagement in the program and a MOUD refill. In these instances, research staff engagement can be used to identify and potentially overcome specific barriers to the initial treatment plan. Recidivism will also be monitored. However, the decision to provide a return patient with a refill prescription will be determined on an individual basis and at the discretion of the prescribing physician.
In the state of Alabama, 2 hours of opioid-specific continuing medical education are required every 2 years, which aligns with the goal of UAB-attending physicians to obtain DATA 2000 waiver training. In the months leading up to the project start date, the principal investigator provided brief presentations at monthly emergency medicine faculty meetings to describe the evidence supporting MOUD initiation in the ED—the high incidence of opioid overdose and death in Jefferson County—and advocate for the importance of a concerted initiative centered around the needs of patients with OUD. In addition, coauthors (LAW and JJH) developed 4 hours of didactic material to deliver to emergency medicine residents in a single, half-day format, including presentations, small group case discussions, simulations, and a presentation by leadership from the RRC. In an effort to encourage learner engagement and provide a general overview and introduction of the in-person didactic, we created and released a peer-reviewed podcast that is available on iTunes and Soundcloud [
The RRC is a local addiction coordinating center that facilitates intake assessment and substance abuse referral and placement for all-comers, regardless of insurance status. Following patient intake and assessment, the RRC uses local resources and networks to direct the patient to the most appropriate definitive MOUD continuing care option available. The engagement of the RRC as a local clinical referral partner in this project was a crucial initial step. Assisting individuals with substance abuse in navigating the treatment system is an RRC mission. Formalizing a referral process with the RRC as a part of this project fulfilled a critical need for our patients and helped them fulfill their vision as a valuable community resource. As described above, when an OUD patient is identified by ED staff, the RRC will be engaged by research staff to dispatch a trained peer recovery specialist to ensure a
In addition, per RRC standard practice, peer navigators will continue to facilitate the patient’s care until the patient has obtained MOUD clinic follow-up or the patient no longer wishes to be contacted by the peer navigator or is otherwise unreachable.
Letters of commitment from referral partners (see the
The GPRA of 1993, which was revised in 2010, requires SAMHSA grantees to collect and report performance data using standardized measurement tools [
Contact barriers for obtaining follow-up data have been considered. Research and CTS staff will rely heavily on MOUD support partners and referral centers, namely, the RRC and the RRC peer navigators, to ensure accurate and up-to-date contact information for enrolled patients is maintained. In addition, contact information for family and friends will also be obtained with patient consent at the time of enrollment. MOUD clinic referral partners will also collect additional contact information.
Project data will be stored in a secure REDCap (Research Electronic Data Capture) database housed on UAB-encrypted servers [
The outcomes and measurable project goals are listed in
Analysis of outcome data will include descriptive statistics, including tables that summarize quantitative data and the number of clients who complete treatment compared with those who do not. We will test for differences in a variety of demographic and socioeconomic variables, including racial and ethnic groups. Client data will be analyzed at the time of enrollment, 3 and 6 months post enrollment, and at the time of discharge from local substance abuse treatment facilities. Program outcomes will be monitored quarterly. Qualitative data will be analyzed according to the project evaluator’s procedures, as appropriate for the variable collected.
Funded in February 2019, this study is in the active enrollment and data collection phase. The UAB IRB approved it in June 2019, and data collection and enrollment began on July 7, 2019. The project end date is projected to be February 26, 2022. As of February 2019, we have enrolled 79 participants. We anticipate the results of the public health intervention to be published in the summer of 2022.
Across the United States, the opioid epidemic continues to rage, disproportionately affecting particular areas of the nation, including Appalachia. Appalachia is characterized by a high poverty rate (16.3% as compared with 14.6% nationally) and limited access to subspecialty care (42% of the Appalachian population is rural compared with 20% of the national population), and Appalachian counties have more health care costs coupled with coverage and access disparities than the rest of the United States [
These characteristics highlight the potential impact of an ED-based intervention for patients with OUD at UAB, the largest and only tertiary care academic medical center in the state of Alabama. They also highlight the necessity of collaboration and community partnerships for a public health intervention such as this to be successful. Many individuals who require addiction care comprise an underserved population with limited access to health care. Our local community partner, the RRC, coordinates care for over 1000 patients with OUD or SUD annually and refers their clients for MOUD, demonstrating an efficient model of care. The linkage of this community resource directly to OUD patients in the ED is critical to ensure continuity of care. EDs have previously served as effective venues to raise awareness of and linkage to care for similar stigmatizing and deadly conditions—specifically HIV and hepatitis C virus [
As we implement the ED-MOUD protocol, a greater number of individuals with OUD will be identified and referred to treatment, increasing the demand for MOUD. As there is a shortage of addiction providers in our region, there is an urgent need to increase the number of clinicians with DATA 2000 training who can effectively provide MAT longitudinally in collaboration with UAB addiction specialists.
An integrated hub and spoke opioid treatment network was developed in Vermont, which may be appropriate for modification and application in our region [
A recent additional grant from SAMHSA will enable the investigative team to establish a Provider Clinical Support System Data 2000 waiver training program at our institution along with a program to train primary care clinicians to deliver MOUD to patients with OUD. This program will facilitate collaboration with FQHCs in Jefferson County to provide addiction training, oversight, and consultation to expand primary care providers’ scope of practice to include MOUD. In addition, we are developing a telemedicine-assisted consultation model to support primary care providers as they deliver care to individual patients. We hope that these additional training programs and models will expand MOUD capacity in Alabama, similar to the Vermont model.
We are also exploring opening a MOUD bridge clinic at UAB to manage patients between the time of identification in the ED and linkage to longitudinal addiction treatment. Such a clinic would also provide an opportunity to incorporate multidisciplinary engagement, including medical social workers and case management services, strategically identifying and addressing patients’ social determinants of health to facilitate treatment of OUD. It will also provide a supervised venue for training physicians in the complexities of MOUD, equipping them to continue these addiction practices as they are subsequently hired throughout the state in rural communities.
Traditionally a niche reserved for psychiatrists or addiction medicine specialists, treatment of OUD with MOUD is expanding to emergency clinicians, primary care clinicians, and other health care providers. EDs are the tip of the spear where societal problems meet health care, and the intersection between the opioid epidemic and the emergency care system highlights this reality. Initiating MOUD in the ED is an evidence-based approach for improving health outcomes in OUD. Community collaboration is critical for developing a feasible, cost-effective, and sustainable approach to combat the opioid epidemic in resource-limited regions.
Emergency departments’ medications for opioid use disorder induction flowsheet.
Alabama Department of Mental Health
brief negotiation interview
Clinical Opioid Withdrawal Scale
Community Tracking Services
Drug Addiction Treatment Act
Drug Enforcement Administration
Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition)
emergency department
electronic health record
Federally Qualified Health Centers
Government Performance and Results Modernization Act
institutional review board
medication-assisted treatment
medications for opioid use disorder
opioid use disorder
prescription drug monitoring program
Recovery Resource Center
Substance Abuse and Mental Health Services Administration
substance use disorder
University of Alabama at Birmingham
urine drug test
SAMHSA provided funding for this project. The funder predefined a standardized data collection instrument as a component of the data collected according to the GPRA, but otherwise, the funder had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results.
LAW is a core research and educational faculty member and a major contributor in writing the manuscript and cocreating the emergency medicine resident OUD education module. LL is an addiction medicine specialist and ED liaison for MOUD linkage support services; she also contributed to the manuscript’s editing. JBR is an emergency research staff member and is integral in grant submission and current program and data maintenance. He also contributed to the editing of the manuscript. JJH created and codirected the emergency medicine resident OUD education module and contributed to the manuscript’s editing. RMS is the core research faculty member responsible for logistical program implementation, and she contributed to the writing and editing of the manuscript. MCD is a core educational faculty member and created the podcast for the emergency medicine resident OUD educational module. JB provided patient demographic data and assisted in the creation of the custom ED EHR opioid order set. EPH is the project’s principal investigator and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.
None declared.