Linking MATTERS: Barriers and Facilitators to Implementing Emergency Department-Initiated Buprenorphine-Naloxone in Patients with Opioid Use Disorder and Linkage to Long-Term Care

Abstract

Background: In March 2019, our health system launched a project called Linking MATTERS (Medication for Addiction Treatment linkage Through Emergency depaRtmentS) to initiate evidence-based treatment for opioid use disorder (OUD) with buprenorphine-naloxone (B/N) in our emergency departments and connect patients to our primary care sites to continue their addiction care. Methods: Six months after project implementation, we conducted in-depth interviews with frontline providers (n = 14), including emergency physicians and hospitalists, recovery coaches, ED and outpatient nurses, and case managers. We used qualitative thematic analysis to identify barriers and facilitators to implementation and suggestions for improving the project. Results: We identified five salient themes: (1) provider trainings: mandated, rather than optional trainings, facilitated provider uptake; (2) provider attitudes: there was a growing recognition of addiction as a chronic, medical disease and the value of B/N in supporting patients’ recovery, driven by a desire to make a difference in patients’ lives; (3) patient engagement: frontline providers with lived experience of addiction who had designated time (such as recovery coaches) were optimally positioned to engage patients; (4) the linking mechanism: personal connections between ED and outpatient providers, rather than follow-up telephone calls, facilitated linkage; and (5) suggestions for improving the program, including: a physical space/bridge clinic to provide patient linkage, expansion of the recovery coach program, and standardized, evidence-based interdisciplinary trainings for all frontline providers. Conclusion: The insights provided will support further program modifications. Healthcare systems should explore whether the components we identified warrant attention locally based on their unique infrastructure and culture.

Keywords:

• Emergency department
• buprenorphine-naloxone
• opioid use disorder
• care continuum
• barriers and facilitators

Acknowledgements

We would like to acknowledge key leaders who helped create and implement the Linking MATTERS program at CHA including: Our Chief of Emergency Medicine: Benjamin Milligan, MD; Our ED site chiefs: Melisa Lai-Becker, MD, Christopher Fischer, MD; our Medical Director for Behavioral Health Integration, Ellie Grossman, MD, MPH; Hospitalist leadership: Donald Moran, MD and Asha Shah, MD; Addiction & Psychiatry leadership: Marshall Reiner, MD, Mark Albanese, MD, Janice Kauffman, RN, MPH, CAS, LADC1; Nursing leadership: Rebecca Sweeney, DNP, MBA, RN, CMAC; and our OBOT RNCMs: Jessica Lamie, Karla Osorio, Grace Poirier, and Lolita Roland.

Additional information

Funding

We received internal funding from the Tufts School of Medicine Family Medicine Department and the Cambridge Health Alliance Departmentof Family Medicine.