Implementation

Barriers and Nudges

We uncovered three key behavioral barriers that impeded completion of the DEA X waiver process for our faculty and residents. Our team of behavioral economists worked to intuit the key psychological or situational factors behind each of these barriers and developed approaches that could be used to address them. These may be common themes and relevant approaches for stakeholders interested in making similar changes at their institutions as well. 

Barrier 1: Absent Social Norm

Behavioral economics defines social norms as the values, actions, and expectations of a culture or group. They offer, often implicit, guides to our behavior and, in particular, descriptive norms make people aware of what “most other people are doing”. These norms can reinforce and amplify an individual’s underlying motivations. The lack of consistent social norms around treating OUD and subsequently getting a waiver undercut the motivation of many attendings in our department to obtain a waiver. We targeted this barrier using six specific nudges including recruiting influential faculty members to be the first group of those waivered, creating a ‘Get Waivered’ Month, and holding a white coat pinning ceremony which was covered in a local news story and social media for those who had completed their waiver process as shown in figure 1.

Barrier 2: Hassle Bias in Obtaining a Waiver

Seemingly irrelevant details that make a task more effortful introduce hassle bias, and can make the difference between following through on an action and putting it off, sometimes indefinitely. Our group identified that many of the behaviors required to obtain their a DEA-X waiver introduced hassle bias including: accessing the online course and submission site after course completion and scheduling the in-person portion of the course. We targeted this barrier using three specific nudges including coordinating all schedules for interested participants, creating an easy to follow website, and presenting about the waivering process at resident and faculty conferences as shown on figure 1.

Barrier 3: Lack of Salience in Treating OUD

Salience refers to the fact that individuals are more likely to focus on items or information that are more prominent and ignore those that are less so. This creates a bias towards undertaking behaviors that are striking and perceptible. In the ED, the long-term benefits of proceeding with an action like starting a patient on MAT may be hidden and are therefore not always factored in at the time of decision making. Moreover, an emergency physician may be hard pressed in daily practice to remember stories of patients with OUD who have been treated successfully and are in recovery. Thus, because they are not regularly exposed to positive outcomes from OUD treatment, emergency physicians may come to develop an impression that patients cannot be treated effectively or recover. This worldview may alter their willingness to expend the effort to undergo extra training to obtain a DEA-X waiver. Making the benefits of our actions in treating patients with OUD more salient through vivid stories provides an opportunity to increase the motivation to follow through on obtaining a waiver. We targeted this barrier using three specific nudges around sharing in-person patient stories, including of physicians with OUD, who used MAT to enter into and stay in recovery as shown on figure 1.

Our hospital created an evidence-based pathway to prescribe medication, as part of an addiction treatment protocol, for patients seeking to overcome their opioid addiction. In December of 2018, MGH Emergency Department initiated the ‘Get Waivered’ campaign leading to 95% of all MGH ED faculty on staff obtaining their DEA-X waiver, a federal requirement to prescribing buprenorphine. In contrast, nationwide only 1% of all emergency physicians nationwide have this waiver. A multidisciplinary team including physicians, addiction specialists, pharmacists, and others planned for over a year before implementing the dual pathway ED-initiated buprenorphine protocol on May 1, 2018. The primary aim is to give patients access to this medication when they present to the ED.

Option 1 in the pathway is the ‘Take Home’ protocol for patients not in opioid withdrawal but seeking treatment for their OUD. . Pre-packaged, pre-labeled bottles of ‘To-Go’ buprenorphine/naloxone are stocked in the ED. When an eligible patient is ready for discharge, MGH ED providers can prescribe two days’ worth of the medication in a small package with instructions on how to dose the medication. An ED pharmacist dispenses a ‘To-Go’ buprenorphine kit (six 8/2 mg sublingual films) and provides comprehensive counseling on home induction. Additionally, the pharmacist dispenses nasal naloxone and provides counseling on its administration for an opioid overdose. The patient is then discharged with guidance to follow up at a specialized addiction Clinic the next day for ongoing care. The patient can then self-administer buprenorphine when they begin withdrawing at home and have clear guidance on how to re-dose themselves as needed prior to follow up at the addiction Clinic. This allows patients to have the medication they need at the point of care instead of requiring them to follow up at the pharmacy to fill their prescription.

Option 2 in the pathway is the ‘ED Administration’ protocol. This option is available for patients in opioid withdrawal in the MGH ED and can take their first dose of buprenorphine while they are still in the hospital. Patients are observed for clinical improvement and discharged with instructions on how to follow up at the addiction Clinic. These patients also receive nasal naloxone with counseling from an ED pharmacist. The ‘To-Go’ buprenorphine and nasal naloxone are given to the patient free of charge (Hayes 2012).

A 34‐year‐old woman with anxiety and recent bimalleolar ankle fracture, status‐post open reduction/internal fixation, presents requesting detoxification from opioids. Eighteen months ago, she was started on a short course of oxycodone after undergoing a minor operation to repair a fractured ankle she sustained during a trip and fall down a short stairwell at her daughter’s day care facility. She finished her prescription and continued to feel pain, tactile chills, and mild nausea. Her PCP felt uncomfortable prescribing her additional opioids, so she began using leftover Percocet from her husband’s previous injury. After these ran out, with persistent pain and seeking feelings of “normalcy,” she started seeking prescription opioids from friends and family and eventually began to buy them from a drug dealer in the town where she grew up. As the cost of her addiction rose, she transitioned to intranasal heroin use one week prior to presentation. After she sobered from this experience, she realized she needed help overcoming her addiction. Accompanied by her husband, she presented for evaluation in the ED requesting “detoxification.” She told the triage nurse, “I didn’t know where else to go … ”

“Seeking detox” for OUD is an increasingly common chief complaint in EDs, particularly those in regions most affected by the opioid epidemic. In our experience, a typical ED would offer this patient assistance in accessing detoxification from opiates in a variety of settings, including nonhospital addiction or mental health treatment facilities, intensive outpatient and partial hospitalization programs, and acute care inpatient settings.13 Some EDs may offer a social worker, recovery coach, or case manager to help her find a facility able to accept her. Others may allow her to make phone calls from the ED waiting room. Unfortunately, these options either refer the patient to non–evidence‐based care, as in the case of referral to detox facilities, or discharge the patient with high risk of relapse, without offering immediate treatment with buprenorphine that has a proven benefit.

Consider, on the contrary, the treatment this same patient received when she presented to this ED for her ankle fracture. She was seen by a provider in the ED who performed diagnostic testing, offered her initial treatment with a splint, and ensured that she had close follow‐up for more definitive treatment with an orthopedic surgeon the next day. It would be unimaginable for a provider in this scenario to diagnose the fracture, forgo splinting it (initial treatment in this case), and discharge her with a list of orthopedic surgeons and ask the patient to keep calling until one could see her within a few days. This is analogous to what is happening to patients with OUD in most EDs currently.

We propose that this patient, upon arrival to the ED, should have undergone brief screening and counseling to determine her eligibility for and interest in medication therapy with buprenorphine. If she were a good candidate, and were in mild to moderate withdrawal, she would have been administered 8 mg of sublingual buprenorphine in the ED and scheduled for follow‐up in a partnering specialized addictions clinic the next morning where she could be maintained on buprenorphine. She could then be discharged home already receiving appropriate treatment, with a plan in place for close follow‐up.

Emergency Departments can implement such a treatment pathway with relatively few barriers. ACEP already offers guidelines for OUD screening and counseling, which would enable clinicians to assess a patient’s candidacy for treatment. Although medication therapy with buprenorphine is highly regulated under the federal DATA 2000 law, emergency physicians are permitted to administer up to 72 hours worth of medication treatment without needing to obtain the DEA waiver required for other providers. As such, no additional licensing is required, although obtaining a waiver offers optimal flexibility by allowing providers to discharge patients with a short prescription to link into community based care.

This leaves only one major institutional barrier to ED induction of buprenorphine, which is the need for next‐day evaluation in clinic by a licensed buprenorphine prescriber. This presents an important opportunity for EDs to collaborate with our colleagues in internal medicine, family medicine, and psychiatry. These professions are rapidly training their clinicians to prescribe buprenorphine to increase treatment capacity. At our institution a “bridge” clinic was established to fill the many gaps in the current treatment system by offering walk in addiction services including on demand medication treatment. Such clinical models with capacity for same or next day referrals should be considered a standard of care for EDs, particularly those in academic centers. Just as an ED patient can typically be guaranteed timely orthopedic follow‐up after a fracture, they should have the same assurances when requiring OUD treatment.

In the midst of what is the biggest public health crisis since the AIDS epidemic in the mid-1990s, we also have an enormous treatment gap that is exposed nightly in our state’s emergency rooms.

Consider: A recent federal survey found that Massachusetts had by far the highest rate of opioid-related ER visits at 450 for every 100,000 residents, a number 10 times higher than the lowest rate in Iowa at 45 visits. Maryland was a distant second at 300 visits. And yet, the data show us that about 80 percent of patients with substance use disorder do not get the treatment they need. This status quo is unacceptable.

Fortunately, some emergency departments are quickly adopting innovative strategies to provide better care for this population. The treatment that holds the most promise is medication-assisted therapy (MAT) in which doctors administer buprenorphine in the ER, a partial narcotic that is less addictive and easier to taper off than methadone.

For instance, emergency physicians at Yale New Haven Hospital recently tested how administering Suboxone, a brand of buprenorphine, and then referring patients to outpatient providers to continue the medication therapy would impact the rate of persistence with addiction treatment. The result: After 30 days, 78 percent of patients who were given Suboxone and a brief interview remained in treatment while only 37 percent of patients who merely received a referral to an outpatient drug rehab provider remained in treatment.

The authors leveraged a little-known exemption to a federal law that allows emergency providers to administer Suboxone in the ER to treat withdrawal symptoms for 72 hours while permanent treatment is being arranged. That exemption allows doctors to provide this valuable treatment without going through the unpopular Drug Enforcement Administration waiver process that currently prevents 97 percent of all physicians from being able to prescribe the drug.

Another study from Medstar Union Memorial Hospital found that starting Suboxone before hospital discharge decreases return hospital and ER visits and improves patients’ perception of quality of life.

These studies point to potentially life-changing solutions for these vulnerable patients.