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BACKGROUND: Overdose is a leading cause of maternal mortality; in response, maternal mortality review committees have recommended expanding substance use disorder (SUD) screening, improving collaboration between obstetric and SUD treatment providers, and reducing fragmentation in systems of care. We undertook an analysis of the perinatal SUD treatment landscape in Baltimore, Maryland in order to identify barriers to treatment engagement during pregnancy and the postpartum period and guide system improvement efforts. METHODS: We conducted a survey of seven birthing hospitals, 31 prenatal care practices, and 108 SUD treatment providers in Baltimore from April-June 2023. Organizations were asked to quantify care for perinatal patients with opioid use disorder (OUD) as well as about screening, service availability, referral practices, and support needed to improve care. RESULTS: 61% of the 145 contacted organizations responded. Birthing hospitals reported caring for pregnant persons with OUD with greater frequency than prenatal care practices or SUD treatment programs. Most birthing hospitals and prenatal care practices reported screening for OUD at intake, but the minority reported using validated tools. Service availability varied by type of organization and type of service. In general, prenatal care practices offered the fewest number of SUD-related services. Most SUD treatment programs that offered buprenorphine or methadone to the general population also offered these medications to pregnant patients. Withdrawal management for comorbid alcohol/benzodiazepine use disorders during pregnancy was more limited. The majority of birthing hospitals and prenatal care practices reported offering neither direct naloxone distribution nor prescriptions. Few SUD treatment programs offered tailored services for perinatal patients or for parents of young children, and many programs do not permit children onsite. Respondents reported high levels of interest in education and consultative support on SUD treatment in pregnancy within obstetric settings and on pregnancy-related medical concerns within SUD programs. CONCLUSIONS: This project provides a comprehensive picture of services available for treatment of perinatal OUD in a major US city. Results have served as a guide for ongoing citywide system improvement efforts by our project team and offer a model for other jurisdictions hoping to strengthen services for perinatal OUD and reduce maternal mortality.

Introduction: As fentanyl has become more readily available, opioid-related morbidity and mortality in the United States has increased dramatically. Preliminary studies suggest that high-affinity, partial mu-opioid receptor agonists such as the combination product buprenorphine-naloxone may reduce mortality from overdose and promote remission. With the escalating prevalence of opioid use disorder (OUD), it is essential to evaluate the effectiveness of opioid agonists like buprenorphine-naloxone. This study examines mortality and remission rates for OUD patients prescribed buprenorphine-naloxone to determine the efficacy of this treatment toward these outcomes.Methods: We carried out a retrospective analysis using the US Collaborative Network database in TriNetX, examining de-identified medical records from nearly 92 million patients across 56 healthcare organizations. The study spanned the years from January 1, 2017–May 13, 2022. Cohort 1 included OUD patients who began buprenorphine-naloxone treatment within one-year post-diagnosis, while Cohort 2, the control group, consisted of OUD patients who were not administered buprenorphine. The study measured mortality and remission rates within a year of the index event, incorporating propensity score matching for age, gender, and race/ethnicity.Results: Prior to propensity matching, we identified a total of 221,967 patients with OUD. Following exclusions, 61,656 patients treated with buprenorphine-naloxone showed 34% fewer deaths within one year of diagnosis compared to 159,061 patients who did not receive buprenorphine (2.6% vs 4.0%; relative risk [RR] 0.661; 95% confidence interval [CI] 0.627–0.698; P < 0.001). The remission rate was approximately 1.9 times higher in the buprenorphine-naloxone group compared to the control group (18.8% vs 10.1%; RR 1.862; 95% CI 1.812–1.914; P < 0.001). After propensity matching, the effect on mortality decreased but remained statistically significant (2.6% vs 3.0%; RR 0.868; 95% CI 0.813–0.927; P < 0.001) and the remission rate remained consistent (18.8% vs 10.4%; RR 1.812; 95% CI 1.750–1.876; P < 0.001). Number needed to treat for benefit was 249 for death and 12 for remission.Conclusion: Buprenorphine-naloxone was associated with significantly reduced mortality and increased remission rates for patients with opioid use disorder and should be used as a primary treatment. The recognition and implementation of treatment options like buprenorphine-naloxone is vital in alleviating the impact of OUD.

Introduction: Initiation of buprenorphine for opioid use disorder (OUD) in the emergency department (ED) is supported by the American College of Emergency Physicians and is shown to be beneficial. This practice, however, is largely underutilized.Methods: To assess emergency clinicians’ attitudes and readiness to initiate buprenorphine in the ED we conducted a cross-sectional, electronic survey of clinicians (attendings, residents, and non-physician clinicians) in a single, academic ED of a tertiary-care hospital, which serves a rural population. Our survey aimed to assess emergency clinicians’ attitudes toward and readiness to initiate buprenorphine in the ED and identify clinician-perceived facilitators and barriers. Our survey took place after the initiation of the IMPACT (Initiation of Medication, Peer Access, and Connection to Treatment) project.Results: Our results demonstrated the level of agreement that buprenorphine prescribing is within the emergency clinician’s scope of practice was inversely correlated to average years in practice (R2 = 0.93). X-waivered clinicians indicated feeling more prepared to administer buprenorphine in the ED R2 = 0.93. However, they were not more likely to report ordering buprenorphine or naloxone in the ED within the prior three months. Those who reported having a family member or close friend with substance use disorder (SUD) were not more likely to agree buprenorphine initiation is within the clinician’s scope of practice (P = 0.91), nor were they more likely to obtain an X-waiver (P = 0.58) or report ordering buprenorphine or naloxone for patients in the ED within the prior three months (P = 0.65, P = 0.77). Clinicians identified availability of pharmacists, inpatient/outpatient referral resources, and support staff (peer recovery support specialists and care managers) as primary facilitators to buprenorphine initiation. Inability to ensure follow-up, lack of knowledge of available resources, and insufficient education/preparedness were primary barriers to ED buprenorphine initiation. Eighty-three percent of clinicians indicated they would be interested in additional education regarding OUD treatment.Conclusion: Our data suggests that newer generations of emergency clinicians may have less hesitancy initiating buprenorphine in the ED. In time, this could mean increased access to treatment for patients with OUD. Understanding clinician-perceived facilitators and barriers to buprenorphine initiation allows for better resource allocation. Clinicians would likely further benefit from additional education regarding medications for opioid use disorder (MOUD), available resources, and follow-up statistics.

Introduction: Recent policy changes in Washington State presented a unique opportunity to pair evidence-based interventions with first responder services to combat increasing opioid overdoses. However, little is known about how these interventions should be implemented. In partnership with the Research with Expert Advisors on Drug Use team, a group of academically trained and community-trained researchers with lived and living experience of substance use, we examined facilitators and barriers to adopting leave-behind naloxone, field-based buprenorphine initiation, and HIV and hepatitis C virus (HCV) testing for first responder programs.Methods: Our team completed semi-structured, qualitative interviews with 32 first responders, mobile integrated health staff, and emergency medical services (EMS) leaders in King County, Washington, from February–May 2022. Semi-structured interviews were recorded, transcribed, and coded using an integrated deductive and inductive thematic analysis approach grounded in community-engaged research principles. We collected data until saturation was achieved. Data collection and analysis were informed by the Consolidated Framework for Implementation Research. Two investigators coded independently until 100% consensus was reached.Results: Our thematic analysis revealed several perceived facilitators (ie, tension for change, relative advantage, and compatibility) and barriers (ie, limited adaptability, lack of evidence strength and quality, and prohibitive cost) to the adoption of these evidence-based clinical interventions for first responder systems. There was widespread support for the distribution of leave-behind naloxone, although funding was identified as a barrier. Many believed field-based initiation of buprenorphine treatment could provide a more effective response to overdose management, but there were significant concerns that this intervention could run counter to the rapid care model. Lastly, participants worried that HIV and HCV testing was inappropriate for first responders to conduct but recommended that this service be provided by mobile integrated health staff.Conclusion: These results have informed local EMS strategic planning, which will inform roll out of process improvements in King County, Washington. Future work should evaluate the impact of these interventions on the health of overdose survivors.

Introduction: We sought to describe emergency department (ED) buprenorphine treatment variability among EDs with varying operational characteristics.Methods: We performed a retrospective cohort study of adult patients with opioid use disorder discharged from 12 hospital-based EDs within a large healthcare system as a secondary data analysis of a quality improvement study. Primary outcome of interest was buprenorphine treatment rate. We described treatment rates between EDs, categorized by tertile of operational characteristics including annual census, hospital and intensive care unit (ICU) admission rates, ED length of stay (LOS), and boarding time. Secondary outcomes were ED LOS and 30-day return rates.Results: There were 7,469 unique ED encounters for patients with opioid use disorder between January 2020–May 2021, of whom 759 (10.2%) were treated with buprenorphine. Buprenorphine treatment rates were higher in larger EDs and those with higher hospital and ICU admission rates. Emergency department LOS and 30-day ED return rate did not have consistent associations with buprenorphine treatment.Conclusion: Rates of treatment with ED buprenorphine vary according to the operational characteristics of department. We did not observe a consistent negative relationship between buprenorphine treatment and operational metrics, as many feared. Additional funding and targeted resource allocation should be prioritized by departmental leaders to improve access to this evidence-based and life-saving intervention.

BACKGROUND: Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients. METHODS: We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics. RESULTS: There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation. CONCLUSIONS: Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients withdrawal experiences.

Introduction: Emergency departments (ED) are in the unique position to initiate buprenorphine, an evidence-based treatment for opioid use disorder (OUD). However, barriers at the system and clinician level limit its use. We describe a series of interventions that address these barriers to ED-initiated buprenorphine in one urban ED. We compare post-intervention physician outcomes between the study site and two affiliated sites without the interventions.Methods: This was a cross-sectional study conducted at three affiliated urban EDs where the intervention site implemented OUD-related electronic note templates, clinical protocols, a peer navigation program, education, and reminders. Post-intervention, we administered an anonymous, online survey to physicians at all three sites. Survey domains included demographics, buprenorphine experience and knowledge, comfort with addressing OUD, and attitudes toward OUD treatment. Physician outcomes were compared between the intervention site and the control sites with bivariate tests. We used logistic regression controlling for significant demographic differences to compare physicians’ buprenorphine experience.Results: Of 113 (51%) eligible physicians, 58 completed the survey: 27 from the intervention site, and 31 from the control sites. Physicians at the intervention site were more likely to spend

BackgroundAchieving equitable access to medications for opioid use disorder (MOUD) such as buprenorphine is a pressing issue. Evidence suggests disparities in MOUD access based on race and socioeconomic status, further exacerbated by the COVID-19 pandemic. However, the drivers behind this access gap remain poorly understood. This study explores barriers to treatment access among individuals with opioid use disorder (OUD) experiencing homelessness.MethodsWe interviewed 28 individuals in and around the Boston Public Health Commission (BPHC) Engagement Center, an area known for its high density of active substance use and homelessness. We asked about people's experiences, perceptions, and attitudes toward OUD treatment. We conducted a thematic analysis of our interview data.ResultsFifty-four percent of participants sampled were not prescribed MOUD. None of the participants reported having an active prescription of sublingual buprenorphine or buprenorphine/naloxone. White participants were more likely to have been prescribed buprenorphine in the past compared to participants of other races even in this socioeconomically homogeneous sample. Themes that emerged in our data included challenges to accessing MOUD due to reduced services during the COVID-19 pandemic, lost or stolen medications, fewer inpatient withdrawal management beds for women, transportation challenges, fear of adverse effects of MOUD, the perception that taking MOUD replaces one addiction for another, and community disapproval of MOUD. Participants also reported stigma and discrimination based on race, gender, and socioeconomic status.ConclusionSystems and individual-level factors contribute to the MOUD treatment gap across race and socioeconomic status. The COVID-19 pandemic posed additional access challenges. This study provides important, actionable insights about the barriers faced by a particularly vulnerable population of individuals with OUD experiencing homelessness.