A new study shows that a financial incentive can dramatically increase the number of emergency department physicians trained to prescribe a potentially life-saving medication that prevents patients from fatal opioid overdose.
Led by researchers in Emergency Medicine at the Perelman School of Medicine at the University of Pennsylvania (Penn Medicine), the study showed that, at its start, just 6 percent of eligible physicians across three different emergency departments (EDs) had the proper training to prescribe the medication buprenorphine. But by offering reimbursement for training and a $750 incentive, 89 percent of physicians in those EDs were fully trained six weeks later. The study was published this month in Annals of Emergency Medicine.
"This study shows how enthusiastically emergency physicians embraced the opportunity to obtain this certification, which speaks to the shifting national conversation surrounding opioid use disorder and the importance of meeting patients where they are," said Sean Foster, MD, an assistant professor of Emergency Medicine and the director of Quality Improvement in Emergency Medicine at Penn Presbyterian Medical Center. "This also gives a 'playbook' of sorts to any leaders and administrators who may be looking for ways to get their group trained."
Buprenorphine is an "agonist" drug, meaning that it soothes the brain's cravings for opioids and has a ceiling effect on their toxic effects, preventing fatal overdose. By prescribing buprenorphine, ED doctors provide a "bridge" from acute care to longer term care that can include everything from counseling to continuing medications that will better support recovery.
A post-intervention survey for the study and actual buprenorphine prescribing data showed that in addition to having such a high rate of those trained, which is called getting an "X waiver," the physicians used their certification fairly quickly. Roughly 65 percent of respondents reported that they either administered or prescribed buprenorphine within the five months of their training.
"Buprenorphine is underutilized because of a lack of X waivered providers and the stigma associated with taking this medication, with some suggesting it's 'replacing one drug with another,'" said Jeanmarie Perrone, MD, a professor of Emergency Medicine and the director of the new Center for Addiction Medicine and Policy at Penn Medicine. "'However, buprenorphine has been shown to unequivocally decrease opioid overdose deaths and decrease the transmission of infections such as hepatitis C or HIV."
To get their X waiver, physicians must devote an entire day to training, which can be difficult to schedule amid their many responsibilities. It also wasn't very common until recently for the emergency department to be the venue for buprenorphine prescription. The incentive and reimbursement ($750 and $200, respectively, in this case) as well as changing attitudes toward the medication seem to make the decision to get an X waiver much easier for the 67 physicians it was offered to.
Of the three emergency department locations, two actually achieved a 100 percent X waiver rate. This included one site that went from zero X waivers to all of its ED doctors having one., and another site that went from just three of its physicians having X waivers to 26.
The variation in X waiver rates by site was not directly studied, but Foster thinks he knows why one site did particularly well.
"That particular site has the most readily available access to certified recovery specialists, who are absolutely essential in making the bridge from the emergency department to the doctor's office," Foster explained. "They are also incredible advocates for the patients while in the emergency department, and can help patients work through any hesitation they may have about participating in these treatments."
A related project at Penn Medicine called CORE that utilized both certified recovery specialists and the promotion of X waiver training resulted in 7 out of 10 patients being in active recovery a month after visiting the emergency department. Typical national numbers without buprenorphine prescriptions hover around 1 in 10.
While $750 could be seen as steep for some health systems, the post-intervention survey in this study revealed that two-thirds of respondents would have felt moved to get their X waiver even if the incentive was $500 or less.
Moving forward, to explore more ways to introduce buprenorphine use, the study team hopes to explore the effectiveness of "mini X waivers," a shorter training course.
"This study targets emergency physicians to ensure that they better understand the way buprenorphine works in order to administer it for opioid withdrawal symptoms in the emergency department," Perrone said. "In this setting, the X waiver certification is not required but it can still be a bridge to getting patients into treatment."
Other authors on this study included Kathleen Lee, MD; Christopher Edwards, MD; Arthur Pelullo; Utsha Khatri, MD; and Margaret Lowenstein, MD.