How emergency departments are responding to the opioid crisis: Results from a statewide survey in Kentucky

Abstract

Objective

There is a rising effort for hospital emergency departments (EDs) to offer and expand substance use disorder (SUD) services. This state-wide evaluation studies SUD services offered along the continuum of implementation across Kentucky’s EDs to inform future state efforts to build ED bridge programs.

Methods

We conducted a mixed-methods study using an online survey of all Kentucky Emergency Department Directors between January and May of 2023. We created a hospital-level dataset which we used to summarize quantitative questions and thematically analyze open-ended responses.

Results

Our sample included 85 unique respondents (89% of all eligible Kentucky hospitals). Nine (11%) had active bridge programs to initiate opioid use disorder patients on buprenorphine. Respondents reported that the most challenging SUD-related services for EDs to implement were buprenorphine induction for opioid use disorder treatment (n = 36, 42%), referrals to community-based providers (n = 34, 40%), and providing social work services (n = 25, 29%). Respondents noted that the implementation and improvement of screening protocols were needed to better identify patients with SUD, expressed concerns about care continuity, and explicitly conveyed the need and desire for additional supports to provide SUD care.

Conclusions

The landscape of Kentucky’s ED SUD supports shows several hospitals that offer services along the continuum of SUD care, and highlights the importance of technical assistance and financial resources to ensure the continuum is broadly available. Kentucky’s experience speaks to broader national challenges in supporting SUD in EDs – specifically the need for financial resources, buy-in and education, and creating referral relationships to ensure care continuity.

Background

As the opioid crisis continues in the United States, emergency departments (EDs) play an increasingly important role in providing both acute care for people who use drugs and as touchpoint to initiate longer-term substance use disorder (SUD) care and social supports [1,2,3]. Providing SUD supports like medications for opioid use disorder (MOUD) in the ED following a non-fatal opioid overdose significantly decreases the likelihood of subsequent negative health outcomes, but many patients do not receive SUD care following an overdose [4, 5]. Without intervention, overdose survivors have an increased risk of subsequent overdoses [6,7,8] and people who experience a non-fatal overdose are three times more likely to die by fatal overdose [9].

While more EDs are adopting SUD supports, screening and treatment are not the standard of care for SUD patients who present in EDs. Existing standards of care encourage, but do not require that EDs offer SUD supports; patients are instead treated for acute needs and discharged once stable [1]. One innovative model to integrate SUD supports in EDs are bridge programs. ED bridge programs integrate low-threshold SUD care into hospital settings for patients who are admitted to EDs for drug-related health events [2, 10]. Bridge clinic supports can include SUD screening and diagnosis, connections to social services, peer supports, and harm reduction supplies, timely patient access to MOUD, and warm handoffs to community providers and resources [2, 10].

Following the success of bridge programs in other states and in response to high overdose mortality in Kentucky [2, 11, 12], the Kentucky Statewide Opioid Stewardship (KY SOS) program has sought to support existing programs and increase the number of bridge programs throughout the state modeled after efforts in other states such as California [10, 13, 14]. KY SOS is an initiative comprised of leaders from the Kentucky Cabinet for Health and Family Services’ Kentucky Opioid Response Effort and the Kentucky Hospital Association that aims to support hospitals in their commitment to combatting the state’s opioid epidemic by providing technical assistance and additional resources for member hospital staff and leadership [15].

While there are increasing efforts across the nation to encourage bridge clinic adoption, there is a lack of comprehensive statewide data on how hospitals are approaching implementation of SUD supports. Baseline assessments of existing SUD supports in hospitals and EDs are important as state and federal policies and programs evolve to support and codify hospital SUD care minimums. Where prior literature focuses on implementation of ED SUD programs in select vanguard hospitals [16,17,18,19], this study provides state-wide evidence of SUD-related care and barriers along the continuum of implementation. To inform Kentucky’s efforts, we conducted a state-wide baseline assessment to understand the existing breadth, capacity, and challenges of offering hospital-based SUD supports in Kentucky, and potential supports needed to implement bridge programs. In this mixed-methods study, we surveyed Kentucky hospitals and examined existing (a) hospital-level SUD services offered in EDs, (b) referral practices, (c) perceived barriers and facilitators, and (d) overall priorities and challenges to offering SUD-related services in individual EDs.

Methods

Study design

We designed a mixed-methods cross-sectional survey to examine current Kentucky hospital ED practices in supporting patients with SUD. The survey instrument included closed-ended multiple-choice and open-ended response questions. The survey was distributed electronically via Qualtrics to an email listserv of 96 ED Directors throughout the state, including ED Directors at nine hospitals with established bridge programs. ED Directors were chosen as primary contacts because they were likely to be the most knowledgeable about hospital and ED protocols to treat patients who present with SUD-related needs. Survey responses were collected between January 26, 2023, and May 15, 2023. Follow-up with potential respondents continued until 89% completion (n = 85) was reached. Respondents were not compensated for participation.

The survey instrument was adapted from the literature and previous surveys of hospitals in Michigan and Pennsylvania that similarly aimed to assess statewide hospital and ED capacity to serve people with substance use-related needs [20, 21]. Survey content was collaboratively tailored with representatives from the Kentucky Hospital Association and Kentucky Opioid Response Effort. We examined Kentucky hospital ED supports for patients with SUD across several key survey domains, including: hospital and ED pharmacy characteristics, SUD screening protocols, buprenorphine prescribing protocols, referrals to community providers, and overall perceived priorities and challenges to implement SUD supports in EDs (Table 1). The complete survey is provided in Appendix 1.

Table 1 Survey domains and exemplary survey questions

We created a hospital-level dataset after surveys were completed. Responses were included in the final analysis if the respondent consented to participate and completed the survey in its entirety. In some cases, more than one respondent completed a survey on behalf of the same hospital. Of hospitals with more than one recorded survey response, we included only the most recent response in the analysis. The most recent respondent was selected because we assumed (1) the response would reflect the most current practices, and (2) if the survey was initially sent to a person without relevant knowledge about the hospital’s ED SUD offerings, the final respondent most likely received the survey from prior, less knowledgeable respondents. Seven of 96 possible respondent hospitals had more than one respondent. Six hospitals had two respondents, one hospital had three respondents.

Analysis

We summarized and tabulated response frequencies of closed-ended multiple-choice survey questions across all hospitals and domains. Some questions were only available to some respondents based on their previous answers (i.e. because of programmed survey logic), so denominators may differ for some survey questions. For open-response questions, two study team members (OS, SH) compiled and reviewed individual responses for thematic trends and exemplary quotes along the key survey domains. Analysts independently reviewed all open responses, then compared findings for each open response until agreement was achieved. This study was approved by the Institutional Review Board at Johns Hopkins Bloomberg School of Public Health. Analysis was completed using SAS software 9.4.

Results

Quantitative results

Final analysis included 85 unique responses, representing 85 of 96 possible respondent hospitals and a response rate of 89%. Survey domains and exemplary questions are provided in Table 1.

Existing protocols and services

Table 2 reports existing hospital protocols for substance use and harm reduction-related services offered in EDs in our study population. While most hospitals in our sample had buprenorphine on their formulary (n = 67, 79%), few EDs had their own pharmacy that could also dispense buprenorphine (n = 6, 7%). Alternatively, some EDs used Pixys Medstations (n = 74, 87%), a secure, mobile, automatic medication dispensing machine. Among EDs with Pixys Medstations, 38% stocked buprenorphine (n = 28 of 74). Nearly 40% of hospitals (n = 33) had an outpatient pharmacy with buprenorphine that patients could use to access longer-term refills (greater than 3 days) of buprenorphine.

Table 2 Kentucky hospital and emergency department substance use disorder services offered

Less than half of EDs reported having SUD screening protocols (n = 37, 44%). Of those with screening programs, almost all (n = 36 of 37, 97%) had their screening protocols programmed into EHRs. When asked about specific practices for SUD screening, the majority, 68% (n = 25) of the 37 hospitals screened all patients for SUD, 30% (n = 11) screened only some based on certain patient characteristics (e.g. have a Hepatitis C diagnosis, opioid prescription, present with overdose).

Buprenorphine prescribing protocols and prescriber capacity were also limited. Nine respondents (the nine established bridge clinics; 11% of all respondents) each had a written protocol to prescribe buprenorphine to patients who screened positive for OUD. Among all hospitals, only two (2%) facilitated home induction. Most respondents reported that there were no ED providers who prescribed buprenorphine in the ED in the previous 12 months (n = 48, 56%), or that they did not know (n = 26, 31%). Seven EDs (8%) required patients to seek counseling or another behavioral health intervention in order to receive MOUD. The minority used peer supports in the ED for patients with SUD (n = 11, 13%), though almost half had direct access to hospital and/or ED-based social workers for patients with SUD (n = 41, 49%). Most EDs offered at least some harm reduction services, with education or naloxone provision as the most common, though still a quarter (n = 20, 24%) offered no harm reduction services.

Barriers and facilitators to offering SUD services

Table 3 describes barriers and facilitators for EDs to offer specific SUD services, including pharmacy buprenorphine availability, screening for SUD, and prescribing buprenorphine.

Table 3 Barriers and facilitators to offering specific substance use disorder-related services

Screening. Triaging competing medical problems was the top barrier to treating people with SUD in the ED for 42% (n = 36) of hospitals. About 40% of respondents (n = 33) said ED providers had a lack of clinical knowledge or training in administering SUD screenings, and 38% (n = 32) said screening patients for SUD was not part of the ED protocol. About a quarter said lack of time and lack of training in what to do with positive screens (both n = 25, 29%), referral resources, and patient privacy concerns were barriers to SUD screening (both n = 23, 27%). Of participants who responded with “other”, common screening barriers were provider attitudes, patients leaving against medical advice, or patients withholding information due to stigma. One said patients with SUD only receive resources if they have a co-occurring behavioral health issue.

Of the 37 hospitals that screened for SUD, embedding the screening tool in EHRs was the most common facilitator to SUD screening (n = 31 of 37, 84%). ED health providers’ clinical knowledge (n = 12 of 37, 32%), comfort (n = 10 of 37, 27%) in administering SUD screening tools, and where to make referrals (n = 11 of 37, 30%) were other common facilitators of SUD screening. One respondent noted that having a behavioral health team in the ED 24/7 facilitated the screening process. Another said peer supports in the ED were helpful.

MOUD prescribing. Respondents generally agreed that patients with OUD in the ED could receive buprenorphine in a timely manner (agree, n = 39, 46%; neither disagree or agree, n = 24, 28%, disagree, n = 12, 14%; not applicable, n = 10, 12%). However, about half said that clinicians didn’t know how to induct patients on buprenorphine (n = 41, 48%), and more than half of respondents indicated that clinicians were not willing to prescribe buprenorphine (n = 44, 52%). Many respondents (n = 36, 42%) said clinicians would not prescribe buprenorphine unless patients were going to be connected to follow-up counseling or treatment. Similarly, a third of respondents said a barrier to buprenorphine prescribing was the lack of community providers to continue prescriptions after take-home supplies run out (n = 29, 34%). A quarter of respondents indicated “other” barriers to get ED providers to obtain an X-waiver, such as a lack of encouragement to prescribe buprenorphine.

Referrals

SUD treatment referrals. Table 4 describes referral processes and barriers and facilitators to making referrals for substance use-related supports after discharge. The most common services EDs referred to were behavioral health providers (n = 57, 67%), primary care providers (n = 48, 56%), and outpatient or inpatient substance use treatment (outpatient, n = 42, 49%; inpatient, n = 35, 41%). Only nine reported having no referral process in place (n = 9, 11%).

Table 4 Hospital referral services, barriers and facilitators to offering referrals for substance use disorder services

The most common barriers to facilitating referrals to outpatient SUD providers for follow-up care in the community, in rank order, were that the ED did not have a protocol for referrals (n = 42, 49%), lacked staff to coordinate handoffs (n = 38, 45%), and lacked partnerships with existing providers (n = 32, 38%). Almost a quarter of respondents (n = 19, 22%) indicated there were no providers nearby to refer to.

Harm reduction referrals. Table 4 also describes ED referrals for harm reduction and social services. While less than half of EDs reported they made referrals for harm reduction services (n = 40, 47%), those who did made such referrals to local health departments (n = 32, 38%) and syringe services programs (n = 18, 21%). Only a quarter offered referrals for take-home naloxone (n = 21, 25%).

Social services referrals. About 70% of EDs reported that they referred patients with SUD to social services (n = 26, 31% did not offer services). Referred social services included Medicaid or other insurance enrollment assistance (n = 35, 41%), assistance with transportation (n = 31, 36%), and housing resources (n = 26, 31%). One “other” service referral mentioned was by an ED that provided patients with crisis phone lines to call.

Barriers and facilitators to offering referrals to social services. The most common barrier to referring patients to social services was a general lack of capacity to contact patients after discharge to ensure care continuity (n = 52, 61%). Similarly, over half of respondents said their ED lacked staff to coordinate referrals (n = 43, 51%). Others cited a general lack of nearby providers to refer to (n = 39, 46%), or lack of service providers with availability for new clients (n = 26, 31%). Roughly a third of respondents said patients were simply not interested in receiving social services or referrals (n = 30, 35%).

Few hospitals said that their ED had social services navigators on staff (n = 17, 20%), had existing partnerships with social service providers (n = 15, 18%), had follow-up care staff who could contact patients after discharge (n = 11, 13%), or had a champion for connections to social services (n = 6, 7%). Several respondents provided additional information about social worker availability in the ED (e.g., several had ED social workers on site or on call 24/7, while others have hospital social workers available during normal business hours).

Training

Table 5 reports awareness of staff participation in trainings relating to stigma and racial equity. When asked about awareness of staff participation in stigma reduction trainings, around a quarter said staff had participated (n = 20, 24%), 46% (n = 38) said staff had not participated in such trainings, and a third of respondents did not know (n = 24, 29%). Over half (n = 45, 55%) did not know whether their ED had plans to implement or expand stigma reduction training. Most participants (n = 60, 73%) endorsed that staff had participated in cultural competency training, often noting it was a requirement in annual trainings.

Table 5 Stigma and racial bias training for ED staff

Most challenging and important SUD services to implement in EDs

Perceptions of the most challenging and most important SUD services to implement in EDs were consistent with findings in other domains (Table 6). Offering referrals to community-based providers was reported as both a top challenge (n = 34, 40%) and viewed as one of the most important (n = 32, 38%) services to implement. The top cited challenging SUD-related service for EDs to implement was buprenorphine induction (n = 36, 42%), though inducting patients on buprenorphine (n = 14, 16%) was viewed as less important to implement than most other services including screening (n = 32, 38%), referrals to community-based providers (n = 32, 38%), counseling and education (n = 22, 26%), providing social work services (n = 22, 26%), or providing naloxone (n = 15, 18%).

Table 6 Top two perceived most challenging, important substance use services for EDs to implement

The other perceived most important services for EDs to implement, in addition to community-based provider referrals (n = 32, 38%), were screening for SUDs (n = 32, 38%), counseling/education (n = 22, 26%), and social work services (n = 22, 26%). Providing social work services, however, was viewed as one of the most challenging (n = 25, 29%) services to implement, likely due to limited availability of social workers in the ED. Respondents did not view screening (n = 14, 16%) or counseling/education (n = 8, 9%) to be as challenging to provide as most other services.

Qualitative results

Table 7 provides exemplary quotes along our survey domains that triangulate quantitative findings. We report key qualitative themes that emerged in our analysis below.

Table 7 Survey domains, qualitative themes, and Exemplary quotes documenting facilitators and barriers to providing SUD services

Perceptions of bridge program need and implementation readiness varied

Perceptions of bridge programs and states of implementation were mixed. Some had well established programs or were interested in expanding SUD services. One said, “There is much desire to improve to the care we give to patients with OUD.” A few did not recognize a need for or were not in favor of offering SUD services. One expressed perceived decreases in patients with SUD receiving care in their ED due to the EDs lack of prescribing controlled substances, saying, “Our volume of patients who have an opioid addiction have decreased drastically ever since they know that most of our physicians don’t prescribe narcotics.” Another believed the ED was not the appropriate venue to provide SUD services at all, stating, “To even think an ED should be the starting place for opioid dependence treatment is poor judgment.”

In anticipation of planning to implement a bridge program, one participant summarized sentiments expressed by several, noting that adequate detection of SUD and staff and patient education would be needed, and recognizing it would take time and there would be “growing pains.” Several supported implementation and requested resources such as implementation toolkits and education opportunities. As one said, “I am very open to any additional support, services, educational materials, or plans for implementation as this is already begun as a passion project in our department.” Another shared, “There is much desire to improve the care we give to patients with OUD. Having resources and successful treatment pathways to model would be very helpful. Outpatient resources are a big knowledge gap.” Others said funding for naloxone and peer support specialists would be helpful.

Referral barriers, stigma, and legal concerns inhibited willingness to prescribe buprenorphine

A lack of community providers to refer patients to was a key barrier to providing SUD services. Concerns about limited referral options often inhibited buprenorphine prescribing, as one said, “Buprenorphine induction is not always done because of how difficult it can be to hand off patients once they leave the ED.” Some expressed the need for additional education, with one saying, “If our staff had education, we could make the appropriate referrals.” Another said, “Our providers are not comfortable prescribing the medications to treat it. This is mostly due to a lack of ability to follow these patients. I do not think this is a treatment that ED should provide.” One attributed the lack of buprenorphine availability in their ED to stigma, saying, “Hospital leadership has been opposed to Suboxone inclusion in the formulary since inception due to stigma.”

Some feared potential legal repercussion from potential adverse health outcomes and/or diversion if buprenorphine was prescribed out of the ED, especially without referrals to community-based care. As one said, “I am terrified of the legal liabilities to the ED physician if these meds are prescribed and negative outcomes occur. There is no outpatient service/system to guarantee proper follow up and coordinated care.” Follow-up care was seen as especially challenging in rural areas, as one respondent said they worked in a “small rural facility with limited community resources.”

Many faced resource constraints that limited perceived ability to provide SUD services

Several respondents noted challenges with implementing SUD services due to resource constraints such as staffing and hospital size. As one said, “Inventory of buprenorphine is difficult to manage in a small facility with few providers.” Social workers and peer support specialists were also not commonly available, with one saying, “Due to our hospitals size we have limited social work services that are always needed.” Another said, “We don’t have peer support specialists in rural communities.” Regarding barriers to reducing stigma and unconscious bias, one said their ED has a “Lack of translators, social workers, and care managers to get marginalized populations into detox programs or follow up care.” One said “staff burnout” made stigma reduction in the ED one of the most challenging issues to address.

Discussion

We surveyed Kentucky hospital ED directors to examine existing ED SUD services, referral practices, and priorities and challenges to offering SUD services in Kentucky hospital EDs. Buprenorphine stocking in hospital or ED pharmacies was relatively low, only some hospitals had an SUD screening protocol, and continuity of care via referrals to outpatient care was a commonly cited challenge. Across domains, respondents expressed concerns about the lack of handoffs for care continuity, including for community provider referrals for MOUD, harm reduction, and social services. Perceptions of the utility of buprenorphine prescribing and bridge programs were mixed, but many supported peer support services and bridge clinic implementation and requested additional resources to support implementation. Three primary challenges in offering SUD services in EDs were: lack of SUD screening, limited buprenorphine availability, and lack of ability to make referrals to community providers.

Our study examines the full spectrum of adoption of ED SUD supports in a state that continues to be hard hit by the overdose crisis [12, 22]. For the past decade, Kentucky has been among the top ten states with the highest death rates. In 2022, Kentucky’s death rate was 53.2 per 100,000 compared to the U.S. average of 32.6 per 100,000 in the same year [12, 23]. Altogether, findings revealed gaps in the availability of SUD care in hospital EDs, but growing interest in offering peer support and SUD screening with additional funding and technical assistance.

SUD screening was one pervasive challenge for EDs, as less than half of hospitals had an SUD screening protocol. SUD was not a primary concern in some communities, so screening for SUD competed with triaging other health needs, and many respondents reported providers were not trained to screen for SUD. Several respondents noted reluctance to screen for SUD because of concerns they had nowhere to refer patients with positive SUD screenings or did not know what to do with a positive screen.

A related challenge was limited ED buprenorphine availability. Kentucky’s EDs may be more likely to initially implement screening, counseling, and education services compared to prescribing buprenorphine. The X-waiver was officially rescinded by the Substance Abuse and Mental Health Services Administration on January 12, 2023. Our survey was developed when the X-waiver was in force, and was fielded by the time the policy change occurred. Despite this landmark policy change, barriers to buprenorphine availability likely persist. Research indicates that the removal of the X-waiver had only a slight impact on the number of prescribers, indicating that workforce challenges are likely to remain relevant [24]. The main barrier to prescribing buprenorphine was a lack of provider training or willingness to prescribe, or preference to prescribe buprenorphine only in conjunction with counseling or treatment from community providers. Limited provider education, stigma, fears of diversion or legal repercussion, and limited follow-up care options were said to limit buprenorphine access.

Following KY SOS’s example, state hospital organizations can offer technical assistance in best practices for buprenorphine induction, how to implement SUD screening protocols, education about legality and limited liability of offering MOUD, and trainings for health care providers and staff alike to combat stigma of people with SUDs and MOUD. Specifically, education about medication-first approaches are needed. Information should present evidence supporting the use of MOUD regardless of counseling or treatment availability in the community, consistent with practice guidelines [25, 26].

Respondents were commonly concerned about improving referral pathways for people with SUD. Many participants endorsed challenges finding available treatment nearby, though access to social workers and peer support specialists were noted as helpful especially when available within the ED 24/7. Losing patients between discharge and follow-up was a recurring challenge and a deterrent from initiating patients on buprenorphine. Challenges were magnified in in smaller, rural hospitals. Respondents that identified working from small rural settings commonly noted resource constraints such as limited availability of social workers and peer support specialists, and respondents from critical access hospitals in our sample noted that expanding substance use services would be burdensome given their already limited capacity and competing priorities. A previous study of Pennsylvania hospitals found that education and addressing stigma, program champions, integration of protocols into data systems, and building relationships with community providers to facilitate warm handoffs were associated with implementation success [20]. Similarly, a study about bridge program implementation in Michigan hospitals found that social workers and peer support specialists, in particular, were key to facilitating relationships with community providers to refer patients [21]. The KY SOS program is currently providing funding to expand the peer support workforce across EDs.

Kentucky’s experience speaks to the broader challenge hospitals nationally are facing to adopt and implement SUD supports as patients with SUDs continue to present in EDs. To alleviate these challenges, policymakers could leverage opioid settlement funds or other state funding to expand staffing of peer support specialists and social workers across Kentucky’s EDs to help establish warm handoff pathways, and to expand access to naloxone. Additionally, other states can look to leverage existing relationships and infrastructure established by hospital organizations like the Kentucky Hospital Association. To fill gaps in local treatment capacity, hospital associations may also formalize methods to distribute funds for building low-threshold bridge clinics across Kentucky’s EDs. State hospital associations may also help hospitals establish referral relationships and networks with SUD supports in the community and encourage continuity of care.

Limitations

First, responses may have been subject to self-response bias and social desirability bias, which may have led respondents to overstate the comprehensiveness of SUD services offered in their hospital EDs. Second, our study was conducted in tandem with the removal of the X-waiver requirement. As such, the context for prescribing MOUD has evolved since the time of our survey. Results reflect general perceptions of MOUD at the time the policy change occurred. Finally, this survey is cross-sectional in nature and does not speak to changes in practice and attitudes about ED SUD services over time.

Conclusions

Our study documents reported substance use services and perceptions of implementing bridge programs across Kentucky’s emergency departments as of January to May 2023 with the goal of informing future bridge program implementation in Kentucky. We found that some KY hospitals were already implementing the full continuum of ED SUD supports, but most would need financial resources and technical assistance to offer bridge services. While some participants explicitly expressed interest in acquiring more resources and implementing bridge services, others reported having few patients in need of services or noted they did not have the capacity to implement due to competing priorities and limited staffing. Generally, EDs needed more support to have buprenorphine readily accessible for patients, integrate SUD screening into current practices, and to establish referral relationships in communities to ensure continuity of care. Kentucky’s experience may speak to the broader challenge of integrating SUD services into EDs writ large. State hospital associations, with support from state policymakers and newly available opioid settlement dollars, can mobilize technical assistance and funding support to address the challenges identified in this study.