Table 7 Survey domains, qualitative themes, and Exemplary quotes documenting facilitators and barriers to providing SUD services
Theme | Quotes |
|---|---|
Perceptions of bridge program need/Readiness to implement | “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 and refer them to their primary care physician if needed.” “To even think an ED should be the starting place for opioid dependence treatment is poor judgment. Establish a state funded mental health and drug recovery system that is freely and immediately available to every patient referred by any Doctor or ACP.” “Staff buy-in of importance and significance of [the] problem is key. To understand the scope of the problem with our patients, we have to know the ‘who’ and ‘how much.’ To get this [bridge program] started and have staff and patients understand why we are asking will be challenging. Like growing pains.” “Funding for Naloxone and Peer Support Specialists is critical.” “Any toolkits or knowledge that can be shared on how to initiate/implement these programs into the ED [would be helpful].” “There is much desire to improve to 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.” “This program will be a burden on critical access hospitals. However, we are not strictly opposed to participating with adequate resources, training and consultation.” “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.” |
Availability of buprenorphine in the ED | “Buprenorphine induction is challenging when the hospital pharmacy is closed and the lack of a specific pathway for a community provider or service to hand off further care for the patient makes it difficult to coordinate the care of the patient and ensure continued MAOT (medication for alcohol and opioid treatment) after they leave the ED.” “Hospital leadership has been opposed to Suboxone inclusion in the formulary since inception due to stigma.” “Inventory of buprenorphine is difficult to manage in a small facility with few providers.” |
Barriers and facilitators to SUD screening | “Lack of provider education on how to treat positive COWS scores. RN will page MD but no orders will be initiated.” “Behavioral Health Team in ED 24/7.” “If they are here for a drug issue only, without a psych component…we lack resources for them.” “Providers are not on board.” |
Barriers and facilitators to MOUD prescribing – community referrals | “Buprenorphine induction is not always done because of how difficult it can be to hand off patients once they leave the ED.” “Resources are provided, but patients are not officially referred.” “Our facility does not see many patients seeking this type of treatment, and 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. It is very difficult to follow up and keep in contact with patients from an ED standpoint. We struggle to get in contact with patients for treating medical conditions after ED visits. Opioid use disorder patients should be encouraged to use the outpatient resources available to them and maintain treatment within that environment. ED should be used to treat emergency conditions that may arise surrounding that outpatient treatment only.” “We are a small rural facility with limited community resources.” “If our staff had education, we could make the appropriate referrals.” |
Barriers and facilitators to MOUD prescribing – fear of legal repercussion & stigma | “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.” “There is a huge concern for liability without those concerns addressed in very specific ways, I WILL NOT initiate any outpatient dependence care.” “Leadership and community related stigma [is a barrier to prescribing buprenorphine].” |
Availability of peer support specialists | “Having a network of providers/provider groups with reliable availability to take care of the patients once treated in the ED is a major barrier to successful MAOT (medication for alcohol and opioid treatment) initiation. Peer support specialists would help assist in keeping patients on track to continue MAOT and have support after they leave the ED. This is especially important in the timeframe between discharge and seeing their next provider outpatient.” “Peer support in the ER is a very beneficial asset. I have seen it benefit so many individuals when having someone to talk to in person at the moment of crisis.” “We don’t have peer support specialists in rural communities.” |
Availability of social workers to assist in making social service referrals | “Presently we have no social workers employed in the inpatient or ER setting of our facility.” “Our social workers primarily care for the Behavioral Health unit patients. Our case workers help coordinate transfers but only pamphlet help for substance abuse disorders.” “We can contact that hospital social worker team during normal business hours or the on-call team after hours for help in referring patients.” “[We] provide patients with a crisis line to call for additional resources.” “Due to our hospitals size we have limited social work services that are always needed.” |
Availability of harm reduction services (e.g., naloxone) | “Narcan and syringes [are] not available in this county [to refer to].” “Co-prescribing naloxone is our best practice.” “In discussions for system wide protocol through vending machines.” |
Barriers to reducing stigma and racial bias | “Need more education and resources for staff to increase their level of competence and overall comfort for this problem.” “Race aside, there is no interest by physicians to prescribe any medications for outpatient opioid use reduction.” “Lack of translators, social workers, and care managers to get marginalized populations into detox programs or follow up care.” |