Penn Medicine: ED Nurse Screening, Clinician Prompts Improve OUD Treatment

An emergency department initiative prompting clinicians to identify and treat opioid use disorder was found to double assessment for opioid withdrawal and increase initiation of evidence-based treatment, according to a study from the Perelman School of Medicine at the University of Pennsylvania.

The findings were published recently in Annals of Emergency Medicine. A triage screening question to be asked by nurses was applied alongside an automated nudge in the electronic health record to increase clinicians’ awareness of patients with opioid use disorder and improve the likelihood patients would receive more comprehensive care in the emergency department. In addition to an observed increase in withdrawal assessments, the prompts were also associated with boosts in prescriptions for life-saving medications used to treat opioid use disorder.

The big-picture context is that treatment with medications for opioid use disorder is highly effective, lowers mortality from overdoses by more than half, and doubles engagement with treatment after discharge from the emergency department,” said the study’s first author, Margaret Lowenstein, M.D., an assistant professor of medicine, in a statement. “Our findings indicate that the screening and prompts help clinicians to recognize patients and increasingly initiate important care for them,” added Lowenstein, who is the research director of the Penn Center for Addiction Medicine and Policy.

The study built upon previous work by Lowenstein and senior author, M. Kit Delgado, M.D., an assistant professor of emergency medicine and director of the Penn Medicine Nudge Unit, which demonstrated that automation in the electronic health record alone was not sufficient for identifying opioid use disorder patients. Involving nurses on the front-end, consulting with patients in triage, proved to be a vital step in the process.

Historically, Lowenstein said, when patients with opioid use disorder came to emergency departments, they were typically discharged once their other urgent issues were managed. Patients would be given information on where to obtain treatment and many struggled to navigate the complicated substance use treatment system on their own.

But the emergency department is often the main, if not only, touch point many patients have with medical professionals. It is now increasingly recognized as a crucial opportunity to provide life-saving care for many patients.

Lowenstein and Delgado’s latest study reveals findings from applying this process in three hospitals and comparing insights to two hospitals as controls for the study. The researchers found that the rates of patients with opioid use disorder who were identified and assessed for withdrawal climbed from a baseline of 26 percent to 48 percent after turning on the intervention.

That boost coincided with a 12 percentage-point increase in prescriptions for naloxone, the overdose-reversing nasal spray, and a 5 percentage-point increase in prescriptions for buprenorphine, a medication that stabilizes opioid withdrawal, reduces cravings, and halves the risk of death among people with opioid use disorder.

his study is the latest in a line of research conducted by Lowenstein and Delgado seeking to coax emergency medicine clinicians into both identifying opioid use disorder patients and initiating recovery-focused care.

These efforts seek to drive more patients toward effective opioid use disorder treatment with medications, as opposed to the older methods of treatment without medication. Important to all of this is that the electronic health record prompt is easy to implement for any hospital looking to nudge their staff toward better opioid use disorder care.

Since the study was conducted, there has been movement to make it easier for opioid use disorder patients to get treatment. Earlier in 2023, a specific training needed to prescribe buprenorphine was eliminated, allowing for any doctor with a license from the Drug Enforcement Agency—meaning any doctor who already can prescribe medications—to prescribe the medication.

“There is a huge group now eligible to prescribe buprenorphine, which could really expand access to treatment,” Lowenstein said. “But that only happens if people actually recognize and treat opioid use disorder. That’s where our findings come in.”