Hudson, Teresa J1,3, Hudson DR2, Beshears J3, Han X1, Wilson MP1,3
University of Arkansas for Medical Sciences, Center for Health Services Research;1 CHI St. Vincent Infirmary Medical Center;2 University of Arkansas for Medical Sciences, Department of Emergency Medicine3
Abstract
Objective: Death from opioid overdose continues to increase in the US despite the availability of effective opioid use disorder (OUD) treatments like buprenorphine. Emergency department-initiated buprenorphine is both safe and effective. Unfortunately, some patients refuse transport to ED after overdose, thus decreasing the opportunity to initiate buprenorphine. Although this approach is growing in popularity, there are no data on what emergency medical service clinicians think about this approach.
Methods: EMS personnel attending a statewide conference were surveyed. Using a Likert scale, respondents rated the extent to which they agreed with questions about buprenorphine initiation in the prehospital setting and general questions about medication treatment for opioid use disorder. The survey also included questions about respondents’ clinical experience (license type, years of experience, number of opioid overdoses treated per month) and demographic characteristics (age, race, sex). One open-ended question in the survey invited respondents to identify barriers to implementing buprenorphine in the prehospital setting.
Results: A total of 70 respondents completed the survey. Approximately 66% of respondents agreed with the statement, “People who use a lot of drugs should be treated with medications,” but 60% disagreed with the statement, “Initiating a medication that must be taken regularly to treat OUD should be part of the job of EMS Personnel.” EMTs, in general, were less likely to agree compared to RNs.
Conclusion: This study suggests that implementation of buprenorphine programs may be limited both by attitudes and by knowledge of prehospital personnel. Education about buprenorphine is needed before implementing a similar program in an EMS system.
Financial Disclosure: This work was funded by the UAMS Clinical Scientist Program to Mike Wilson. All Authors have no financial conflicts of interest to disclose.
Keywords: (3-6) buprenorphine, OUD, EMS, paramedic, emergency medical technician
Introduction
Opioid use disorder (OUD) and opioid overdose remain serious national crises in the United States (U.S.). In the 12-month period ending in April 2021, the Centers for Disease Control and Prevention (CDC) estimated 100,306 drug overdose deaths in the United States during the 12-month period ending in April 2021, an increase of 28.5% from the 78,056 deaths during the same period the year before.1 These grim statistics occur in the face of multiple strategies to combat opioid overdose, including drug take-back programs,2 the widespread distribution of naloxone3 and expansion of medications for OUD.4
One of the most efficacious treatments is medications for opioid use disorder (MOUD), particularly buprenorphine. Buprenorphine is a partial agonist at the mu-opioid receptor that both reduces cravings and withdrawal symptoms. Unlike methadone, another type of MOUD, buprenorphine, can be prescribed by emergency departments (EDs) rather than in a specially licensed treatment facility. Patients who receive buprenorphine from the ED have increased engagement in treatment,5 and the National Institute of Drug Abuse has recommended that all EDs offer buprenorphine.6
Perhaps not surprisingly, some researchers have even argued that, as an “invaluable ally” in the fight against overdoses,7 emergency medical services (EMS) should also offer buprenorphine in the prehospital setting. In one such trial,8 patients receiving care from buprenorphine-equipped ambulances by EMS were more likely to engage in OUD treatment and less likely to have a repeat overdose compared to patients treated by a non-buprenorphine-equipped ambulance.
Unfortunately, many buprenorphine programs, including a recent one in New Jersey9 have been initiated without asking EMS workers themselves about this practice. The rationale of the present study is that any change in the scope of practice that is this significant should only be undertaken after surveying prehospital workers themselves. Only limited research has assessed prehospital provider attitudes towards substance use disorder treatment in general,10 and no study has yet evaluated the acceptability of prehospital buprenorphine in particular.
Consequently, this study attempted to evaluate a range of possible beliefs about buprenorphine, including perceived barriers and facilitators to prehospital use, by utilization of the Consolidated Framework for Implementation Research (CFIR).11 Given the stigma of opioid overdose among the general public,12 persistent negative attitudes among prehospital/ED clinicians,13 and even slightly negative views about prehospital use of naloxone,14 the present study concentrated on perspectives of prehospital healthcare clinicians with different demographic and clinical experience characteristics.
Methods
Setting
A convenience sample of emergency medical personnel who attended a statewide EMS meeting15 in August 2019 in a southern state (Arkansas) was assessed. The rationale for choosing Arkansas is that this state has a rate of overdose that is higher than the national average, with a slower uptake of buprenorphine statewide.
Survey
A short 10-question survey was constructed using a 5-point Likert scale to examine respondent’s perspectives on the treatment of substance use disorders in general, buprenorphine as a treatment of OUD, and participation of EMS in the treatment of OUD on ten aspects of the treatment of OUD with buprenorphine. An open-ended question asked the respondents to identify barriers to implementing buprenorphine in the prehospital setting. The survey also requested information about clinical experience and other demographics but did not ask for identifying information such as name.
Clinical experience questions included license type, number of years of experience, and estimated number of opioid overdoses treated per shift. Demographic information included age, race, and gender. Survey responses were collected on tablet computers without oversight or interference by study investigators. The University of Arkansas for Medical Sciences Institutional Review Board reviewed and approved this project before data collection. The survey was piloted before its first use.
Analysis
Survey responses were grouped into two categories: somewhat/strongly agree vs neutral/strongly/somewhat disagree. Logistic regression models were used to examine the relationship between respondent demographic characteristics and clinical experience and the probability of somewhat or strongly agreeing on each of their beliefs about the treatment of MOUD. Each model included demographic characteristics, years of experience, license type and experience caring for overdose patients.
The survey included an open-ended question asking the respondent to identify barriers that could prevent the implementation of buprenorphine as a treatment used in the field by EMS personnel. Using thematic analysis, two authors (TH and MW) working independently categorized responses into different themes. As per best practices,16 these categorizations were documented with consensus agreement by authors. To ensure that the categorizations fairly captured disparate responses, authors with varying backgrounds were utilized (TH is a pharmacist with health services and qualitative research training/expertise in OUD; MW is a board-certified emergency physician).
Results
Table 1 provides descriptive statistics for the demographic characteristics of the 70 respondents (29 female, mean age 43) who completed the survey. The majority were male, white, and experienced emergency medical responders who were emergency medical technicians (EMT) or emergency medical technician paramedics (EMTP). Overall, EMS personnel agreed that people who use drugs have a treatable disease (see Table 2), although approximately 37% somewhat/strongly agreed with the statement, “Patients who overdose are not interested in treatment for their drug use.”
| Table 1: Demographic Characteristics of Survey Respondents (n=70) N (%) | ||
| Variable | ||
| Demographic information | ||
| Age (mean, sd, range] | 43.34 (11.29, 20-71) | |
| Sex * | Female | 29 (42.03) |
| Male | 40 (57.97) | |
| Race* | Native American | 2 (2.90) |
| White | 66 (95.65) | |
| Clinical experience | ||
| Years of Experience * | 0-5 | 12 (17.39) |
| 6-10 | 15 (21.74) | |
| 11-15 | 13 (18.84) | |
| 16 | 29 (42.03) | |
| License group a* | EMT | 25 (36.23) |
| EMT_P/AEMT | 32 (46.38) | |
| RN/Physician | 12 (17.39) | |
| Estimated number of opioid overdose patients treated per month a* | 0-5 | 46 (67.65) |
| 6-10 | 16 (23.53) | |
| 11-15 | 5 (7.35) | |
| 16 | 1 (1.47) | |
| * Missing data due to non-responders | ||
| Table 2: Grouped Question Responses (n=70) N (%) | ||
| People who use drugs have a treatable disease | Strongly/Somewhat Disagree/Neutral | 10 (14.29) |
| Somewhat/Strongly Agree | 59 (84.29) | |
| I do not know | 1 (1.43) | |
| People who use a lot of drugs should be treated with medications | Strongly/Somewhat Disagree/Neutral | 22 (31.43) |
| Somewhat/Strongly Agree | 46 (65.71) | |
| I do not know | 2 (2.86) | |
| People who use a lot of drugs should just stop immediately | Strongly/Somewhat Disagree/Neutral | 64 (91.43) |
| Somewhat/Strongly Agree | 5 (7.14) | |
| I do not know | 1 (1.43) | |
| Reversing the effects of drugs where possible should be the job of EMS | Strongly/Somewhat Disagree/Neutral | 18 (25.71) |
| Somewhat/Strongly Agree | 52 (74.29) | |
| Buprenorphine (Suboxone) helps people get off opioids | Strongly/Somewhat Disagree/Neutral | 21 (30.00) |
| Somewhat/Strongly Agree | 33 (47.14) | |
| I do not know | 16 (22.86) | |
| Initiating a medication that must be taken regularly to treat OUD should be part of the job of EMS personnel | Strongly/Somewhat Disagree/Neutral | 42 (60.00) |
| Somewhat/Strongly Agree | 28 (40.00) | |
| Patients who overdose are not interested in treatment for their drug use | Strongly/Somewhat Disagree/Neutral | 43 (61.43) |
| Somewhat/Strongly Agree | 26 (37.14) | |
| I do not know | 1 (1.43) | |
| Patients who overdose should not be started on medications like buprenorphine while in withdrawal | Strongly/Somewhat Disagree/Neutral | 45 (65.22) |
| Somewhat/Strongly Agree | 9 (13.04) | |
| I do not know | 15 (21.74) | |
| There are no doctors who prescribe buprenorphine (Suboxone) in my county of employment | Strongly/Somewhat Disagree/Neutral | 15 (21.43) |
| Somewhat/Strongly Agree | 10 (14.29) | |
| I do not know | 45 (64.29) | |
Table 3 presents the results of logistic regression models for the outcomes (or the variables of interest). In the logistic regression model, years of experience were associated with willingness to treat OUD. However, only sex was statistically significant for the statement “people who use a lot of drugs should be treated with medications,” with odds of somewhat/strongly agree with this statement 0.25 times for female clinicians compared to males (OR=0.25 95% CI: 0.07, 0.87).
Years of experience and license type were statistically significant for “initiating a medication that must be taken regularly to treat OUD should be part of the job of EMS personnel,” with respondents who had 6-10 years of experience being more likely to agree compared to those with 0-5 years of experience (OR=.003, 98.3% CI: <0.001, 0.27). The number of overdose patients cared for in the last month was not statistically significant for any of the variables. However, those who saw six or more overdose patients per month had nonsignificantly lower odds of agreeing with each statement except for “people who use drugs have a treatable disease” and “people who use a lot of drugs should be treated with medications.”
| Table 3: Logistic regression models examining associations between demographic, clinical characteristics and the outcomes | ||||||||
| Question | ||||||||
| People who use drugs have a treatable disease | People who use a lot of drugs should be treated with medications | People who use a lot of drugs should just stop immediately | Reversing the effects of drugs where possible should be the job of EMS | Buprenorphine (Suboxone) helps people get off opioids | Initiating a medication that must be taken regularly to treat OUD should be part of the job of EMS Personnel | Patients who overdose are not interested in treatment for their drug use | Patients who overdose should not be started on medications like buprenorphine while in withdrawal | |
| Variable: | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) |
| Demographic Characteristicsa | ||||||||
| Female vs male | 0.25 (0.06,1.17) | 0.25* (0.07,0.87) | 0.06 (0.003,1.15) | 1.18 (0.34,4.06) | 0.57 (0.14,2.40) | 1.90 (0.42,8.65) | 0.84 (0.25,2.77) | 0.59 (0.11,3.19) |
| Years of experience | ||||||||
| 6-10 vs 0-5 | 1.05 (0.14,7.88) | 0.91 (0.15,5.51) | 0.04 (0.001,1.52) | 0.96 (0.15,6.10) | 1.56 (0.18,13.75) | 0.003* (<0.001,0.12) | 0.29 (0.04,2.06) | 2.13 (0.06,74.26) |
| 11-15 vs 0-5 | 2.53 (0.29,21.90) | 1.46 (0.22,9.71) | 0.03 (<0.001,1.19) | 1.00 (0.15,6.67) | 2.63 (0.24,28.49) | 0.30 (0.04,2.49) | 1.13 (0.20,6.58) | 0.42 (0.01,29.17) |
| 16+ vs 0-5 | 6.18 (0.72,53.19) | 1.38 (0.28,6.88) | 0.07 (0.005,1.03) | 0.70 (0.14,3.42) | 1.83 (0.26,12.77) | 0.10 (0.01,0.72) | 1.99 (0.45,8.82) | 6.03 (0.26,137.9) |
| Number of overdose patients/month | ||||||||
| 6+ vs 0-5 | 1.44 (0.25,8.21) | 1.06 (0.29,3.89) | 0.14 (0.01,1.70) | 0.84 (0.25,2.87) | 0.27 (0.04,1.88) | 0.81 (0.20,3.24) | 0.74 (0.23,2.45) | 0.81 (0.16,4.02) |
| License group | ||||||||
| EMT vs RN, Physician | 0.18 (0.01,4.54) | 0.09 (0.01,0.88) | 1.01 (0.03,32.86) | 0.09 (0.00,1.65) | 0.31 (0.05,1.99) | 0.01* (<0.001,0.14) | 12.41 (1.21,127.0) | 1.74 (0.17,18.19) |
| EMT_P, AEMT vs RN, Physician | 0.08 (0.00,2.06) | 0.13 (0.01,1.33) | 1.36 (0.06,30.48) | 0.08 (0.00,1.46) | 1.39 (0.35,5.54) | 0.08 (0.01,0.75) | 9.49 (1.01,89.36) | 3.32 (0.41,26.78) |
*Significant at .05 level. Variables with more than two categories were corrected using Bonferonni p-value was used to adjust for multiple comparisons to the reference groups.
Logistic regression modeled the probability of somewhat or strongly agree.
Twenty-four respondents listed potential barriers to the implementation of buprenorphine initiation by EMS personnel. Some respondents listed more than one barrier, resulting in a list of 27 barriers. Thematically, barriers were grouped into five categories: cost, patient factors, education/EMS personnel knowledge (most common), administrative/regulatory issues, don’t know/unknown, and none.
Discussion
The results of this study suggest that the beliefs of EMS personnel in a small rural state may be a barrier to providing medications like buprenorphine. Approximately 60% of respondents disagreed with the statement, “Initiating a medication that must be taken regularly to treat OUD should be part of the job of EMS personnel.” However, respondents were more likely to agree with this statement if they had greater experience.
Given that education and knowledge were also frequently reported barriers, it may be that this attitude is amenable to change, although this study was unable to examine this. Nonetheless, these results suggest that an important first step in implementing buprenorphine programs is the education of EMS personnel. In addition, these results indicate that EMS may not be a “natural ally” of addiction medicine physicians, who may have little to no formal training in emergency medicine without further education on substance use disorders.
These analyses are subject to several limitations. First, the sample size is relatively small (n=70). However, each logistic regression model adhered to the general guideline of at least 10-20 participants for each binary outcome in the model.17 Second, these data are most generalizable to EMS in southern states, and it is possible that this sample is different from EMS personnel in other states. To the extent that this is true, we would hypothesize that the study sample should be more conservative regarding medications for opioid use disorder than in other areas of the country.
Conclusions
This study suggests that implementation of buprenorphine administration by EMS personnel may be limited both by the attitudes of the personnel and by knowledge about buprenorphine. EMS systems that wish to provide buprenorphine for patients with opioid overdoses should give significant consideration to educational interventions prior to implementation.
About the Authors
Teresa Hudson, PharmD, PhD, is the vice chair for Research and Professor in the Department of Emergency Medicine at the University of Arkansas for Medical Sciences in Little Rock, Arkansas.
Dennis R. Hudson, RN, is a nurse in the Department of Emergency Medicine at CHI: St. Vincent Infirmary in Little Rock, Arkansas.
Jade Beshears is a research assistant in the Department of Emergency Medicine at the University of Arkansas for Medical Sciences in Little Rock, Arkansas.
Xiaotong Han is a Biostatistician in the Department of Psychiatry at the University of Arkansas for Medical Sciences in Little Rock, Arkansas.
Michael P. Wilson, MD, is an associate professor in the Departments of Emergency Medicine and Psychiatry at the University of Arkansas for Medical Sciences in Little Rock, Arkansas.
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