June 13, 2019

EMBED: Pragmatic trial of User-centered clinical decision support to implement EMergency department-initiated BuprenorphinE for opioid use Disorder

Opioid use disorder (OUD) is a major public health concern taking a devastating toll on Americans, their families, and communities. An estimated 2.1 million Americans had an opioid use disorder in 2017, and 47,863 died from an opioid-related overdose. [1,2] The emergency department (ED) frequently care for patients with OUD. Buprenorphine/naloxone (BUP), a partial opioid agonist combined with an antagonist, has been shown to be an effective OUD treatment. [3,4] In 2015, D’Onofrio et al. demonstrated that initiation of BUP in the ED followed by referral to outpatient medication for opioid use disorder (MOUD) treatment programs was nearly twice as effective compared to just brief intervention with referral in retaining OUD patients in formal addiction treatment at 30 days. [5]

Despite the proven efficacy of ED-initiated BUP, this is currently not part of routine ED care.[6–8] One of the major challenges to implementation evidence-based practices is poor usability and workflow integration of health information technology. As such, well-designed clinical decision support (CDS) that streamlines ED workflow presents a potential solution to accelerating the adoption of this best practice. The EMBED (Emergency Department-Initiated Buprenorphine for Opioid Use Disorder) project is a multicenter, pragmatic, parallel cluster randomized trial currently in the UG3 grant planning phase. The EMBED team has developed a user-centered CDS which guides ED clinicians to initiate BUP treatment for OUD patients and facilitate outpatient referral with MOUD sites. A key focus of the project has been incorporating user-centered design to create an automated, rapid CDS which simultaneously provide a direct care pathway and flexible decision support with minimal disruption to normal ED EHR workflow. The trial aims to increase ED-initiated BUP and ultimately improve OUD patient retention in MOUD treatment with its user-centered CDS.

More information on the EMBED project can be found here.

The first EMBED-related manuscript, "Computerized Clinical Decision Support System for Emergency Department–Initiated Buprenorphine for Opioid Use Disorder: User-Centered Design,” is now published at JMIR Hum Factors 2019;6(1):e13121 doi:10.2196/13121. Link.

  1. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health [Internet]. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2018. Report No.: SMA 18-5068. Available: https://www.campusdrugprevention.gov/sites/default/files/files/2017%20NSDUH%20Findings.pdf
  2. Products - Vital Statistics Rapid Release - Provisional Drug Overdose Data [Internet]. 11 Dec 2018 [cited 10 Jan 2019]. Available: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
  3. Sullivan LE, Fiellin DA. Narrative review: buprenorphine for opioid-dependent patients in office practice. - PubMed - NCBI [Internet]. [cited 10 Jan 2019]. Available: https://www.ncbi.nlm.nih.gov/pubmed/18458279
  4. Larochelle MR, Bernson D, Land T, Stopka TJ, Wang N, Xuan Z, et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Ann Intern Med. 2018;169: 137–145.
  5. D’Onofrio G, O’Connor PG, Pantalon MV, Chawarski MC, Busch SH, Owens PH, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA. American Medical Association; 2015;313: 1636–1644.
  6. Sharfstein JM. The Opioid Crisis From Research to Practice. Milbank Q. 2017;95: 24–27.
  7. We have the tools needed to cut overdose death rates by half — but we aren’t using them. In: Paperpile [Internet]. [cited 6 Aug 2018]. Available: https://paperpile.com/app/p/964b2025-4e4d-0756-9b7a-d12f213481d7
  8. Walsh L. Buprenorphine Waiver Management | SAMHSA - Substance Abuse and Mental Health Services Administration [Internet]. [cited 17 Jul 2018]. Available: https://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/training-materials-resources/buprenorphine-waiver 

Jodi Mao, B.A.
MD Candidate | Class of 2021
Eastern Virginia Medical School

Ted Melnick, MD, MHS
Lead Researcher on EMBED
Assistant Professor of Emergency Medicine
Director of Clinical Informatics Fellowship, Yale