Background
Methods
Sampling
Data collection
Data analysis
Results
1. Variable management of opioid withdrawal i. “I think it’s a much more nuanced decision-making process to deal with withdrawal than with a patient who is acutely intoxicated and not breathing, someone you can use naloxone with as an intervention.” (Physician 12) ii. “I have a lot less experience treating people with opioid withdrawal than with an overdose and that I find can be extremely frustrating.” (Physician 19) iii. “There are some physicians who just simply take more time in terms of providing patient education and some who do less of that because of time restraints. There’s also variability in terms of physician interest in the subject matter. There’s variability in terms of what physicians feel should be done about these issues and what they feel their role is in the whole realm of addictions.” (Physician 4) iv. “I think more and more in terms of habits, people are comfortable using [buprenorphine].” (Physician 12) v. “There are a variety of different medications that you can use to deal with these people when they’re leaving. There’s low doses of clonidine, NSAIDs and laxatives. Before you discharge them, you want to sure that people are comfortable enough to leave. It depends on what kind of symptoms they’re having, whether or how quickly you’re able to discharge them.” (Physician 13) vi. “Clonidine is something that people have been using for a long time and using acetaminophen and naproxen to treat other symptoms of withdrawal. I think those things people are comfortable with and have been using for quite a while. I suspect there’s probably some people that give opiates and some people that give a lot of benzodiazepines, but I don’t. Some people, they give nothing and say no one dies of opiate withdrawal. I think it probably varies a lot.” (Physician 19) vii. “As a group we’ve decided we would not like to prescribe narcotics. I think there’s still a large number of other individuals that take other stances. Oh well, it’s Friday. Oh well, this person’s a nuisance. I’m just going to write whatever it is and give it to them and get them out of the department. I think that still goes on.” (Physician 8) viii. “Opioid withdrawal is not terribly successful. We don’t have the same medications as we do for alcohol withdrawal and I don’t think they’re effective.” (Physician 15) ix. “We never would have given them naloxone kits. We never would have given the buprenorphine. So all that is pretty new.” (Physician 13) |
1. Departmental champions support physician knowledge i. “I did not have formal training. Before [physician] came along and started working in our department, I never used it. I was aware it existed, but I never had any exposure. Once [physician] came along, they provided some guidelines on paper and gave some presentations to the group.” (Physician 1) ii. “I’ve never started it before, but I would be quite happy to start it now that there’s a order set that I can use and other colleagues that I work with that I can ask about it.” (Physician 5) iii. “I was able to prescribe [buprenorphine] with [physician] supporting me on What’sApp.” (Physician 19) iv. “You know it’s easy to approach [physician] and say, ‘here’s a situation I had, what do you think I could have done with that?’ So that is how I got my exposure.” (Physician 1) v. “[Physician] has also given us follow up stories, success stories essentially, of people who have followed up in the clinic and have significantly decreased their use of opioids. I found that very helpful.”(Physician 6) 2. Physician empowerment & patient satisfaction i. “I can describe two scenarios where the patient went from uncomfortable … just kind of “suffering through it” withdrawal where they know it is going to get worse … they went from feeling awful to smiling. One of them just shook my hand before leaving. He tracked me down and said thank you and then left, which is not necessarily part of my interaction with patients. It’s above and beyond to see that reaction in a patient. There are very few patients that feel that great when they leave the ED. I think it’s been quite positive.” (Physician 10) ii. “I don’t know what the outcomes are, I’ve heard they are good but the patient satisfaction when they leave the ED with an almost near resolution of their symptoms after one or two doses in most cases … it seems to be a positive from what I see.” (Physician 11) iii. “I’m giving someone who has a substance abuse issue a benzodiazepine and potent hypertensive medication to just go home with. I think they were never fully satisfied, and I was never satisfied with the interaction.” (Physician 7) iv. “It’s kind of fatiguing as a doctor to be like “No, I can’t fix this, I can’t fix that. We don’t do anything with this.” It is the helpless and useless which we do not like feeling. And so now that there is a tool in our hands, it has inspired us a bit. I feel this collectively in hearing how other people deal with patients. I think people feel a little bit more inspired to engage and to problem solve with patients, to counsel and positively support them … because we feel like we have something instead of nothing.” (Physician 19) 3. Order sets i. “Now that we have the order set, it makes it so much easier. It empowers people to use it because if someone looks at this, there are very straightforward including inclusion criteria, exclusion criteria. It’s become a lot easier to operationalize this knowledge not having to look it up on third party sources, about the proper dosing, the proper COWS threshold for instance, just all this stuff that we have had to find in other places. To have the institution and the Department behind a reviewed order set certainly empowered even myself. I think it has been a big change.” (Physician 12) ii. “We’ve got a good explanation hand out for patients and a good walk through for a physician with dosing suggestions and how to assess withdrawal. Given that it wasn’t part of my training formally, I’ve really found it helpful to have that resource.” (Physician 10) 4. Timely access to follow-up care i. “If there was no follow up for the patients, I wouldn’t go prescribing buprenorphine.” (Physician 2) ii. “It’s great when patients come in Monday evening, you can treat them accordingly and all they have to do is show up at a [follow-up clinic] at 9 am and an addiction specialist and a team will see them. I think that’s a great message to send to patients and its a great follow up plan that we have.” (Physician 12) iii. “If I’m sending patients with opioid withdrawal on [buprenorphine] on a Friday evening, then there’s a barrier to me saying they can see someone on Monday - I just feel its like too much time.”(Physician 11) |
1. Lack of knowledge & experience among the care team i. “The ones who are a little bit trickier is sometimes we see people who present with the gastrointestinal side effects. So, lots of diarrhea and stomach cramps. Those are cases where I find sometimes it is a bit harder to tease out and they may be in people who are misusing their prescribed opiates.” (Physician 19) ii. “I think generally people are not comfortable and don’t think that prescribing [buprenorphine] is a good idea in an emergency setting because of concern about precipitating withdrawal.” (Physician 4) iii. “The only thing I worry is that, and I have not looked this up myself, is long term safety. So do we know that this is a good long term intervention or the possible harm that we just haven’t encountered yet because we don’t have the numbers or the research for it that we’re going to pick up in five or 10 years.” (Physician 16) iv. “When I ordered it the nurses were almost all like “what’s a COWS”. They had never heard of COWS the first time I did it and that was after it had been going on for a little while.” (Physician 19) v. “[Buprenorphine] was supposed to kind of package it all together and so even though we have suboxone readily available there’s a lot of gray area where it can’t be prescribed. And so then we still don’t know what to do with those patients.” (Physician 9) vi. “Sometimes it was other co-diagnoses like mental health disorders that made it challenging for them to organize the new information. And sometimes it was just someone who had been to our hospital like over 150 times with overdoses and he’s just so unwell that he isn’t able to be open to a new idea.” (Physician 10) vii. most of the time my patients arrive, and it is too short a time frame since their last consumption. By the time we get to the point of having a conversation about taking a prescription of that stuff home quite often they are ready to bolt and they’re not prepared to consider it.” (Physician 1) viii. “If they are on methadone, it’s not a medication we can really give them.” (Physician 10) 2. Patient disposition and behavior i. “I would say it’s challenging: rarely an easy interaction, rarely do they understand the consequences of what happened especially if they’ve been given Narcan because they often don’t have a recollection of the events and don’t believe what you’re telling them.” (Physician 16) ii. “The challenge, the biggest point of conflict I find is often when someone should probably stay but they want to go home. We don’t think it’s safe for them to leave. It can be really challenging trying to decide: are they competent to make the decision? Do you restrain them and keep them here?”(Physician 19) iii. “When I refuse to give them [opioids], the first step that they usually go for is “well get somebody else here” … that they want to see another doctor. I will not give them that. Then they’ll say, “well I’m going to complain to the hospital” and … “I’m going to report you to the college” and I’ll say “be my guest”. Then they’ll start calling me names and swearing at me and using foul language and that’s usually when I get security to escort them out.” (Physician 2) iv. “Some people have told me “Look I’m not interested. I’ve tried it and I don’t like it.” (Physician 10) 3. Logistical constraints i. “When people come in intoxicated or in withdrawal, they take up a bed for a long time … And so our gut reaction is “we have a busy emergency department and now you’re being demanding of my time and a pain”. It takes time with repeated doses in the emergency department.” (Physician 19) ii. “I don’t think that we can be doing a good job at providing all that counseling ourselves. So given the volumes of patients that we see typically, the length of the interaction with each patient, I don’t think its feasible.” (Physician 14) iii. “They are very high users of the emergency department, and you can put in a little bit of time upfront and decrease their burden on the department.” (Physician 11) iv. “I think ED overcrowding plays a big role in our management of patients in withdrawal … the issue of physical space is not without significance.” (Physician 19) v. “Some people sometimes are reluctant to talk about them in the hallway if they’re in a hallway stretcher because they don’t want everybody else around to hear what their problems are.” (Physician 4) 4. Initiating a chronic medication in an acute care setting i. “[Buprenorphine] is really a chronic medication that people will start and continue taking indefinitely. And you know it’s a bit of a philosophical change. I don’t think most ER doctors like the idea of prescribing medications that are used long-term.” (Physician 15) ii. “I think that its akin to saying like do you start blood pressure medications in the emergency department. The patients who are hypertensive. And I have to say that a lot of my colleagues do not because we don’t have a way of following up on those prescriptions.” (Physician 14) iii. “Follow up, repeated prescriptions and … titration of dose would be the other thing. We don’t really aim to provide that in the ER for pretty much any other condition mostly because we don’t intend on seeing you ever again. That’s our philosophy.” (Physician 15) iv. “[Buprenorphine] is not necessarily a medication that I thought would be an emergent use but the more that I see that it can kind of quench some of the significant opioid withdrawal symptoms ... I think once we kind of heard that as a group there was more of an acceptance of using this medication in the emergency department.” (Physician 6) v. “The patients that I have prescribed it for, I’ve had a good response from them initially whether those patients continue to do other follow up and things like that I have no idea.” (Physician 18) vi. “I think the biggest thing is the follow up is unclear always. I mean we initiate these things and we don’t know whether our initiation of them is having an actual positive effect. It’s not really a barrier to our starting it but I guess it’s more if we are starting it, is it definitely helpful or not?” (Physician 3) |