By Jim Lloyd, interviewing Dr. Alexis LaPietra
In the face of persistently high rates of opioid overdose and very high risks of subsequent adverse outcomes faced by individuals who survive overdoses, New Jersey hospitals are innovating to improve care for individuals treated for overdose in their emergency departments, implementing multiple interventions to help engage these individuals with lifesaving medication for treatment for opioid use disorder, such as buprenorphine. A particular focus of intervention has been in the Robert Wood Johnson Barnabas Health System (RWJBH). To understand these innovations, we interviewed Dr. Alexis LaPietra, DO, FACEP, the System Director of Addiction Medicine at the RWJBH System and Medical Director for RWJBH’s Institute for Prevention and Recovery (IFPR). We spoke with Dr. LaPietra about RWJBH’s initiatives, and the whys and hows of improving care for New Jerseyans with opioid use disorder (OUD).
Q: Can you describe the origins of your program for us, briefly?
Dr. LaPietra: In the RWJBH system, despite having made peer support available 24/7 in the ED [emergency department] and hospital setting since 2016, there was almost no utilization of medications for opioid use disorder within the RWJBH acute care setting. In 2023, Dr. Chris Freer decided to make buprenorphine administration and prescribing for naloxone-reversed ED patients one of the three emergency department quality metrics for 2023-2025. This represented a major culture change in the organization, as the quality metrics identified are highlighted as a priority by leadership and linked to incentives for physicians, so everyone pays close attention. I was brought on to a brand-new role as System Director of Addiction Medicine as well as Medical Director of IFPR with the expectation that I would provide support and continued education and guidance for the entire care team. I worked with our twelve hospital sites to increase the rate of buprenorphine administration in our EDs, and to increase distribution of naloxone kits to patients discharged from the ED.
Q: How did implementation go, once you decided to put this in place?
Dr. LaPietra: One of the first things we did was get physicians enrolled in electronic prescribing. Buprenorphine is a Schedule III controlled substance, and electronic prescribing is preferred, and we worked with RWJBH’s IT team and ED leadership to get every physician enrolled. We also developed a “Smart Set” in our electronic health record (EHR) for OUD care, so it was treated the same way as many other common ED conditions. Navigating the >20 different prescription options for Buprenorphine in the EHR complicated treatment, and the Smart Set presented to physicians a preset grouping of formal diagnoses, appropriate prescriptions, and discharge instructions for the patients. But we’re still evolving and getting better every day. We provide foundational and continued support for nursing and the medical team about the neurobiology of OUD, why it’s a medical disease, why we need to treat it, how we treat it, and what success looks like.
Q: Turning to those successes, how have you been measuring success for the program?
Dr. LaPietra: Because the EDs administered buprenorphine to less than 1% of OUD patients in 2022, we set the year one mark for buprenorphine prescribing for naloxone-reversed patients at 25% and our current year two goal is 50%. The end of year one data (which was June through November 2023) showed we provided 30.2% of naloxone-reversed opioid overdose patients buprenorphine, which was about 230 patients. Our physicians are also providing buprenorphine to OUD patients who present for other reasons. Between June and November 2023, we wrote over 1,000 total buprenorphine scripts across our EDs.
Q: Thanks so much for this conversation. We can’t wait to see the impact of your work in the coming years. Any final thoughts you’d like to share with us and readers?
Dr. LaPietra: First, I have to acknowledge that IFPR has played a massive role in the program’s success, along with the IFPR’s data team who play a huge role in analyzing our treatment patterns and keeping ourselves accountable. Looking forward, we’re currently expanding MOUD [medications for opioid use disorder] programming to the inpatient hospitalist and maternal health teams, and building additional order sets, protocols, and education. We’re focused on rebuilding trust within the community so those suffering from SUD [substance use disorders] understand we want to provide stigma-free medical care in a trauma-informed, evidence-based manner. Robust SUD programming and the ability for physicians to engage with and treat any patients presenting in all healthcare settings is the ultimate goal.