Opioid use disorder (OUD) affects millions of Americans and has contributed to hundreds of thousands of overdose deaths in the past few years (Centers for Disease Control and Prevention, 2022). Medications for opioid use disorder (MOUD), including buprenorphine, are the best available treatment for people with OUD and provide protection against relapse, overdose and death (Blanco & Volkow, 2019), yet many patients lack access to MOUD (Zuckerman et al., 2020). Emergency departments (EDs) are important points of intervention for patients with OUD. People who have experienced overdoses are often brought to EDs for treatment; EDs are also a setting where less acute OUD-related conditions are treated, and OUD is discovered via screening or other means. ED physicians can administer and prescribe buprenorphine to patients presenting with OUD, initiating treatment immediately from the ED. However, EDs frequently discharge patients without prescribing buprenorphine and instead deliver other OUD interventions or link patients to community-based care (Substance Abuse and Mental Health Services Administration (SAMHSA), 2021).
Using mixed methods, we sought to understand ED practices related to buprenorphine administration and prescribing in New Jersey. First, we analyzed 2017–2022 NJ Medicaid claims data to examine Medicaid-enrolled patients who presented to the ED with an OUD-related diagnoses code and received buprenorphine. Next, we interviewed leaders in EDs with varying levels of administration and prescription of buprenorphine to better understand hospital practices, facilitators, and barriers to the provision of buprenorphine. Results from this study have been published in JEM Reports (Bowden, et al., 2026).
Our quantitative results show that receipt of buprenorphine among NJ Medicaid beneficiaries immediately following an opioid-related ED visit increased from 4.0% in 2018 to 14.4% in 2022. Despite this growth, only a small fraction of total patients presenting with OUD in EDs were prescribed buprenorphine throughout the study period. Qualitative interviews with ED leaders illuminated numerous barriers to the provision of buprenorphine, including patient resistance, insurance barriers, regulatory and pharmacy obstacles, and a lack of local outpatient and community connections. In addition, the overall culture of the ED and providers’ limited education and training, stigma, misconceptions, and general conceptualization of the ED environment as a place to initiate longer-term treatment were the most significant challenges for increasing the provision of buprenorphine.
Despite these challenges, a consistent facilitator cited in the qualitative interviews was the presence of peer navigator programs. Peer navigators increased capacity to handle the growing population of OUD patients, supporting tasks like care coordination, treatment education, and outpatient appointment scheduling. In EDs where peer navigators were embedded within the hospital, interviewees spoke highly of their value as a part of the team. An additional facilitator discussed in the qualitative interviews was the shift in the workforce towards physicians whose medical training included more education on OUD and its treatment.
Several policy implications can be drawn from our findings. First, continued investment in medical education surrounding OUD and MOUD is imperative in training the workforce to be comfortable and confident in treating patients with OUD. Second, further integration of peer navigators into the healthcare system should be prioritized, given the additional support they can provide to practitioners in the busy ED environment. Third, states and health care organizations should consider greater investment in physical space and resources in EDs, to provide dedicated space to deliver interventions for patients with OUD, particularly those with complex behavioral and social needs. Fourth, EDs and community-based providers should focus on establishing strong connections to facilitate warm hand-offs from the ED. Finally, for EDs that administer and prescribe MOUD, our findings support the need for clinical guidelines, rather than policies, to aid clinical decision making.