(23) The Impact of Mandatory Buprenorphine Training for Emergency Medicine Residents

Background & Introduction: As the opioid epidemic continues to surge, with mortality rising annually (1) and a rise in Emergency Department (ED) visits resulting from opioid misuse (2), increasing access to treatment is a priority. Training medical students, residents, and fellows with a standardized substance use disorder (SUD) curriculum is thus a cornerstone. In 2019, the Accreditation Council for Graduate Medical Education required all graduate medical education programs to incorporate addiction training into their curricula. Additionally, Emergency Medicine (EM) organizations have adopted policies supporting the use of medications for opioid use disorder (OUD). (3) Yet, a SUD curriculum, particularly OUD education and training, is not standardized or incorporated into EM resident education nationally. Programs that have incorporated addiction training into their curricula have shown tremendous success in improving knowledge and reducing the stigma of OUD treatment among residents. (4) However, no study has explored the effects of a standardized SUD curriculum and buprenorphine (previously “X-waiver”) training on residents post-graduation. This study seeks to examine the impact of this intervention on graduated residents' practice and comfort with treating patients with SUD. Additionally, we aim to explore the perceptions of the SUD curriculum and mandatory buprenorphine training on graduated residents' career opportunities and successes.

Methods: We successfully implemented an overall SUD curriculum with mandatory buprenorphine training for residents starting in 2018.(5) Before 2018, residents received SUD training solely through clinical experience and a limited lecture series. The authors of this poster utilized a running list of contact information from physicians who have completed EM residency between 2016 and 2022. EM residents were excluded if they had not completed the survey or had yet to graduate from EM residency. The study team sent recruitment emails to these eligible participants with a unique link to the survey. The survey asked about their current career and whether the SUD curriculum at Cooper had improved their career. One open-ended question was asked: “If your career was impacted by education and training at Cooper in SUD and medications for opioid use disorder/X-waiver training, please explain below.” The participants were compensated for completing the survey. For the analysis, answers were grouped into three groups: all graduated residents, graduated residents who received SUD training solely through clinical experience and a limited lecture series (2016-2017), and graduated residents who received a standardized SUD curriculum (2018-2022).

Results: Of the 80 graduated residents invited to complete the survey, 63 (78.8%) responded and finished the survey. Most graduated residents worked in an urban setting (58.7%) within a community hospital (60.3%). Overall, 71% of the graduated residents were currently prescribing buprenorphine, and 92% of them had received their X-waiver. Half (50.8%) of the graduated residents were working within an ED that had a formal protocol for buprenorphine initiation or dosing; of those graduated residents, 12.5% had helped create that protocol.

In our next analysis, we separated the graduated residents into two groups: before the standardized SUD curriculum was added to the program (pre-curriculum) (2016-2017) and after the curriculum was in place (post-curriculum) (2018-2022). We found that 58.8% of pre-curriculum graduated residents prescribed buprenorphine to their patients currently, while 77.8% of the post-curriculum residents were currently prescribing buprenorphine to their patients. Of the post-curriculum graduated residents, 93.5% felt that they were better prepared to treat patients with SUDs than their colleagues where they work now, and 36% of them said education and training at Cooper in SUD and medications for opioid use disorder had positively impacted their careers. Lastly, of the post-curriculum graduated residents who answered the open-ended question, “If your career was impacted by education and training at Cooper in SUD and medications for opioid use disorder/X-waiver training, please explain.”71.7% said the training had a positive effect on their careers. Examples of positive answers included:

● “I was asked to help with the group creating the bupe initiation protocol since it was known that I had great SUD training coming from Cooper. It was mentioned on my initial interview for an academic position.”
● “Gave me tools to work with this patient population in the ED. Increased my interest in treating opioid use disorder and learning more, contributed to me choosing a fellowship in addiction medicine. My training empowered me to provide better care to my ED patients.”
● “My training has helped me build my career in the ED as well as in public health, working with overdose systems of care and building networks for treatment for patient with OUD.”

Conclusion & Discussion: To our knowledge, this is the only study that examines the effects of a standardized SUD treatment and mandatory buprenorphine training on EM residents post-graduation. We found that the residents who graduated from the ED residency were more likely to prescribe buprenorphine and receive their X-waiver than the national average.(6) The graduated residents who received standardized SUD curriculum and mandatory buprenorphine training felt that they were better prepared to treat SUD patients with SUDs than their colleagues where they work now and that this training had positively impacted their careers. A limitation of this study is that all EM residents at this hospital were exposed to a higher than average population with SUDs and had access to a robust outpatient referral capacity. While the X-waiver is no longer mandatory for prescribing buprenorphine, residency training remains essential to promote the implementation of evidence-based addiction treatment in the emergency department.

References: 1. Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2022.
2. Soares WE 3rd, Melnick ER, Nath B, D'Onofrio G, Paek H, Skains RM, Walter LA, Casey MF, Napoli A, Hoppe JA, Jeffery MM. Emergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care Systems. Ann Emerg Med. 2022 Feb;79(2):158-167.
3. Hawk K, Hoppe J, Ketcham E, et al. Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department. Annals of Emergency Medicine. 2021.
4. Gonzalez, Miriam, et al. "The impact of educational interventions on attitudes of emergency department staff towards patients with substance-related presentations: a quantitative systematic review." JBI Evidence Synthesis 15.8 (2017): 2153-2181.
5. Gruber, E., Zapp, Z., Pescatore, R., Salzman, M., Haroz, R., & Nyce, A. (2017). 177EMF Development of a Sustainable Curriculum on Substance Use Disorders for Emergency Medicine Residents at Cooper University Hospital. Annals of Emergency Medicine, 70(4), S71.
6. Yu, M.J.; Hawk, K. Resident attitudes, experiences, and preferences on initiating buprenorphine in the emergency department: A national survey. AEM Educ. Train 2022, 6, e10779.