Initiating buprenorphine in New Jersey emergency departments: a mixed methods study

Background: Emergency departments (EDs) represent a critical touchpoint in the treatment of opioid use disorder (OUD), yet evidence-based practices such as buprenorphine initiation have not been widely adopted. Objectives: This study describes state-wide uptake of buprenorphine by Medicaid-enrolled patients with OUD who are seen in New Jersey (NJ) EDs and examines related clinical ED practices. Methods: This sequential mixed-methods study used NJ Medicaid claims and qualitative interviews with ED leaders. Quantitative analyses included NJ Medicaid enrollees aged 18–64 treated in NJ EDs for OUD-related diagnoses. The primary quantitative outcome was ED-associated buprenorphine utilization, defined as buprenorphine that was dispensed or filled 0–4 days after ED discharge. Results of the quantitative analyses were used to classify EDs as higher and lower prescribing, from which ED leaders were then purposively sampled to participate in semi-structured interviews. Qualitative data were analyzed inductively. Results: Overall buprenorphine initiation peaked at 14.4 % in 2022 and there was wide variation across EDs. Interviewees commonly reported that peer navigator programs, availability of community-based providers, and a positive culture toward MOUD facilitated buprenorphine initiation. Conversely, provider hesitancy, limited community resources, and regulatory factors were reported as major barriers. Conclusions: While volumes of patients presenting to NJ EDs with OUD remain high, low rates of buprenorphine initiation and prescription persist. Providers and institutions possess great variation in their comfort with and ability to initiate buprenorphine in the ED and future work to standardize this evidence-based practice is needed.