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Cosmos Study

Buprenorphine Prescriptions Remain Uncommon After Opioid-Related ED Encounters 

July 31, 2023
Dual-Team Study
Team A:Dave Little, MD, MSAndrea Singletary, NRAEMTEric Barkley
Team B:Kersten Bartelt, RNTed Stamp

Key Findings

  • Although prescribing rates have increased since 2015, buprenorphine was prescribed in 7.6% of opioid use disorder (OUD) emergency department (ED) encounters and 1.6% of opioid overdose ED encounters that did not result in an admission in the second quarter of 2023. 
  • Males were 36% more likely than females to be prescribed buprenorphine after an OUD ED encounter in the second quarter of 2023. 
  • In that same quarter, Hispanic patients were 70% more likely than non-Hispanic White and 77% more likely than non-Hispanic Black patients to be prescribed buprenorphine for OUD. 

Buprenorphine is a medication that can be used to treat opioid use disorder (OUD). Unlike other medications for OUD, buprenorphine can be prescribed and dispensed to patients to take with them for ongoing treatment.1 However, until 2023, an additional waiver was required to prescribe buprenorphine, limiting which providers could prescribe the medication.2 That requirement was removed as part of the Mainstreaming Addiction Treatment Act (MAT Act) in December 2022, which expanded the number of clinicians that could prescribe buprenorphine.3 

The American College of Emergency Physicians (ACEP) recommends initiation of buprenorphine in the ED to help facilitate increased rates of outpatient treatment and decreased drug use for those diagnosed with OUD.4 We sought to understand whether the proportion of patients prescribed buprenorphine in the emergency department (ED) has changed over time.  

We studied 542,381 OUD and 271,272 opioid overdose ED encounters from January 2015 through June 2023 to assess whether the proportion of patients prescribed buprenorphine changed over time. We excluded patients who had an active or reported buprenorphine, methadone, or naltrexone prescription prior to their ED visit. We found that the percentage of OUD ED encounters where buprenorphine was prescribed increased over time from 0.1% of encounters in the first quarter of 2015 to 7.6% of encounters in the second quarter of 2023. Comparatively, the percentage of opioid overdose encounters with a buprenorphine prescription also increased over the same time period but reached only 1.6% of opioid overdose encounters in the second quarter of 2023, as shown in Figure 1.  

Figure 1
Opioid Use Disorder and Opioid Overdose ED Encounters with Buprenorphine Prescription
Opioid Use Disorder and Opioid Overdose ED Encounters with Buprenorphine Prescription
Figure 1. Rate of ED OUD and opioid overdose encounters with a buprenorphine prescription by quarter from Q1 2015 to Q2 2023.

The increase in OUD and overdose encounters prescribed buprenorphine since the removal of the additional waiver requirement does appear to be rising at a greater rate than previous years, but it remains to be seen whether the increase in buprenorphine prescriptions will be maintained over time. We did not observe a difference in prescribing rates between initial and subsequent encounters for OUD or overdose. 

Men have been consistently more likely to receive a buprenorphine prescription than women after an OUD encounter, with men about 36% more likely to receive a prescription than women in the second quarter of 2023. In that same quarter, Hispanic patients were 77% more likely than non-Hispanic Black and 70% more likely than non-Hispanic White patients to receive a buprenorphine prescription after an OUD encounter.  

Figure 2
Opioid Use Disorder ED Encounters with Buprenorphine Prescription by Sex and Race
Opioid Use Disorder ED Encounters with Buprenorphine Prescription by Sex and Race
Figure 2. Rate of OUD ED encounters with a buprenorphine prescription in Q2 2023.

These findings support the need cited by the Substance Abuse and Mental Health Services Administration (SAMHSA) for more providers to initiate treatment for OUD.3 

These data come from Cosmos, a HIPAA-defined Limited Data Set of more than 196 million patients from 208 Epic organizations including 1,197 hospitals and more than 25,400 clinics, serving patients in all 50 states and Lebanon. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. 

References

  1. Substance Abuse and Mental Health Services Administration. What is Buprenorphine? SAMHSA. What is Buprenorphine? | SAMHSA Accessed July 18, 2023. 
  2. Substance Abuse and Mental Health Services Administration. Waiver Elimination (MAT Act). SAMHSA. Waiver Elimination (MAT Act) | SAMHSA Accessed July 18, 2023. 
  3. US Department of Health and Human Services. 86 FR 22439: Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. Federal Register :: Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. Published April 28, 2021. Accessed on July 18, 2023. 
  4. Hawk K, Hoppe J, Ketcham E, et al. Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2021;78(3):434-442. doi:10.1016/j.annemergmed.2021.04.023