A qualitative assessment of emergency physicians’ experiences with robust emergency department buprenorphine bridge programs

Emergency departments (EDs) are a critical point of entry into treatment for patients struggling with opioid use disorder (OUD). When initiated in the ED, buprenorphine is associated with increased addiction treatment engagement at 30 days when initiated. Despite this association, it has had slow adoption. The barriers to ED buprenorphine utilization are well documented; however, the benefits of prescribing buprenorphine for emergency physicians (EPs) have not been explored. This study utilized semistructured interviews to explore and understand how EPs perceive their experiences working in EDs that have successfully implemented ED bridge programs (EDBPs) for patients with OUD.


INTRODUC TI ON Background
The Centers for Disease Control and Prevention estimated more than 105,000 overdose deaths in the United States in 2022, with more than 82,000 deaths involving opioids. 1 As the opioid epidemic continues, only 13.4% of patients with opioid use disorder (OUD) receive evidence-based treatments. 2 There are three FDA-approved medications for OUD (MOUD): methadone, buprenorphine, and extended-release naltrexone (XR-NTX).Methadone and buprenorphine are considered criterion standard treatments. 3cessibility remains one of the biggest barriers for patients to receive such care. 4To alleviate the obstacles to care, the emergency department (ED) has become a critical point of entry into treatment for patients struggling with OUD. 5 In the United States, between 2005 and 2017, ED opioid-related encounters increased by approximately 180%. 6][9][10] Mortality rates after ED visits for nonfatal opioid overdoses are high; more than 5% of patients discharged after a nonfatal overdose die within 1 year. 11Because of this risk and the increased number of patients with OUD seeking treatment in the ED, it is a perfect venue to initiate MOUD.3][14][15] Emergency physicians (EPs) can use buprenorphine to initiate treatment and manage withdrawal.[18] A much-studied model is the "emergency department bridge program" (EDBP), in which MOUD is initiated in the ED, and the patient is then followed up urgently in an affiliated longitudinal clinic designed to stabilize patients further and support them with long-term care.The EDBP model has been shown to be effective. 19Identified barriers to adopting buprenorphine in the ED include lack of department support, limited follow-up services, and EPs holding negative views toward initiating buprenorphine in the ED. 20[23][24][25][26]

Goals of this investigation
The potential benefits to physicians of a successfully implemented EDBP have not been explored.In this cross-sectional study, we utilized qualitative methods to explore and understand how EPs make meaning of their perceptions and experiences treating patients with OUD within an EDBP model.EPs who work in EDs that have successfully implemented buprenorphine programs for patients with OUD (EDBP) were interviewed.A priori, we hypothesized that EPs would report the benefits of these programs, including improved care for their patients with OUD and decreased moral injury.

ME THODS Eligibility criteria and recruitment
To be eligible for this study, physicians had to be board certified in emergency medicine, possess a DEA waiver to prescribe buprenorphine (the "X-waiver," which has since been abolished but was in place during this study), have self-reported to have written ≥10 buprenorphine prescriptions after board certification, and not be an addiction medicine fellow or board certified in addiction medicine.
The physicians must work in the ED while prescribing buprenorphine to be invited to participate in the study.The authors of this paper understand that some hospitals have "bridge clinics" within their ED that serve patients with substance use disorders.8][29] The four urban academic EDs were selected because they are known to the last author as institutes that have robust ED bridge programs.Key stakeholders (RH, AH, JH, ML) recruited participants who were employed to work within the ED at one of four urban academic hospital systems.The stakeholders were known to the last author to be a person who championed the buprenorphine bridge program within the hospital's ED.The stakeholders sent out email invitations that included the eligibility criteria to all EPs in their hospitals.
Interested EPs contacted the research coordinator to be screened for eligibility.All EPs (n = 28) that contacted the research coordinator were screened as eligible for the study.Six of the eligible participants did not respond to multiple email invitations and were deemed lost to follow-up.The research coordinator scheduled and completed remote video interviews with the eligible remaining participants (n = 22).The interviews took place between February 2022 and June 2022.This study was reviewed by our institutional review board and found to be exempt.The study is reported in accordance with the Standards for Reporting Qualitative Research (Appendix S2). 30

Qualitative interview procedures
The interview protocol was constructed by JML with input from the project team members based on the aims of the study and prior research literature related to EP experiences working with patients with OUD. 4,28The protocol contained six prompts that explored (a) participants' motivation for participating in an EDBP; (b) the professional impact of participating in EDBP, (c) the personal impact of participating in EDBP; (d) barriers, resilience, and strengths related to EDBP implementation and maintenance; (e) physicians' attitudes about patients and perceived impact on patients with OUD; and (f) the impact of the EDBP on professional relationships PROGRAMS (Appendix S1).We used the critical incident technique (CIT) to uncover existing realities or truths so they can be measured and predicted, which involves participants recalling a specific incident (or story) in which the phenomenon under study was activated in their consciousness and influenced their experiences. 29,30The technique gives participants freedom in describing the experience and assumes that participants will describe incidents (stories) that have high priority and that have been most impactful for them.For example, participants were instructed, "Tell me a story about how participating in the ED bridge program has impacted you as a person." All participants were presented with all six CIT prompts.Short follow-up questions or prompts were utilized to gather more detail when a participant gave their initial response and the interviewer perceived needing additional details.The research coordinator reiterated throughout the interview that we were specifically asking about their work within the ED and not a clinic within the ED that serves patients with substance use disorders, sometimes called a "bridge clinic." The research coordinator conducted the individual interviews through a HIPAA-compliant video conferencing platform.In addition to recording audio and video, the research coordinator took notes.
The notes were written up into memos directly following each interview.The memos contained noteworthy statements from the participant and the interviewer's reaction to the interview.The content of these memos was used to adjust the interview guide allowing for a more iterative process.Interviews took an average of 38:03 min to complete (range of 8:55-42:35 min).Participants received a $100 gift card for completing the interview.
The interviewer was a research coordinator with 7 years of experience in quantitative and qualitative research focusing on substance use treatment in and outside the ED.Additionally, the interviewer works with EPs and is married to an EP.This experience allowed the interviewer to create a better rapport with the participants.

Positionality statement
The qualitative analysis team consisted of five members from diverse backgrounds.Author JML, a Black American samegender-loving licensed clinical psychologist and health equity researcher with 10+ years of experience conducting qualitative research, led the analyses.Four research assistants (RAs; two graduate students and two undergraduate students) who were members of author JML's laboratory comprised the analysis team.
All RAs were women of color who received training in coding using the codebook by author JML.The analysis team noted several similarities in their subjectivities while conducting the analyses.
As people of color and nonphysicians, they were cultural outsiders who were not completely familiar with the professional, cultural, historical, and sociopolitical contexts of the participants.Overall, team members used best practices (i.e., memos and reflexive discussions) throughout the project to track subjectivities and distinct perspectives.We worked to bolster the trustworthiness of our findings by including, throughout this article, logical and clear descriptions of the research processes and rationale for them.
We avoided claims of saturation, as recommended by the developers of thematic analysis, and instead focused on information power. 31Information power is having enough participants enrolled a study to develop new knowledge from the analysis. 32Information power is said to be higher when (a) the study aim is narrow, (b) the study sample is targeted while also possessing between participant variation in the phenomena under study, (c) a specified coherent theory is used to guide study design and data analysis/interpretation, (d) there is strong and clear communication between interviewer and interviewee, and (e) an in-depth narrative analysis of a few participants is conducted.Our study meets these criteria.We are confident that our information power is sufficiently high given our development of new knowledge.

Rationale for choice of methods
Qualitative data were analyzed using thematic analysis.Thematic analysis is a robust data analytic method for identifying, analyzing, and describing patterns of meaning across a data set in rich detail. 33is study utilized a codebook approach to thematic analysis. 34,35e codebook allowed us to develop codes from our textual data.
The codebook also facilitated consistency among coders, thus bolstering the reliability of findings.

Codebook development
Author JML developed a codebook using a bottom-up (inductive process) whereby he adhered to guidelines of the first two phases of thematic analysis: familiarization with data (Phase 1) and coding (Phase 2).First, he began by coding a random sample of five of the transcripts from the data set using an inductive approach.He created codes primarily at the semantic level-staying close to the participant's language-which entailed reading the transcripts and labeling sections that seemed to be relevant to the research questions.Next, latent coding was conducted with each transcript to uncover implicit meaning in participants' transcripts.Through this process, 18 codes were developed and comprised the codebook, which included code names, code abbreviations, and extracted quotes from the transcripts that illustrated each code.Four RAs in JML's laboratory were then trained how to use the codebook.
RAs were deemed proficient in codebook utilization when they began to achieve at least 90% accuracy in coding the original five transcripts utilized by JML to make the codebook.RAs.Discrepancies in coding were resolved with discussion until a consensus was reached.

Data analysis process
NVivo was used to analyze the qualitative data.Each coder followed the steps outlined by Braun and Clarke in analyzing transcripts. 30ecifically, each coder familiarized themselves with the data by reading and rereading each transcript before coding.Coding was informed by the codebook.Nine additional codes were identified and added to the codebook during coding of subsequent transcripts.

Trustworthiness
To ensure the trustworthiness of our findings, we have focused on four criteria specified by Nowell and colleagues 36 throughout the research process: credibility, transferability, dependability, and confirmability.We established credibility through peer debriefing.
Peer debriefing was completed by a professor at the same institution as author JML but who works in a separate department from any of the study team members.This person has several years of experience conducting qualitative research.Her assessment of our analysis processes was that all codes were applied consistently across the data set.We have tried to ensure transferability of our findings by providing clear descriptions of our research process and results.With these descriptions, readers will be able to determine transferability of our findings from this study to their sites of research.We have worked to ensure dependability of our findings by providing a logical description of our methods and analyses.Finally, we have attempted to bolster the confirmability of our findings by detailing the rationale for our analytical choices throughout this article.

RE SULTS
Twenty-two EPs with a mean (±SD) age of 43 (±10) years participated in the study.The predominately White (95.5%) and male (68.2%) sample reported primarily living in the Northeast (59.0%) region of the United States.Participants had been practicing medicine for a mean (±SD) 13 (±10) years and most (59.0%) reported having a DEA X-waiver for 3 to 5 years (Table 1).We constructed three themes that described the positive effects of participating in the EDBP for physicians (Table 2).

Theme 1: Providers gained agency through their participation in EDBP
EPs expressed that participating in the EDBP helped them develop a sense of agency in their work by giving them access to treatment options they needed to take multilevel action.This sense of agency allowed them to provide effective treatment to their patients with OUD and address barriers that hindered the provision of treatment.
EDBP help physicians effectively respond to the needs of a population with frequent contact in ED and help EPs to provide an opportunity for patients to overcome the seemingly insurmountable problem of OUD (Table 2).
One participant (P4, 55, White, male) discussed how EDBP was a way not only to help patients get effective medical care from EPs but also to get additional services related to recovering from OUD.
He shared, "So we were doing more than just, you know, prescribing medications-that we actually were getting people plugged into a system that could help them, sort of, move from coming in-get help to, uh, successfully move on to treatment."

Theme 2: Transformation in providers' emotions, attitudes, and behaviors related to participation in EDBP
Providers disclosed how they evolved from pathological and patient-blaming attitudes and emotions to developing more holistic understandings of their patients with OUD.These holistic understandings facilitated positive emotions and more engaged physician-patient relationships.One participant (P13, 51, White, male) revealed, "I don't want to say that I judged them-I judged them in the past, but probably to a degree I did, because I didn't understand as much [as] now." Participating in an EDBP seems to help EPs cultivate a greater degree of empathy for patients suffering from OUD.This empathy, once developed by EPs, is then shared with colleagues through advocating for them in conversations with colleagues (Table 2).

Theme 3: EDBP participation improved professional quality of life
Physicians shared stories about how their participation in an EDBP contributed to a better quality of life for themselves, their patients, and society as a whole.They reported feeling more helpful, appreciated, energized, and supported.One participant (P14, 38, White, male) shared, "… in terms of … getting the X-waiver and then prescribing it … it is actually rewarding to do so … I find it's actually really important.… I didn't know that at the time when I started it … but I'm glad I did it because you kind of are the, the doc that can do that for people."The participant's comment hints at a sense of personal pride in being able to serve his clients in a way that he was unable to do before.
Physicians perceived improving their patients' quality of life by providing more in-depth education about OUD treatment.
Participants also endorsed being able to better care for this patient population, resulting in experiencing several professional benefits, including helping reduce burnout.Overall, physicians who participated in EDBP reported feeling a renewed sense of fulfillment and purpose in their personal and professional lives.

DISCUSS ION
In this cross-sectional study, we identified three major themes that suggest a positive impact of prescribing buprenorphine from the ED.
Working in an EDBP (1) provided EPs agency; (2) transformed EP emotions, attitudes, and behaviors related to treating patients with OUD; and (3) improved EP professional quality of life.While there is ample evidence of the potential benefits of EDBP to patients, to our knowledge, this is the first report to demonstrate a potential benefit to ED physicians.
We found that EPs gained agency by working in EDs with bridge programs because they can provide effective treatment to patients that were not previously available to them.8][39] This is also the case when physicians have the capability to treat complex patients. 40ncurrently, the stigma surrounding patients with OUD is a barrier to those seeking care for their disorder.[23][24][25][26] Most EPs in this study reported having negative attitudes toward patients with OUD prior to participating in an EDBP.Participating in EDBP changed these views, decreasing stigma and increasing empathy.In the ED, patients with OUD perceive discrimination and stigma due to their substance use, so modifying physician behavior and attitudes may be a key toward engaging more patients into treatment. 41nally, we discovered that EDBP participation increased the professional quality of life of participating physicians.Physicians are at higher risk for burnout than the general U.S. working population, likely because of the high intensity of clinical practice, higher risk of litigation than some other specialties, and chronic fatigue related to circadian rhythm disruption. 42EPs reported the highest burnout rate of all specialties in 2022 (60%), a large jump from 43% the year prior and likely related to changes in the health system post-COVID. 43ere may also be a component of moral injury or second victim syndrome resulting either from feeling helpless when treating patients with OUD or from the trauma incurred to the physician when a patient under their care dies from an opioid overdose.The results of this study suggest that the first two themes (gained agency and changed attitudes) augment the experience of caring for this patient population, making EPs feel helpful and rewarded, potentially decreasing at least one of the many reasons for burnout.
TA B L E 2 Themes and exemplar quotes.Unfortunately, many hospitals have been slow to adopt buprenorphine programs because of well-described barriers. 44adequate follow-up remains a key barrier for EPs and contributes to reluctance to prescribe buprenorphine.A recent Canadian study cited access to follow-up resources as one of the top barriers to initiating buprenorphine in their EDs, along with inadequate training on buprenorphine prescribing and time restraints related to patient education on safe buprenorphine use. 28There was a 300% increase in the number of EPs prescribing buprenorphine between 2016 and 2021. 45This increase may be due to increased implementation of EDBP.For example, California's CA Bridge program resulted in 100% of the 52 participating hospitals routinely treating OUD with buprenorphine in the ED. 27t only do EDBPs improve clinical outcomes for patients, but this study provides evidence that such programs may also be ben-

LIMITATIONS
This study has several limitations that may impact the interpretation of the findings.The study's cross-section design limits temporality and causation conclusions.All interviews took place after the physician worked in an established EDBP; therefore, there is a potential for recall bias.It is possible that this sample of EPs had lower baseline stigma, which made them more likely to work in an ED with a bridge program, as opposed to their participation in an established bridge program thereby reducing stigma.However, the consistency of the themes across EPs makes recall bias less likely.
Also, these data cannot be generalized to all EPs who prescribe buprenorphine, as most EPs in this sample were White males.
Virtual interviews may have hindered rapport building between the interviewer and the interviewee.Participants may have felt less at ease in divulging certain types of information during the interview process.Our study may be limited by selection bias in that physicians with more positive experiences may have elected to participate in our study than those with more negative or neutral attitudes and experiences related to bridge programs.Thus, our findings may not be generalizable to all EPs and EDs.

CON CLUS IONS
The ED remains the safety net and point of entry into the health care system for many patients struggling with substance use disorders.
In this study, the presence of an ED bridge program empowered physicians; led to a shift in their emotions, attitudes, and behaviors when treating patients with opioid use disorder; and ultimately enhanced their overall professional quality of life.This study's results can help hospital leadership and policymakers to adopt an ED bridge program at their hospitals.Future research should include collecting quantitative data (quality-of-life scales, burnout measures, and stigma) from emergency physicians before and after introducing a bridge program into their hospital or health care system.Researchers should also carry out this study in different settings (rural, community, etc.) to generate more generalizable data.
Once proficiency was achieved by all RAs, JML randomly assigned the remaining 17 transcripts to the RAs.Each transcript was coded by two different | 579 HEIL et al.
All transcripts were then reanalyzed to determine the presence or absence of those new codes.Once all transcripts were completely coded, author JML utilized NVivo to generate initial themes (Phase 3) by clustering together potentially connected codes based on similarities into candidate themes.This process yielded three themes.After examining the themes in the context of the full data set to ensure that they clustered around a singular central idea (Phase 4), in Phase 5, the themes were presented to the larger study team for feedback.After revisions, theme names and definitions were finalized.

Theme 1 :
Providers gained agency through their participation in BP Exemplar quotes … all of a sudden, now you have a tool that you can use to kind of help this population that you see over and over and over again in the department.-P2,40, White, female eficial for EPs as well.Buprenorphine prescribing provides agency to EP clinicians, potentially decreases stigma toward patients with OUD and improves professional quality of life.The first-hand testimonies from EPs in this study may help provide leverage to influence EDs across the globe to pursue implementing EDBPs.