(112) Buy-In Without a Blueprint: ED Buprenorphine Initiation in Puerto Rico

Background & Introduction: Although buprenorphine initiation in the emergency department (ED) is a nationally endorsed, evidence-based intervention for opioid use disorder (OUD), it remains markedly underused, with fewer than 10% of eligible ED patients in the United States receiving treatment. This gap persists despite strong evidence that treatment with buprenorphine is associated with substantial reductions in overdose and all-cause mortality, on the order of 50–70%, and significantly improves engagement in ongoing addiction care. Randomized trials and implementation studies demonstrate that ED-initiated buprenorphine increases treatment retention and continuity, yet adoption remains highly variable across health systems.

In Puerto Rico, this implementation gap is likely amplified by limited access to formal addiction training, lack of standardized ED initiation protocols, and fragmented outpatient referral pathways within a resource-constrained healthcare system. Because EDs frequently function as a primary or sole point of healthcare contact for individuals with OUD on the island, underutilization of ED-initiated buprenorphine represents a critical missed opportunity for evidence-based, life-saving intervention.

The objective of this study was to assess physician knowledge, confidence, attitudes, and perceived barriers related to ED-initiated buprenorphine in Puerto Rico, and to determine whether underuse reflects clinician-level factors or system-level implementation barriers.

Methods: We conducted a cross-sectional, anonymous survey of physicians practicing in emergency department (ED) settings at a single academic medical center in Puerto Rico. Eligible participants included resident and attending physicians from Emergency Medicine, Psychiatry, and Family/Internal Medicine. Recruitment occurred via institutional email distribution lists, and participation was voluntary.

The survey was administered using REDCap and assessed clinician demographics, prior formal addiction training, knowledge and confidence regarding buprenorphine initiation, attitudes toward ED-based OUD care, prior exposure to ED buprenorphine practices, and perceived implementation barriers. Survey items were informed by prior ED buprenorphine implementation studies and clinician readiness frameworks. Responses were measured using 5-point Likert scales and categorical items. The instrument also included open-ended questions to capture additional clinician perspectives regarding implementation barriers.

The study was approved by the University of Puerto Rico Institutional Review Board as Protocol #2509468020. Descriptive statistics were used to summarize participant characteristics and survey responses. Inferential analyses were conducted to examine associations between clinician characteristics (including addiction training) and readiness to initiate buprenorphine, with statistical significance defined a priori. Qualitative responses were not formally analyzed in the present report.

Results: A total of 41 physicians completed the survey. Most respondents were residents (63.4%), and only 19.5% reported prior formal training in addiction medicine or addiction psychiatry. Overall, clinician readiness to initiate buprenorphine was moderate, with a composite knowledge and confidence score of 3.3 ± 0.8 on a 5-point Likert scale.

Participants demonstrated strong conceptual understanding of buprenorphine, including its mechanism of action and role in treating opioid use disorder (mean 4.2 ± 0.9), and overwhelmingly endorsed ED-initiated buprenorphine as high-quality patient care (mean 4.5 ± 1.0). In contrast, substantial gaps were observed in practical implementation domains. Confidence in dosing for initiation and maintenance was low (mean 2.7 ± 1.2), as was confidence in determining when and how to initiate buprenorphine in the ED (mean 2.6 ± 1.2). Confidence in arranging post-ED follow-up care was similarly limited (mean 2.9 ± 1.3).

Despite these gaps, most respondents (82.9%) agreed or strongly agreed that they would feel confident initiating buprenorphine if a clear, standardized ED protocol were available. Frequently reported barriers to initiation included lack of training (68.3%), absence of institutional protocols or workflows (65.9%), concerns regarding continuity of care after discharge (56.1%), and ED time constraints (51.2%).

Formal addiction training was the only clinician characteristic significantly associated with higher readiness scores (p = .006). Readiness did not differ significantly by specialty, clinical role, or years of experience, suggesting that observed gaps were driven primarily by system-level factors rather than individual clinician resistance.

Conclusion & Discussion: These findings suggest that the underuse of ED-initiated buprenorphine in Puerto Rico is driven primarily by system-level implementation gaps rather than clinician resistance or negative attitudes toward opioid use disorder treatment. Physicians demonstrated strong conceptual understanding of buprenorphine and strong support for ED initiation, yet lacked practical readiness regarding dosing, initiation workflows, and post-ED referral processes. The finding that more than 80% of respondents would feel confident initiating buprenorphine if a clear protocol were available identifies standardized ED protocols as a high-impact, low-resistance intervention.

Notably, formal addiction training was the only factor associated with higher readiness, underscoring the potential effectiveness of targeted educational initiatives across specialties and training levels. Together, these findings support efforts to strengthen infrastructure, workflows, and continuity of care.

Study limitations include the single-site design, modest sample size, and reliance on self-reported measures, which may limit generalizability. Although qualitative, open-ended responses were collected to further explore clinician perspectives, formal qualitative thematic analysis has not yet been completed, as the project remains ongoing. Nonetheless, the study highlights actionable system-level targets to strengthen ED buprenorphine implementation and expand equitable access to evidence-based OUD treatment in Puerto Rico.

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