Table 3 Participant quotes supporting barriers to treating withdrawal and initiating buprenorphine

1. Lack of knowledge & experience among the care team

 i. “The ones who are a little bit trickier is sometimes we see people who present with the gastrointestinal side effects. So, lots of diarrhea and stomach cramps. Those are cases where I find sometimes it is a bit harder to tease out and they may be in people who are misusing their prescribed opiates.” (Physician 19)

 ii. “I think generally people are not comfortable and don’t think that prescribing [buprenorphine] is a good idea in an emergency setting because of concern about precipitating withdrawal.” (Physician 4)

 iii. “The only thing I worry is that, and I have not looked this up myself, is long term safety. So do we know that this is a good long term intervention or the possible harm that we just haven’t encountered yet because we don’t have the numbers or the research for it that we’re going to pick up in five or 10 years.” (Physician 16)

 iv. “When I ordered it the nurses were almost all like “what’s a COWS”. They had never heard of COWS the first time I did it and that was after it had been going on for a little while.” (Physician 19)

 v. “[Buprenorphine] was supposed to kind of package it all together and so even though we have suboxone readily available there’s a lot of gray area where it can’t be prescribed. And so then we still don’t know what to do with those patients.” (Physician 9)

 vi. “Sometimes it was other co-diagnoses like mental health disorders that made it challenging for them to organize the new information. And sometimes it was just someone who had been to our hospital like over 150 times with overdoses and he’s just so unwell that he isn’t able to be open to a new idea.” (Physician 10)

 vii. most of the time my patients arrive, and it is too short a time frame since their last consumption. By the time we get to the point of having a conversation about taking a prescription of that stuff home quite often they are ready to bolt and they’re not prepared to consider it.” (Physician 1)

 viii. “If they are on methadone, it’s not a medication we can really give them.” (Physician 10)

2. Patient disposition and behavior

 i. “I would say it’s challenging: rarely an easy interaction, rarely do they understand the consequences of what happened especially if they’ve been given Narcan because they often don’t have a recollection of the events and don’t believe what you’re telling them.” (Physician 16)

 ii. “The challenge, the biggest point of conflict I find is often when someone should probably stay but they want to go home. We don’t think it’s safe for them to leave. It can be really challenging trying to decide: are they competent to make the decision? Do you restrain them and keep them here?”(Physician 19)

 iii. “When I refuse to give them [opioids], the first step that they usually go for is “well get somebody else here” … that they want to see another doctor. I will not give them that. Then they’ll say, “well I’m going to complain to the hospital” and … “I’m going to report you to the college” and I’ll say “be my guest”. Then they’ll start calling me names and swearing at me and using foul language and that’s usually when I get security to escort them out.” (Physician 2)

 iv. “Some people have told me “Look I’m not interested. I’ve tried it and I don’t like it.” (Physician 10)

3. Logistical constraints

 i. “When people come in intoxicated or in withdrawal, they take up a bed for a long time … And so our gut reaction is “we have a busy emergency department and now you’re being demanding of my time and a pain”. It takes time with repeated doses in the emergency department.” (Physician 19)

 ii. “I don’t think that we can be doing a good job at providing all that counseling ourselves. So given the volumes of patients that we see typically, the length of the interaction with each patient, I don’t think its feasible.” (Physician 14)

 iii. “They are very high users of the emergency department, and you can put in a little bit of time upfront and decrease their burden on the department.” (Physician 11)

 iv. “I think ED overcrowding plays a big role in our management of patients in withdrawal … the issue of physical space is not without significance.” (Physician 19)

 v. “Some people sometimes are reluctant to talk about them in the hallway if they’re in a hallway stretcher because they don’t want everybody else around to hear what their problems are.” (Physician 4)

4. Initiating a chronic medication in an acute care setting

 i. “[Buprenorphine] is really a chronic medication that people will start and continue taking indefinitely. And you know it’s a bit of a philosophical change. I don’t think most ER doctors like the idea of prescribing medications that are used long-term.” (Physician 15)

 ii. “I think that its akin to saying like do you start blood pressure medications in the emergency department. The patients who are hypertensive. And I have to say that a lot of my colleagues do not because we don’t have a way of following up on those prescriptions.” (Physician 14)

 iii. “Follow up, repeated prescriptions and … titration of dose would be the other thing. We don’t really aim to provide that in the ER for pretty much any other condition mostly because we don’t intend on seeing you ever again. That’s our philosophy.” (Physician 15)

 iv. “[Buprenorphine] is not necessarily a medication that I thought would be an emergent use but the more that I see that it can kind of quench some of the significant opioid withdrawal symptoms ... I think once we kind of heard that as a group there was more of an acceptance of using this medication in the emergency department.” (Physician 6)

 v. “The patients that I have prescribed it for, I’ve had a good response from them initially whether those patients continue to do other follow up and things like that I have no idea.” (Physician 18)

 vi. “I think the biggest thing is the follow up is unclear always. I mean we initiate these things and we don’t know whether our initiation of them is having an actual positive effect. It’s not really a barrier to our starting it but I guess it’s more if we are starting it, is it definitely helpful or not?” (Physician 3)