**4.1 Interdisciplinary understanding of substance abuse and mental health in the ED**

Participants from different disciplines express to different degrees that the complexity of substance abuse and mental health disorders is not always properly understood in the ED. One participant explains the importance of having other experts in the ED to understand brain chemistry and social conditions by noting, "addiction is now understood as a brain disease for which we have brain medication." She further elaborates that "conversations need to be had with ER physicians to emphasize drug addiction as the underlying problem to the presenting issue." Another participant explains that some "patients who have substance use and mental health issues also have current life devastation issues, like they have no friends anymore because they alienated everybody. So now [they're] here in the ER. They will come in the ER every other day for no other reason other than opioids." Substance abuse is a complex issue that requires more time than can be provided in an ED visit.

One participant explains that other experts can help ER physicians "understand all the different components of substance abuse". This participant further explains that ED practitioners "don't care about reasons that contribute to the problem. I think, they think, if they can see the person, treat the person and get them out and now they are not causing harm but helping them."

ED physicians may also have distorted expectations when treating someone with an opioid addiction. One participant explains that opioid treatment outcomes have to be "clear, relevant and realistic… Physicians want to see 100% of patients who start buprenorphine do so when completely sober. And you're like that's just not a realistic thing." The ED physician supports this claim, stating, "if physicians believe that patients cannot get better there is hopelessness of engaging in other options." Having unrealistic expectations of how well someone will do when treated with MAT goes hand-in-hand with not being familiar with the science of opioid addiction, coupled with the mental health and other co-occurring conditions that challenge the effectiveness of treatment. Enhancing physician knowledge of opioid addiction and related conditions, supported by the availability of practitioners from other specialties, is therefore an important aspect of addressing the opioid epidemic.

### **4.2 Interdisciplinary teams, networks and training to fight the opioid epidemic in the ED**

A running theme throughout the focus group discussions is the value placed on being part of an interdisciplinary team or network. One participant said that she "extremely values being part of the team." She adds that she is "very big on collaboration. I think no one knows everything and when people come together with their different level of experience of expertise you see the best results whether it's implementing new policy or the care of an individual." Some participants noted how interdisciplinary education should be part of the curriculum in medical school. As an example, participants highlighted the interdisciplinary curriculum of the geriatric program, which incorporates dental services, occupational therapy, physical therapy, social work, and physicians. Oncology was cited as another interdisciplinary field, with one participant noting the value of social work in it: "I think that's also true in palliative care. They really value the social worker."

*Building Interdisciplinary Teams in Emergency Care to Respond to National Emergencies… DOI: http://dx.doi.org/10.5772/intechopen.99206*

Although working together in an interdisciplinary team appears to make sense, one participant said that such a perspective is often lost in medical school, where medical doctors may not learn how to work with other to have the most impact on health …"So maybe we should bring in that model [to medical school] of interdisciplinary and the social work theory of empathy, active listening, and put them together in a class, presentation or workshop."

The dual benefit of interdisciplinarity was also highlighted. That is, conversations should be initiated with ED providers or seize the opportunities in the ED to demonstrate that interdisciplinary teamwork benefits both the patient and the ED prescriber. The ED prescriber's network may also help ED practitioners increase their understanding of the opioid problem. According to the presenters describing the process of seeking advice, "It depends on the qualities of the expert, the quality of their expertise, how accessible they are to you, it depends upon your needs as an advice seeker, and a lot of it depends on accessibility." These networks can be defined "in terms of physical proximity, social proximity, or history of prior relationships." Findings from the scientific presentation suggest that quality of expertise and accessibility to the expert were significant indicators when predicting the presence, absence, or a tie of a network formation. Furthermore, the presenters noted that "faculty experts and supervisors were more likely to be new sources of advice for clinicians over time. Also, being in the same organization and being from the same discipline were significant predictors of the tie formation." Participants also highlighted the effectiveness in working across disciplines and departments. Every participant has had an opportunity to work with colleagues from other disciplines, and clearly acknowledge how the depth and quality of conversations are enriched by collaboration.

## **5. Team demographics and collaboration**

#### **5.1 ED practitioners' prescribing and collaboration**

Participants highlight that the ED is a major player in the prescribing of opioid medication and would benefit from greater collaboration from other disciplines. For example, one participant investigated whether differences in belief systems exist among ED practitioners, affecting how often they prescribe opioids. The participant noted that ED practitioners rely on a set of values to determine when to prescribe, with ED doctors "making decisions in a different way" when treating patients who show in the ED seeking opioid prescriptions. ED practitioners may assess the deservedness of patients, based on their race, language, complaint, etc.

One participant offered a physician's perspective, explaining that "most doctors do not confront patients about their opioid use, and have a conversation about other options. Almost never happens, it requires too much energy. Doctors have two easy ways out, kick them out of the ED or give them the pills."

ED practitioners may have continued the problem by refilling narcotics prescriptions. "That has been our response to this problem," one participant states. One ED leader reports that opioids and antibiotics are prescribed 80% of the time when pain is the chief complaint. Participants say that in many instances ED providers "feel they don't have the background or the experience" to prescribe opioids. They further state that "right now we don't have a current approach to prescribing opioids that includes providing incentives to [ED providers]." One participant suggests working collaboratively with other professionals on "the process and structure and referral to treatment, rather than attempting to change prescriber behavior." "Doctors want to solve the problem and they wonder about

the result." This participant explains that even when prescribing an opioid like hydrocodone, physicians focus on the number of pills prescribed, usually prescribing a lower number of pills, "12 pills from 20-30." This participant also feels that "there is a sense of helplessness around responding to addiction requiring other professions to improve treatment effectiveness." This suggests ED practitioners' need for interdisciplinary approach to support each other and help improve treatment.

Moreover, this participant explains that providing Medication Assisted Treatment (MAT) requires an interdisciplinary team effort, but currently is disjointed because "ED doctors' structure of work is in shifts. They go away!" ED physicians and ED practitioners understand there is a real opioid abuse problem; however, they do not have the time, energy, or even the incentive to treat ED patients from start to end. Creating dialog with ED providers seems to be key to educating them and changing their opioid diagnostics and prescribing behavior. Moreover, ED providers need to be engaged carefully otherwise "they get really defensive and it's not a very productive conversation." The consensus among participants was that by creating dialog between ED practitioners and interdisciplinary experts on opioid addictions and treatment, ED prescribers can move away from refilling prescriptions to focusing on treating and resolving some of the underlying issues of substance abuse.

Participants described several ways in which interdisciplinary collaborations can help ED practitioners improve their opioid prescriptions. One expert physician noted that one traditional approach is to become familiar with the state of the science regarding opioid addiction and treatment, coaching prescribers and telling positive stories. By understanding current methods of opioid addiction treatment, ED prescribers will gain confidence in their ability to properly treat opioid addiction, rather than continue to refill opioid prescriptions. One participant explained "coach[ing]" a senior ED attending physician through the decision process when a patient presented to the ED with opioid withdrawal symptoms. "Telling positive stories" of how ED practitioners saved their patients' lives by providing the opioid treatment they needed. This participant explained that "[ED practitioners] come on board once they see that it works or when they are shown evidence or support. Then it makes them a little more open." Participants suggested disseminating these types of success stories visually, perhaps through documentaries that retell the struggles and success of opioid addiction.

However, some participants noted that there is pushback against having ED practitioners initiate individuals with chronic opioid abuse on MAT. When they discussed poignant findings from an exploratory survey in the ED, "33% strongly agreed or agreed while the rest were uncertain to initiate MAT for OUD." In some instances, the hesitation to start MAT is based on not knowing if the patient will "follow up with treatment" or the provider being uncertain if treatment "will cause harm." But, as one participant stated, "if [they] read the papers and the science behind it, the ED doctors should all be like of course we're going to do this life saving treatment [initiate MAT in the ED]."

The lead presenter in the health systems science meeting explained that organizations can respond to change. They "can be proactive in basically having the systems in place to respond to that change in terms of leadership, management practices, [and] structures." The presenters further explain that:

Based on the systems approach, organizations are made up of the sub-systems and it is important that we engage these different sub-systems, so in the case of hospitals, of course, management vs. clinical, a lot of the cultural competency work started more on the clinical side and often times, the management was not engaged. It is important to have those two components together.

*Building Interdisciplinary Teams in Emergency Care to Respond to National Emergencies… DOI: http://dx.doi.org/10.5772/intechopen.99206*

Overall, behavioral change among ED practitioners will take much effort, including changing the institutional culture to be less siloed and more based on collaboration, supported by dissemination of information on evidence-based treatment practices. At the institutional level, changing the ED prescriber's behavior may happen through the collaboration among professionals to adopt frameworks of change, such as the "Causal Model of Organizational Performance and Change." Although the focus has been on the behavior of the ED prescriber, the overall responsibility of fostering change should also be at the institutional level.

#### **5.2 Team composition and effectiveness in the ED**

Working in interdisciplinary teams in healthcare was deemed instrumental to new treatment implementation and the health outcomes of patients. However, teams were required to have certain characteristics in order to be effective. According to one participant in the interdisciplinary symposium, teams are described as bounded: "who's on the team and who's off the team." Teams are also interdependent: "there's a reason to be together and work together." The presenters further explained teams as having "some stability to the membership over time, norms of conduct, and some authority for executing work processes so they can't just be mindless in terms of just executing what leadership, and some process for them to determine how to do the work."

Team size was also considered important, especially for teams in healthcare. The presenters explained that "how large the team is can affect its effectiveness or affect the implementation of best practices. When teams become too heterogeneous it can be challenging for teams." Similarly, the presenters explained that too much diversity in the team is associated with worse outcomes for team functioning. The presenters also noted that "when professional identities are too disconnected, it's hard to find a common ground." Moreover, connections between teams, team climate, relational coordination, and psychological safety can influence the effectiveness of the team. The presenters suggested that if healthcare teams are structured appropriately, "they can yield all the things we want: implementation of evidencebased practices, the effectiveness of these practices, and improved patient care." Participants also noted that team science suggests that feedback should be provided to teams so as to make them more effective. In healthcare, patient instant feedback from a survey is not generally enough to determine team effectiveness. Overall, the impact healthcare teams have on implementation and patient care is highly dependent on the membership composition and purpose. Additionally, feedback loops, rather than a linear approach to providing feedback should be a part of efforts to improve how effective teams are in providing treatment.
