Originally Published in the Association of American Medical Colleges News
Tuesday, May 14, 2019
By Beth Howard
In a novel approach, ED doctors at several teaching hospitals treat more than overdose symptoms. They start patients on the road to recovery.
When Anna Wilson* was hospitalized with blood clots in her lungs at age 16, she was put on a morphine drip and then discharged with a prescription for Vicodin. The high school student was soon hooked on the drug and buying it on the street. Eventually her habit led her to heroin. “It was a lot cheaper and I got more of it,” she says.
For four years, Wilson careened from hit to hit. But when she tried to get help for her addiction, she was turned away. “I was told to quit cold turkey and I tried multiple times, but I just couldn’t,” she says. “It was excruciating.”
Wilson, now 21, learned about a program to help people with opioid addiction at the emergency department of a local hospital. When she went to the emergency department (ED) in October 2018, she was given a dose of buprenorphine, an addiction medication that works by reducing drug cravings and eliminating withdrawal symptoms.
Within a few minutes, Wilson’s symptoms subsided, and she could think clearly for the first time in years. “I was able to collect my thoughts and go back to myself in a way,” she says. She has been taking buprenorphine regularly through the hospital’s “bridge” program, which connects patients to primary care doctors for ongoing treatment, and hasn’t gotten high since.
A new role for EDs
This novel approach to treating addiction is far from the norm. Although EDs treat patients for opioid overdoses everyday, patients in withdrawal are typically given medicines for their symptoms, like nausea or diarrhea, and sent on their way. Now, a small but growing number of hospital emergency departments are tackling addiction head-on.
“From the moment someone decides they don’t want to use any longer, the race is on to how quickly you can initiate medication treatment and continue that treatment without lapse,” says Andrew Herring, MD, an attending emergency physician and associate director of research at Highland Hospital of the Alameda Health System in Oakland, California, which is affiliated with the University of California, San Francisco. “There are many practices for treatment that have wait lists or complicated entry processes so that when you’re actually ready, you have to hurry up and wait. And that’s when we lose people. That moment passes, the withdrawal comes back, and they use again. We have to prioritize getting people onto medication as soon as possible.” The ED, he and others argue, provides a unique opportunity to break the cycle of addiction and shepherd patients into long-term treatment.
But the treatment model is full of challenges — from the need for special training to administer medication-assisted treatment to maintaining the drug after a patient leaves the ED.
Here are several emergency departments that are figuring it out.
Massachusetts General Hospital
Soon after Alister Martin, MD, started his emergency medicine residency at Boston’s Massachusetts General Hospital in 2018, a woman in her 30s came to the ED in withdrawal. A mother of two, she’d become addicted to oxycodone after suffering a painful ankle break. She was desperate to quit, but there was no protocol for treating her. Martin had no choice but to discharge her.
Martin was unsettled, but the incident spurred him to act. Along with Sarah Wakeman, MD, MPH, medical director of the Substance Use Disorders Initiative at the hospital, he and fellow residents drew up a plan to treat patients with opioid use disorder in the ED.
In order to prescribe buprenorphine, the Drug Enforcement Agency (DEA) requires doctors to apply for a waiver, which entails an eight-hour training course. So the ED launched a three-month “Get Waivered” campaign for its physicians, complete with a website, and worked with the DEA to streamline the training. In the end, 95% of Mass General’s ED doctors earned a DEA waiver. (Nationally, only about 5% of ED doctors have it.)
The hospital’s medication-assisted treatment protocol gives patients three days worth of medication without having to go to the pharmacy. “By giving the patients access to the medication right then and there in the ER, we made it easier for them to start their road to recovery,” Martin says. To continue treatment, the ED partners with a clinic that offers the medication on a short-term basis until patients can be transitioned to a primary care practice for maintenance.
After the program’s success, Massachusetts passed a law in August 2018 mandating that the state’s 80 hospital EDs make medication-assisted treatment available for all patients. Other states are exploring the model.
Highland Hospital, Alameda Health System
Highland’s jump into medication-assisted addiction treatment in the ED was sparked by a 2015 Yale study, which found that patients with opioid use disorder treated with buprenorphine in the ED were twice as likely to be in treatment 30 days later than patients who were just given a brochure with addiction resources. “It blew my mind,” says Herring. “I saw that there are effective evidence-based treatments that we can apply in the ER.”
When a patient presents in withdrawal or seeks help for addiction at Highland, they are triaged to a fast-track, diagnose-and-treat protocol. “Emergency physicians are ideally suited to this problem-focused kind of care,” says Herring, who started the program in 2017. “They’re not used to working with appointments. And it’s a really pragmatic approach that is perfect for folks early in addiction treatment who often have a multitude of distracting needs.” Highland’s ED doctors were encouraged to seek a DEA waiver and nearly all have.
After the first dose of buprenorphine in the ED, patients are referred to a follow-up clinic staffed by ED faculty to continue treatment. Nonclinical support for patients with substance use disorders comes from “navigators,” who are people tasked with providing motivation, reassurance, and problem-solving savvy. “They help with everything from transportation to childcare, landlords, and legal issues — anything needed to help patients stay on track,” Herring says.
State University of New York Upstate Medical University in Syracuse
Ross Sullivan, MD, assistant professor of emergency medicine at the State University of New York Upstate Medical University in Syracuse, used to refer overdose victims he saw in the ED to local addiction treatment centers. But when he learned that they often faced long wait times, risking the chance of relapse, he took matters into his own hands.
In 2016, Sullivan, a toxicologist who is also board certified in addiction medicine, started the Upstate Emergency Medicine Opioid Bridge Clinic, housed in a space adjacent to the ED. Because he has a DEA waiver, he can prescribe buprenorphine. But he got pushback when he tried to encourage other ED doctors to seek it themselves.
“A lot of them don’t want to do it,” Sullivan says. “But I found that if I teach them how to just give a single dose to someone who’s in withdrawal, a much higher percentage of them will do that.”
Patients who get the treatment are then referred to the clinic for a follow-up visit within one to three days. The clinic partners with Onondaga County, which provides peer specialists — people who have walked the walk and can provide information and encouragement. They help patients with imperatives like finding housing and accessing social security benefits. “We’ll see them for up to two months while we get them into long-term treatment facilities,” Sullivan says.
The results of the approach are promising. About 85% of patients come to the first appointment. And at two months, 75% to 80% of them are successfully referred to another treatment program.
University of Maryland in Baltimore
Eric Weintraub, MD, medical director of Psychiatric Emergency Services at the University of Maryland Medical Center, was an early adopter of initiating addiction treatment in the ED. More than a decade ago, he noticed that most of the mental health issues he saw in the ED were related to substance use. “Patients had trouble getting the appropriate treatment,” he says. “I thought if we could take care of that then their mental health problems would get better.”
Weintraub, also the director of the division of Alcohol Research and Treatment at the University of Maryland School of Medicine, simply started asking ED patients if they wanted to start addiction treatment immediately. Many took him up on it. “People would feel a lot better,” he says. “They weren’t in withdrawal anymore.” Many got stabilized and began to reengage with their families.
Over time the intervention has become formalized and it is now in place in every ED in Baltimore. It starts with screening every ED patient for substance use. Those who screen positive are paired with a peer recovery specialist. Patients with opioid use disorder are then offered treatment with buprenorphine as appropriate.
The DEA waiver is less critical to the ED’s medication-assisted treatment program, Weintraub says. An emergency DEA exemption clause allows any doctor nationwide to give patients one dose of buprenorphine daily for up to three days. And Baltimore has nearly a dozen drug treatment centers that patients can be referred to for next day and long-term buprenorphine treatment.
To get ED doctors on board with the protocol, Weintraub’s team routinely shares the experiences of patients with opioid use disorder treated in the ED. Otherwise, “they’re not seeing the success of this intervention,” he says. “As an ED doctor, you only see the people who do poorly and come back.”
He often has to clear up misconceptions about treatment, such as that giving patients buprenorphine is just getting them hooked on another drug. Decades of research, however, have led experts to conclude that buprenorphine and other FDA-approved medications are both safe and highly effective at preventing deaths in people with opioid use disorder.
Whether patients are in the ED as a result of an overdose or withdrawal symptoms, or for a drug-related medical issue like an abscess or infection, Weintraub says, “this is one of the few places where patients may be contemplating making changes in their lives, where you might have an opportunity to engage a patient. Hopefully this will become universally accepted as a way to treat patients.”