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A new randomized trial shows patients who present to the ED with opioid dependence are much more likely to engage in treatment when they receive buprenorphine along with coordinated follow-up than when they just receive a brief intervention and a facilitated referral for treatment or just screening and referral. However, barriers to prescribing are robust, and many ED leaders are not persuaded they should be in the business of providing treatment for addiction.
• In the trial, at 30 days 78% of patients in the buprenorphine group (89 of 114 patients) were engaged in addiction treatment, compared with just 45% of the patients in the brief intervention group (50 of 111 patients) and 37% of patients in the referral group (38 of 102 patients).
• To prescribe buprenorphine for addiction disease, providers must undergo training and pass a test to obtain a DEA waiver; they are limited to treating 100 patients.
• While experts note there are not enough providers to prescribe buprenorphine and provide the follow-up needed to patients with addiction disease, they also acknowledge concerns about drug diversion as well as potential problems with capacity if EDs take a larger role in treating addiction.
With the problems of addiction and the misuse of prescription drugs raging across the country, emergency providers are under increasing pressure to put new solutions on the table. After all, they are the ones who interact with these patients when they present to the ED from overdoses or withdrawal symptoms. While emergency providers may be reluctant to get into the business of treating addiction, a new study suggests when these patients are treated in the ED with buprenorphine, a medication that reduces withdrawal symptoms, cravings, and opioid use, they are significantly more likely to receive formal addiction treatment than patients who only receive a brief intervention and referral to treatment. Further, the data show patients who receive buprenorphine are less likely to report subsequent illicit opioid use or to use inpatient addiction services, although buprenorphine does not appear to significantly reduce the rate of HIV risk or of urine samples testing positive for opioids.1
Study investigators, led by Gail D’Onofrio, MD, MS, chair of the Department of Emergency Medicine at Yale University School of Medicine in New Haven, CT, randomly assigned opioid-dependent patients who presented to the ED to one of three treatment arms: screening and referral to treatment, brief intervention and facilitated referral, or screening and brief intervention combined with ED-initiated buprenorphine/naloxone and referral to primary care for 10-week follow-up.
At 30-days after the ED visit, 78% of the patients in the buprenorphine group (89 of 114 patients) were engaged in addiction treatment compared with just 45% of the patients in the brief intervention group (50 of 111 patients) and 37% of patients in the referral group (38 of 102 patients).
While the authors note their findings need to be replicated at other centers, they also stress the urgent need for action.
“Overdoses are an enormous problem, and opioid addiction is really escalating, so we have to do something,” D’Onofrio says. “We know these patients come to the ED and this is where they get their care, so what we need to do is get as many people into treatment as possible.”
For patients in withdrawal, buprenorphine will help them feel better, D’Onofrio observes.
“You are then able to talk to them; you can try to motivate them and then to directly engage them with treatment,” she explains. “This gives us the opportunity to get more people into treatment, and that is the whole point.”
Given the huge gap between the need for addiction treatment and the supply of such service providers, EDs can be an additional available option, D’Onofrio suggests.
“Primary care physicians can offer it in their clinics and we can offer it in the ED, and if we set up these partnerships, this can only be good,” she says.
However, despite the study results, it’s clear that not all ED leaders are persuaded that they should play a bigger role in providing treatment for addiction, or that they should be involved in prescribing buprenorphine to opioid-dependent patients at all.
“The whole pain issue is a big deal and it is complicated, and there is a real difficult balance between patient satisfaction, appropriate pain control, addiction and drug seeking and diversion,” observes Mark Notash, MD, FACEP, the medical director of the ED at San Leandro Hospital in San Leandro, CA. “We purposely do not deal with the addiction piece. That is absolutely not our business to do … and I think most docs feel that way in the emergency setting.”
Notash acknowledges that addiction touches the providers in his ED on a daily basis, sometimes in a very dark way when patients who have overdosed experience brain damage and other problems. However, he doesn’t think providing patients with buprenorphine is the answer.
“Medicine needs to be involved, but it is about having a support network, having therapy, and having all of the right social and psychological pieces present in order to ensure the patient recovers,” he says. “Giving that one drug or any one drug is very unlikely to actually succeed. Even if someone is extremely motivated to change and to get off the drugs, it is highly unlikely that it is going to succeed.”
For these reasons, Notash is not particularly troubled by the multiple barriers in place that make prescribing buprenorphine for addiction disease difficult. For instance, unless they are board certified in addiction medicine or psychiatry, providers need to undergo eight hours of mandated training and a test in order to prescribe buprenorphine for opioid use disorders. Further, once providers receive waivers from the DEA enabling them to prescribe buprenorphine for addiction disease, they are then limited to treating just 100 patients under the Drug Addiction Treatment Act, passed by Congress in 2000.
In addition to these barriers, many states and payers have placed added limitations on prescribers of buprenorphine. These range from prior authorization requirements and lengthy waiting periods to requirements that patients undergo counseling or be enrolled in formal rehabilitation programs. Of course, cost is a big factor as well, especially for Medicaid pharmacy benefit managers.
The American Society of Addiction Medicine believes such barriers are preventing more patients from getting the addiction treatment that they need.
“I’d like to see more physicians of all specialties get their DEA waivers to prescribe buprenorphine if they are seeing a substantial number of people with addiction disease in their practice,” explains Kelly Clark, MD, MBA, FASAM, DFAPA, the president-elect of ASAM, and chief medical officer of CleanSlate Centers based in Northampton, MA, a group of nine centers offering outpatient medication-assisted treatment programs for addictive disease. “We don’t have enough physicians who are waivered to prescribe, and the majority of physicians who are waivered are not using their waiver for a variety of reasons.”
In particular, Clark finds the 100-patient limit to be problematic for patients as well as the EDs they frequent when there is nowhere else to turn. However, she also agrees with Notash that simply providing buprenorphine to a patient with addiction disease is not enough.
“Unless there is follow-up in place, the relapse rates are enormous,” she observes.
Nonetheless, Clark emphasizes the best treatment for opioid dependence is maintenance therapy with medication, either buprenorphine or methadone.
“That is beyond question,” she says. “Medication is the best treatment according to the data, and that is a maintenance treatment, not a detox treatment.”
Clark acknowledges there are valid concerns about prescribers of buprenorphine. For instance, providers and regulators alike have their eyes on the problem of drug diversion.
“We have seen some doctors prescribe what are considered to be relatively high doses of buprenorphine, and patients divert those substances and get cash for them in order to pay for treatment because much of [addiction] treatment is not covered by a variety of healthcare plans,” she explains. “Then there is diversion simply because people can’t access the drug.”
Buprenorphine is a partial agonist, Clark explains. If someone is intoxicated on heroin, oxycodone, or hydrocodone, and they are given buprenorphine, it will put them into withdrawal.
“If, however, they are in withdrawal, it will control their signs and symptoms of withdrawal,” she says. “While it is very unusual for someone to overdose on buprenorphine … there are issues of diversion.”
Another concern is patients may flock to busy EDs to obtain buprenorphine, creating capacity problems. Clark notes any ED interested in following the protocol described in D’Onofrio’s study should first make sure there is an adequate number of physicians to follow up with these patients.
“I would recommend EPs establish relationships with high-quality addiction treatment providers, particularly addiction specialist physicians who have the capability of bringing all the appropriate treatments to these patients,” she explains. “Then they will be able to stop that cycle of patients coming to the ED that we see so often.”
The most important thing is to make sure that patients get the longitudinal care that they need, Clark advises.
“That would mean a relationship with an outpatient physician who can continue buprenorphine treatment,” she says. “I would suggest having that piece in place before prescribing [the drug.]”
D’Onofrio acknowledges that while many emergency medicine professionals disagree with her views regarding the role of EDs in dealing with addiction, she is nonetheless taking steps to ensure that all attending physicians in her ED receive the necessary training to receive a waiver from the DEA, enabling them to prescribe buprenorphine.
“I am also going to offer [the training] to my graduating residents. We are going to start incorporating that so when they go out in their world they can have their waiver,” she says. “We should train all of our residents — every one of them — how to prescribe this drug. It should not be different than any other medication.”
D’Onofrio is hoping that her study will fuel more interest.
“I try to put the systems in place and talk to other EDs about how they can do this. It is not a revolving door of people coming back,” she says. “The old days of treating and streeting people are over. In emergency medicine we know we are the primary access [point] for many patients.”
The paradigm is already in place for emergency providers to treat both newly-diagnosed chronic problems and exacerbations of chronic problems, D’Onofrio adds.
“This is no different. I am just trying to make addiction similar to any other chronic disease,” she says. “You just have to work in an ED on Friday and Saturday nights, and you are going to see that half your population is connected to some type of drug addiction or misuse. This is where you find the patients, so why don’t we try to help them and get them into treatment?”