While many emergency providers remain hesitant to start patients on medication-assisted treatment (MAT) for an identified addiction to opiate medications while such patients are still in the ED, there is growing interest in this approach. This is in part due to research published in 2015 showing that starting these patients on buprenorphine, a drug that helps with withdrawal symptoms, at the time of their ED encounter considerably increases the chances that patients will remain in treatment.1

Researchers at Yale New Haven Hospital in New Haven, CT, studied 329 people with opioid addictions who presented to the ED for any reason. One-third were referred to an addiction treatment center, another one-third received 10 minutes of counseling about treatment and were referred to an addiction treatment center, and the final one-third immediately received a dose of buprenorphine in addition to the 10 minutes of counseling and referral to an addiction treatment center.

One month following the ED encounter, researchers reported that 78% of the patients in the buprenorphine group were enrolled in a formal addiction treatment program, while just 45% of those who received counseling and referral were enrolled in treatment, and just 37% of those who received referral for treatment were actively enrolled.

Since these findings were reported, administrators at Yale New Haven Hospital have worked to bolster infrastructure in the ED to initiate buprenorphine for patients who present with opiate addictions and are candidates for MAT, explains Kathryn Hawk, MD, an instructor in emergency medicine and a K12 research fellow on drug abuse, addiction, and HIV in the Yale Department of Emergency Medicine.

“We have established a collaboration with multiple local buprenorphine providers that offer services in the area,” she says. “We have also developed protocols and we are in the process of implementing them on a larger scale for getting people the treatment they need, starting in the ED.”

Provide Education, Training

Hawk notes that she has not observed any resistance to this treatment approach from emergency providers at Yale New Haven Hospital, but she acknowledges that implementing this type of addiction pathway typically requires education and training.

“I think that any initial pushback or concern is because this is not something emergency providers are familiar with,” she argues. “Also, ED-initiated buprenorphine is something that only works if you have local community providers that can take over care of the patient. In New Haven, we don’t have any kind of a waiting list now, but that is not the case everywhere.”

Nonetheless, Hawk observes providers want to help and are keeping an open mind about new approaches.

“Physicians want to help people, they want to do the right thing for them,” she says. “What is happening with the opioid epidemic ... and the deaths associated with it over the past several years has really gotten the attention of a lot of emergency medicine physicians, and people who wouldn’t necessarily have considered doing this a couple of years ago ... are more willing to learn about it and figure out how to integrate it into their practice. But you have to have the infrastructure in place in order to do it. That is one of the biggest barriers.”

At Yale New Haven Hospital, there are a couple of different mechanisms in place to transition patients with addiction problems into ongoing care. For instance, the hospital’s “Project Assert” program leverages health workers to find beds for patients and even go so far as to arrange for transportation, if that is needed.

“These are health promotion advocates who specialize in linking patients with drug and alcohol disorders with addiction treatment,” Hawk explains. “These are people who provide motivational interviewing, they assess willingness to engage in treatment, they look at patient insurance status, and they call treatment centers.”

The hospital also has a second system in place in which emergency medicine physicians can fill out a one-page form for referral that can be expedited to one of several treatment centers in New Haven. The form includes medical information that treatment providers typically request, including the results of urine toxicology and liver enzyme tests, Hawk says.

“The form then just gets faxed over to these treatment centers that have agreed to take patients that we send over,” she says. “[The patients] will get a phone call the next morning to arrange to be seen in the next couple of days.”

To successfully implement a model like the one used at Yale New Haven Hospital, providers first must identify local partners who can provide long-term care for patients suffering from addiction.

“It is important to know your community resources and to discuss them with your patients, whether these resources include buprenorphine and MAT or not,” Hawk observes.

Also important is patient education about factors that increase the risk of overdose, such as taking opioids with benzodiazepines, alcohol, or other sedatives. A previous overdose or recent periods of abstinence also can increase the risk of overdose, Hawk notes.

“One thing that all emergency providers can do is prescribe take-home naloxone, which is something that is supported by the CDC, the AMA, and the Office of National Drug Control Policy at the White House,” Hawk says. “While naloxone does not necessarily treat addiction, it can help keep people alive so they can get to the ED and get referred to treatment. It gives people a chance.”

Hawk advises emergency providers find out which pharmacies in their region stock naloxone, and share that information with patients.

“The thing about this is people [with addictions] get better,” she says. “If we can help them access the treatment to get better, it is a win for all of us.”

REFERENCE

  1. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence. JAMA 2015;313:1636-1644.

SOURCE

  • Kathryn Hawk, MD, Instructor, Emergency Medicine; K12 Research Fellow, Drug Abuse, Addiction, and HIV, Yale Department of Emergency Medicine, New Haven, CT. Email: Kathryn.hawk@yale.edu.