With a new report showing dramatic surges in both ED visits and hospital admissions because of problems related to opioid misuse, it’s clear that current approaches to the problem are not sufficient.
The report, published by the Agency for Healthcare Research and Quality, indicates that in 2014, ED visits prompted by problems related to opioid use were double what they were a decade earlier, and opioid-related inpatient stays were up by 64%.1
While many emergency providers have long resisted getting involved with addiction treatment, the scope of the problem has prompted some EDs to re-examine their role in potentially connecting patients with treatment at a time when they are highly motivated to make a change. For instance, following a two-month research period last summer, the ED at Providence Sacred Heart Medical Center in Spokane, WA, began initiating medication-assisted treatment (MAT) to presenting patients with opioid use disorders, and then immediately connecting them to a MAT provider for continuing care.
There were initial concerns about potential provider resistance as well as spikes in volume, but these issues did not materialize. In fact, while these are still early days with the new approach, providers report that the program is working well, and that they are taking calls from colleagues who are interested in spearheading similar approaches.
The decision to consider initiating MAT in the ED was driven, in part, by a sense of frustration with the available treatment options for patients who present with symptoms of opioid withdrawal.
“There is a perception that there is a lot of medicine that is really effective at combating withdrawal symptoms, which are diarrhea, abdominal pain, sweatiness, agitation, and anxiety, but there is not a lot that we can do,” explains Darin Neven, MD, an emergency physician at Providence Sacred Heart Medical Center. “There are some addictive substances we can use to treat symptoms, but obviously that is not what we want to do in someone we are treating with addiction, so a lot of times we would give them over-the-counter medicines, and they would have to tough it out.”
For example, patients would be given antihistamines, acetaminophen, or ibuprofen, Neven explains. “We tried to stay away from benzodiazepines, but generally it wasn’t a rewarding experience,” he says. “Patients would often stay in a sobering center where they were often sent for just a short period of time, and then they would relapse.”
Neven knew that unless patients were given treatment that could alleviate their physiologic cravings, the prospects for recovery were dim, so he took part as the principal investigator on a two-month study, testing an approach whereby appropriate patients would be given their first dose of Suboxone (a combination of buprenorphine and naloxone) in the ED, and then immediately would be connected with a MAT provider who would pick up their care from that point.
“This was actually a medicine that completely removed [the patient’s] withdrawal symptoms, took away all of their physiologic cravings, and then set them up for long-term stability if they could follow through the next day and subsequent days with the Suboxone treatment,” Neven says.
Ariana Kamaliazad, a medical student at the University of Washington School of Medicine in Seattle who served as an investigator on the study, concurs that the Suboxone essentially enabled patients to make it to their follow-up appointments with a MAT provider.
“Before, if you saw someone in the ED who was interested in a MAT program ... you could give them the information on how to do that, but it would be difficult for them to follow up because they would be feeling these withdrawal symptoms so much,” she explains. “Usually, these people would just be enticed to just use [opiate drugs] when they got out of the hospital, rather than follow up with a treatment program.”
During the two-month study period in the summer of 2016, Kamaliazad would be contacted by phone or text message by the emergency provider whenever a patient presented to the ED with symptoms of acute withdrawal and he or she was interested in treatment for their addiction.
“I would respond to the ED in person and go in and meet the patient to determine their eligibility for the program,” she explains.
For instance, the patients would need to be able to get to the Spokane Regional Health District every day for daily dosing of Suboxone, and they couldn’t have other addictions or comorbidities.
Kamaliazad notes that another critical piece of information involved determining when the patient last used opiate medications because if they were still feeling the effects of the opioids, Suboxone actually could send them into withdrawal rather than ease their symptoms. Also, Kamaliazad would use a clinical opiate withdrawal scale (COWS) to assess the severity of withdrawal that the patient was experiencing.
“Then, I would give the emergency provider the information that I had gathered, and we would both come up with an assessment of whether or not we thought it was appropriate for this patient to receive Suboxone,” she says. “If it was appropriate, we would administer [the pill], watch the patient take it, and I would set the patient up with an appointment the following morning at the MAT program where they would go in and enroll.”
Kamaliazad would keep tabs on whether the patient kept the follow-up appointment the next day. “As the patient is feeling better, he or she is more likely to make it to that appointment rather than go out and find more drugs,” she says.
After 30 days, 71.4% of the patients who received a dose of Suboxone in the ED were still enrolled in MAT at the Spokane Regional Health District, and 28.6% were no longer participating, according to data provided by Kamaliazad. Among the 25 patients still in treatment, six patients had switched from taking daily doses of Suboxone to daily doses of methadone.
At 60 days, 51.4% of the patients were still in treatment at the health district, and three additional patients left to seek MAT at a program that offered weekly rather than daily dosing, although these patients were lost to follow-up by investigators at this point.
Ensure Prompt Follow-up Care
There were some limitations during the two-month study period. For example, with the available funding for the project, the health district could accommodate only two patient enrollments in MAT per day. “During the research, when we had a third person who wanted to be enrolled for that day and we couldn’t fit him in, we had to turn that person down,” Kamaliazad notes.
Also, under the Drug Addiction Treatment Act of 2000, providers who have not received a Drug Enforcement Administration (DEA) waiver to prescribe Suboxone can administer only one dose, and only if the patient is connected to a MAT provider who can continue with the treatment. “Under that law, we couldn’t give people treatment if they weren’t going to be able to follow up the next day in a clinic,” Kamaliazad notes. Because the health district was open to provide MAT services only from Monday through Thursday, emergency providers were limited to enrolling patients in the program from Sunday through Wednesday. “The law says [providers without DEA waivers] can’t prescribe Suboxone; we have to physically administer it, so we can’t give patients three days of the drug,” Neven says. “We were only treating patients in the ED when we knew we could get them into a clinic the next day, which was Sunday through Wednesday.”
Despite these limitations, the results of the study convinced the hospital to continue offering the approach, although there have been some logistical changes. For instance, now nurses from ED case management fulfill the role that Kamaliazad handled during the study. This involves determining when patients qualify for MAT, working with emergency physicians to initiate the Suboxone treatment, and arranging for follow-up. Also, instead of working with the health district to connect patients with ongoing MAT, the ED has partnered with a large Suboxone provider.
Although the program still is limited to patients who present to the ED from Sunday through Wednesday, Neven notes that it is nonetheless a big plus for the ED to have a referral resource for patients in need of MAT. “That is a major barrier [for many EDs],” he says. “There is a shortage of clinics that will take these patients, and [the approach] definitely requires a cooperative clinic to provide MAT.”
Rely on Evidence
There is often a concern among emergency providers that if they begin inducting patients into MAT, the ED will be overwhelmed with patients wanting this service, potentially leading to crowding, boarding, and other volume-related issues. Neven acknowledges that he had concerns along these lines as well, but, in fact, demand for MAT has been modest and manageable.
“We estimated that, at most, we would refer five patients per day to the Suboxone provider, and we haven’t hit that yet,” Neven reports. “We are treating what feels like about four patients per week in an ED that sees 60,000 adults and 30,000 pediatric patients a year.”
Kamaliazad acknowledges that the study conducted last summer had a bigger impact on ED volume. “It did attract more people to the ED because they had heard about [the MAT] program and wanted to get into treatment,” she says. “We were referring patients to the health district, and that was the only program at that time that was accepting Suboxone patients or any type of MAT patients.”
However, Kamaliazad notes that now patients don’t need to come to the ED to access MAT treatment; they can go straight to the MAT treatment provider.
Still, Neven acknowledges that he was worried that the program could cause volume to spike. “There are so many patients who come to the ED with an agenda to get prescription opioids,” he says. “I have been really surprised that we have not been overrun with people who want to get Suboxone.” While Neven is supportive of offering Suboxone in the ED, he used the study period to determine whether the rest of the emergency providers would buy into the concept as well. “That was one of the major things we were testing,” he says. “There were vocal physicians that I knew of who felt that methadone programs are misplaced and misguided ... and that they are a waste of money.”
However, all the physicians ultimately agreed to participate in the program and offer Suboxone to the patients they determined were appropriate for the treatment, Neven explains.
Although many emergency providers have been hesitant to get involved in the treatment of addiction, the opioid crisis has gotten so severe that more physicians are willing to engage on this issue, Neven observes. He also has a ready comeback for physicians who question whether MAT is the right approach. “My main answer to that is to look at the data on what is most effective for treating opioid addiction. It is not abstinence-based therapy. It is not tough love. And it is not a 12-step program,” he says. “These things do not work for opioid addiction, and it is very clear in the literature that they do not work.”
People relapse at rates topping 90% when those approaches are used, and outcomes are much better when opioid substitution therapy or MAT is used, Neven adds.
“We are slowly educating physicians that this is the best, evidence-based approach, and it is also a harm reduction method,” he says. “Every dose of Suboxone is one less dose of heroin, which is one less dose of harm, so we should do everything we can to reduce harm. We shouldn’t go for a lifetime of sobriety because that is not realistic.
Kamaliazad adds that the ED may offer the best opportunity to connect with patients who have opioid addictions. “A lot of these patients have other social factors that are going to predispose them to not make regular appointments with doctors, so whether or not people in the ED want to treat people with addictions, it might be that the healthcare system is only able to capture these patients when they are in an acute setting because they tend not to follow up with regular physicians,” she says.
How might emergency medicine clinicians move forward with a similar program to what Neven and colleagues are doing in Spokane? One easy first step is to take the Suboxone course that will enable providers to obtain a DEA waiver to prescribe the drug, Neven advises. “It is four hours of a webinar online and then four hours in front of a computer doing online learning,” he says. “You will learn a comprehensive approach for giving Suboxone ... and obtain your DEA number.”
While the approach offered at Providence Sacred Heart does not require providers to prescribe Suboxone or to obtain a DEA number, it does give physician leaders added flexibility, Neven explains. He also advises providers who are interested in initiating MAT in the ED to spend a day or two in a Suboxone clinic.
“You will get an idea of how a clinic works and how you get someone inducted,” he says. “I worked in a Suboxone clinic for several months, and that is how I learned [the approach].”
Kamaliazad adds that when implementing the program it is helpful to employ a community health worker or some type of healthcare professional who has taken the Suboxone course, can consult on some of the more difficult cases, and facilitate the transition of patients to a MAT program.
“It is difficult for every physician in the ED to learn about all the options people have for MAT, so if one person knows about all the available programs, and he or she can be called and consulted, it makes it a lot easier,” she says.
Other emergency providers are taking an interest in developing MAT programs similar to the approach used at Providence Sacred Heart. Neven has fielded calls from colleagues on the subject, and he is looking at opportunities to expand the approach to other EDs.
Meanwhile, Lauren Whiteside, MD, MS, an emergency physician at Harborview Medical Center in Seattle, says she is one of the principal investigators for a large, multisite trial that will be evaluating the effectiveness and implementation of ED-initiated buprenorphine/naloxone for patients with opioid use disorder. The study includes sites in New York City, Cincinnati, and Baltimore, in addition to Seattle, and researchers anticipate recruiting 2,000 patients to participate in the investigation. (For more information about this trial, please visit: http://bit.ly/2ueJrnq.)
Investigators will be looking to see if outcomes confirm earlier findings from a randomized, controlled trial conducted by the Yale School of Medicine from 2009-2013. In that study, researchers found that providing patients with Suboxone and a referral to treatment in the ED made them more likely to remain in treatment for an opioid use disorder for at least 30 days than patients who only received a referral to treatment. The findings showed that 78% of the patients given Suboxone were still in treatment at 30 days, while just 37% of the patients who only received referrals to treatment were still engaged in treatment.2
1. Agency for Healthcare Research and Quality. Patient Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014. Available at: http://bit.ly/2tL4Ggi. Accessed June 28, 2017.
2. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA 2015;313:1636-1644.