EXECUTIVE SUMMARY

Community hospitals work with fewer resources than large, academic medical centers. However, these facilities can create effective treatment programs for patients with opioid use disorder (OUD). In fact, experts state that when patients with OUD present to the ED, or are admitted as inpatients, there is a powerful opportunity to place them on the road to recovery. Still, clinicians in these settings need to engage with their leaders to set up a positive path.

  • In a recent Joint Commission-sponsored forum, experts noted that a primary step in curtailing the opioid epidemic is to refrain from starting patients on chronic opioids for nonterminal conditions. This can be facilitated by providing emergency providers with a range of alternative options for pain relief and then making it easy to prescribe them.
  • When patients who already are dependent on opioids present to the ED, physicians have an opportunity and a responsibility to provide treatment for OUD.
  • Experts recommended buprenorphine as a first-line treatment for patients who present in withdrawal from opioids, noting that this treatment is easy to prescribe and can accelerate ED flow.
  • To put an effective treatment program in place, community hospitals need to add buprenorphine and methadone to the hospital formulary, arrange order sets or guidelines, and forge agreements with community clinics to provide ongoing addiction treatment to hospital patients.

Several large, academic medical centers have launched comprehensive initiatives to address the opioid crisis. For example, many systems have hired addiction counselors and navigators to work with patients who present to their EDs with opioid use disorders (OUD) and link these individuals into care. Some have created and staffed on-site clinics to provide addiction treatment to these individuals on an ongoing basis. A number of these approaches also include provider education, IT interventions, revamped pain treatment guidelines, and robust social support systems to address the problem.

Although impressive in their scope, such programs may seem completely out of reach to the hundreds of community hospitals that face many of the same issues regarding pain management and addiction, but lack the resources to spearhead such large-scale endeavors. However, some smaller, innovative hospitals are finding effective ways to confront the opioid crisis in their communities, and many are willing to share their roadmaps to success with others.

In a forum sponsored The Joint Commission (TJC) on Jan. 15, two pioneers in this area shared their insights on how community hospitals can take steps to meet the needs of the growing number of patients who present with OUD and perhaps in the process make a dent in a crisis that has not yet shown any sign of ebbing.

Try New Approach

Hannah Snyder, MD, practices primary care, hospital medicine, and addiction medicine at Zuckerberg San Francisco General Hospital and is the inpatient director for California’s ED-BRIDGE project, which helps hospitals bring evidence-based treatment for substance use disorders to patients in inpatient and emergency settings. During TJC’s forum, Snyder acknowledged that she frequently encounters clinicians in the ED or the hospital who feel as though they are powerless to make a difference with patients in the throes of addiction. However, she noted that with effective treatment, such patients can and do recover, and that facilitating this process is one of the most fulfilling things for a provider.

“Our job as healthcare providers is to prevent deaths and prevent morbidity. Opioid use disorder in particular has such a high rate of death from overdoses and morbidity from non-fatal overdoses,” she said.

Snyder also noted that OUD is associated with infections and many other medical problems. “That is why we also think of this as a public health intervention. It is about the patient who is in front of you in the hospital that day, but it is also about reducing the burden of drug use on the community. That means reducing rates of HIV and hepatitis C, reducing healthcare costs, and even reducing the rates of assaults and accidents,” she explained.

Snyder argued that the case for new and different approaches to the problem is compelling, given the fact that the overdose rate continues to rise despite more than a decade of efforts to address the crisis. She noted that fentanyl is one of the primary reasons why such efforts have been stymied of late.

“We are having fentanyl contaminate the opioid supply, including heroin, but it is also contaminating all of our street drug supply, including our stimulants like cocaine and methamphetamine,” she said. “What we see now is that in the last year, the number of people who died from opioid overdose is more than all of the Americans who died in the Vietnam War. It is more than the peak rate of deaths from HIV. It is a huge epidemic, and we in the healthcare system need to be addressing it.”

Facilitate Change

Casey Grover, MD, is the director of the ED and chairman of the pain management workgroup at Community Hospital of the Monterey Peninsula (CHOMP) in Monterey, CA, and the physician champion for the Monterey County Prescribe Safe Initiative, a coalition focused on reducing the burden of prescription drug misuse and opiate addiction in the community. During TJC’s forum, Grover observed that a primary step in curtailing the opioid epidemic is to refrain from starting patients on chronic opioids for nonterminal conditions.

One way to make it easy for emergency physicians to opt for nonopioid alternatives is through the use of preprinted discharge prescriptions that include many nonopioid options that providers can simply check.

“One check box is much more efficient than writing out eight to 10 letters,” Grover noted. “It is easier and more efficient for me to write [prescriptions] for the nonopioid medications than it is to give me a blank script where I can write whatever I want.”

At CHOMP, these preprinted prescriptions are all loaded in the electronic medical record (EMR), and they include directions along with the specific medicines. There is a button for “nonopioid RX” that will display the forms, Grover explained. “All of our physicians have really embraced this. It is fast, it is easy, and it provides multiple nonopioid therapies,” he added.

One of the complaints Grover often heard from physicians is that there were few nonopioid alternatives in the hospital. To correct the problem, he worked with the ED pharmacist to ensure that several pain relief options were available.

“I believe there are 35 different options for pain management in my ED and probably fewer than 25% are opioids,” he explained. “We can use intravenous lidocaine for kidney stones; we can do low-dose ketamine; and nitrous oxide can be really helpful when you are trying to reset a fracture.”

Grover also now asks the hospital physical therapist to become more involved in helping some patients with pain relief, many times in concert with other pain relief options. “Often, combining [several options] is really good,” he noted.

Another option Grover has integrated into the ED’s approach to pain is the use of transcutaneous electrical nerve stimulation (TENS) units.

“They are inexpensive devices and they are reusable,” Grover said, adding that ED providers have found TENS units to be very effective at delivering relief to patients experiencing pain.

A key point is that emergency physicians can offer patients several options for their pain, Grover stressed. “For the longest time, we would tell our doctors in our EDs: No on opioids. Now, we are telling them yes to 25 different other medicines that they can use instead of opioids. My providers really like that,” he said.

“I think they felt stifled and that they had to disappoint patients when they said they couldn’t help them with their pain.”

When patients who are already dependent on opioids present to the ED, it is not sufficient to simply turn them away, Grover said. “We have an opportunity and a responsibility to treat them,” he said, pointing out that many of these patients became dependent in the first place because medical providers prescribed them opioids.

However, clinicians tend to think of addiction treatment as something that happens in primary care or an addiction treatment center. However, more often the opportunity to place these patients into treatment is in the ED, Snyder explained.

“Whether we like it or not, the ED is a really frequent site of care for patients with opioid use disorder,” she said. “They are often not engaged in other forms of care. These folks are not going to primary care, and they aren’t going to addiction treatment — but they are there in front of you.”

In particular, when a patient presents with symptoms of withdrawal, that is an emergency, Snyder noted. “If that patient doesn’t receive treatment, [he or she] is much more likely to use drugs in a riskier way and have a much higher risk of overdose,” she shared. “This is a time when there are really high mortality rates, and we can intervene.”

In such cases, Snyder recommends buprenorphine as a first-line treatment. “We find this is a quick and easy thing to provide in the ED. It can actually speed up your ED flow,” she said. Further, Snyder noted that initiating buprenorphine in the ED has been well-tested in several randomized, controlled trials, the results of which have revealed that when patients receive their first dose of buprenorphine in the ED, they are much more likely to stay engaged in treatment.

Snyder added that another important opportunity to engage patients with OUD is when they enter the hospital as inpatients. These patients may be visiting the hospital for an issue that is incidental to their OUD, but many of them are open to receiving help for their problem, she shared.

“We know that two-thirds of hospitalized people who use drugs want to cut back or quit, and they are looking to use [their admission to the hospital] as an opportunity to do that,” Snyder said. “They’re sitting there in the hospital, and they are afraid of bad outcomes, such as death from endocarditis, which might be related to their drug use.”

Consequently, it is a powerful moment for change if attentive healthcare providers seize the opportunity to engage these patients and start them on either buprenorphine or methadone in the inpatient setting, Snyder suggested. “If you are walking out of the hospital, you feel comfortable, and you have had a good experience with this medicine, you are much more likely to follow up with outpatient treatment. But these folks are often not being engaged or helped directly,” she said.

Cut Through Barriers

Community hospitals willing to make improvements in this area are fully capable of doing so, Snyder stressed. In fact, many barriers that administrators worry about are more of a mirage. For example, Snyder noted that people tend to misunderstand what the DEA requires regarding the use of methadone or buprenorphine.

For example, Snyder noted that patients in the hospital for non-OUD-related reasons can start buprenorphine or methadone. Further, she explained if a patient presents to an ED or urgent care center in withdrawal, there is a specific regulation that states it is legal to administer, but not prescribe, buprenorphine or methadone for up to 72 hours. “Upon discharge, regular rules apply, and [patients] need to go to a methadone clinic or an [authorized] buprenorphine provider,” she said.

Many community hospitals usually cannot afford to support a clinician with advanced addiction training who can oversee treatment of patients with OUD, let alone navigators or social workers who can devote their time to helping bridge such patients into follow-up. However, these facilities can provide the needed care to patients with OUD, according to Snyder.

“I work with hospitals all the time that don’t have specific funding for this, but are able to do it. You just need to get buprenorphine and methadone on the hospital formulary, and put together some order sets or guidelines,” she said.

Also, community hospitals need to forge an agreement with community clinics to the effect that they will accept patients for ongoing addiction treatment in a timely fashion. “Then, one of your providers needs to start prescribing,” Snyder added. “It is pretty straightforward, and it is all protocolized.”

As an example, Snyder pointed to Marshall Medical Center in Placerville, CA, as one community hospital that has successfully integrated initiation of buprenorphine into the care that it provides in the ED. “The [program] was completely unfunded. There was no navigator. They just set up a standing appointment at their FQHC [Federally Qualified Health Center],” she explained. This facilitated ongoing treatment for patients started on buprenorphine in the ED.

“When I last checked in with [Marshall Medical Center], 35 of the 38 patients that they started on buprenorphine in their ED presented for follow-up treatment, and 26 are still in treatment,” Snyder reported. “That 68% of patients are still in treatment is huge. That is a much higher rate than what we often see even in community addiction treatment programs.”

In addition to taking the steps necessary to initiate buprenorphine while patients are in the hospital or ED, Snyder urged clinicians to provide naloxone to all patients with OUD.

“No matter how motivated your patient is, there is a chance of relapse. This is the reality of this disease process. Whenever counseling any patient who uses drugs, I talk about the possibility of return to use,” she said. “We have to be realistic, and we have to set them up for success.”

Grover notes that CHOMP has taken all the steps that he and Snyder discussed even though it is a community hospital with no associated teaching facility, no residents, and no medical students. “We must treat addiction and dependence when patients have [these problems]. But we have to also own the fact that we as medical providers started people on opioids,” he observed. “When [patients] are having problems with their medicines, we have to offer them treatment.”

These resources can assist community hospitals with setting up effective OUD treatment programs: ED-BRIDGE (https://bit.ly/2RdqIDO), Project SHOUT (https://bit.ly/2DvuuF0), CHOMP’s Prescribe Safe (https://bit.ly/2R7eLjb), and Prescribe to Prevent (https://bit.ly/2WfQsmU).