While many emergency physicians are reluctant to tackle the issue of addiction, there is growing recognition that EDs offer a huge opportunity to identify patients with opioid use disorders (OUDs) and link them to meaningful care. The obstacles are many, but forward-thinking emergency medicine leaders in regions hit hard by the opioid epidemic are finding paths to success, often in partnership with other agencies or community groups.
For instance, officials at the University of Kentucky Center on Drug and Alcohol Research (CDAR) have teamed up with the University of Kentucky’s department of emergency medicine to develop a new, streamlined solution for patients who present to the ED with OUD.
In Jefferson County, AL, which has seen some of the highest rates of opioid overdose (OD) deaths in the country, emergency providers at the University of Alabama Birmingham (UAB) Hospital start appropriate patients on approved medications for their opioid addictions. Providers also use plenty of other new resources at their disposal, all of which are aimed at ending the cycle of addiction that brings patients to the ED repeatedly.
Identify Opioid Use Disorders
According to the CDC, Alabama leads the nation in opioid prescriptions, and the consequences are evident in Jefferson County, where Birmingham is located. In 2017, the county’s OD rate was 48.75 per 10,000 people, more than double the statewide average, according to data from the Substance Abuse and Mental Health Services Administration (SAMHSA). Those deaths were attributed not only to prescription opioids but other drugs such as heroin. The department of emergency medicine at UAB is tackling the issue head-on by taking steps to equip all its providers with the ability to prescribe medication-assisted treatment (MAT) and by working with community partners to immediately link patients with OUD to the services they need to recover. The new program is funded with a $1.5 million grant from SAMHSA, part of the U.S. Department of Health and Human Services.
Patients in need of care for an OUD are identified in multiple ways, explains Erik Hess, MD, MSc, vice chair for research in the department of emergency medicine in the UAB School of Medicine and the principal investigator for the new ED MAT program.
“There are some more obvious ways that patients present. They may have an overdose or they may present in withdrawal from opioids,” he says. However, Hess adds that patients with OUD also may present with other issues, such as bloodstream infections, endocarditis, or even sepsis, all of which can be complications from drug use.
Hess notes that investigators have developed an online clinical decision support tool to guide physicians if they suspect a patient may have OUD and assist them in making the diagnosis. “If a patient has symptoms of withdrawal for consideration, there is a scale at that point, the COWS [Clinical Opiate Withdrawal Scale], which clinicians can apply to determine the severity of the withdrawal,” he shares. “If the score is greater than 8, then the patient is in a significant enough withdrawal to consider the administration of Suboxone [buprenorphine and naloxone]. If the score is less than 8, then the patient is a candidate for a short-term prescription for Suboxone. That can then be initiated in the outpatient setting.”
Further, all patients diagnosed with OUD are linked with peer navigators. “These are individuals who are in sustained recovery from opioids who come meet with the patients while they are in the ED, help explore their interest in engaging in treatment, and help them navigate the system so they can get into rehabilitation,” Hess relates.
Although the peer navigators are based in the ED, they have been identified and trained to serve in this role by the Jefferson County Department of Public Health and other community agencies. “The community had already invested in and developed [the navigators] to bring on board and add another link to the chain [of support],” Hess notes.
Obtain DEA Waivers
Although emergency physicians are empowered to administer a dose of Suboxone to patients in the ED to ease immediate withdrawal symptoms, Hess is working to significantly increase the number of emergency physicians at UAB who undergo the required training to receive a physician waiver from the Drug Enforcement Administration (DEA), enabling them to write prescriptions for the drug, too. Hess cites research data to explain the need for this step.
“A trial ... of an ED-based administration of MAT protocol showed that patients who were provided with a short-term prescription of Suboxone — an outpatient prescription — were twice as likely to be in treatment at 30 days. There was a substantially lower rate of opioid use within the week [of their ED visit],” Hess explains.1
Simply providing a referral without providing a bridge treatment often results in patients developing severe withdrawal symptoms, which renders them less likely or unable to engage with the health system for rehabilitation, Hess cautions. “Getting these patients on Suboxone deals with their cravings and withdrawal symptoms. It creates a degree of stability to where they function better,” he says. “It really kind of primes them and gives them the ability to engage in treatment or long-term rehabilitation.”
Hess acknowledges that not all emergency physicians welcome the idea of confronting addiction in the ED. “There has been pushback, but there are different reasons for it,” he says. “One of the first barriers in the department that I worked on was the stigma [associated with addiction]. That is often based on [providers] not understanding how addiction affects people.”
Further, providers often believe there is little that can be done to address addiction. Providers need to understand there are effective treatments, Hess says. Then, there is the practical barrier of physicians needing to acquire a DEA waiver. “The government has made a decision to require physicians to get an eight-hour training certification in order to ... prescribe Suboxone,” he says. Hess allows that this can irk some emergency physicians who see the requirement as just one more task they are asked to handle.
Program administrators are working to overcome these obstacles, and they have established lofty goals for the effort. They intend to enroll 550 patients with OUD in the ED MAT program over three years. They hope 75% of those participants report abstinence from opioids at six months. Further, working with community partners, program leaders hope to decrease the number of OD deaths in Jefferson County by more than 30%. The MAT trial to which Hess alluded suggests these goals are achievable.
“In the context of that trial, 78% of patients were still in treatment at 30 days,” he says. “What is going to be the biggest challenge in this particular [program] is getting people into treatment and getting them to stay in treatment.”
Hess notes there are several different community agencies working simultaneously to address the opioid problem in the region. “[Alabama] Gov. [Kay] Ivy is putting together a task force trying to make a dent in this. The Jefferson County Department of Health has already invested in this area,” he explains. For instance, the Jefferson County Recovery Resource Center, established with the help of the county health department, serves as a referral hub to coordinate patients to appropriate treatment centers. “The combined efforts have more potential to produce an effect,” Hess adds.
Fortunately, the ED at UAB Hospital has infrastructure in place to effectively link patients to care and to keep tabs on their progress. This is thanks to earlier work focused on identifying and treating patients with HIV and hepatitis C. The same systems can be leveraged in the ED MAT program, Hess notes. In fact, there is considerable overlap in the affected patient populations of these three diseases, according to program administrators. Another goal of the ED MAT program is to ensure 75% of UAB’s emergency physicians possess their DEA waiver to prescribe Suboxone. Currently, data show only 3% of physicians in Alabama have received this training.
Officials at the University of Kentucky CDAR also recognize that the ED presents an opportunity to intervene with patients with OUD and link them to care. However, this opportunity has been missed in the past when these patients have presented for care. Part of the problem was there was no way to place these patients in treatment for their OUD quickly.
To address the issue, the CDAR teamed up with the EDs at UK HealthCare to establish the First Bridge Clinic, a setting where patients can be seen quickly after their ED visit and receive evidence-based care, counseling services, and ongoing monitoring to promote recovery from their OUD. Funds for the initiative were provided by the state through the 21st Century Cures Act. The First Bridge Clinic opened for patients in January 2018.
“The challenge is that OUD patients have a lot of issues in their lives, and it is hard for them to make it to scheduled appointments. We have had to try to break down as many barriers as possible to get them to the clinic after their ED visit,” explains Roger Humphries, MD, professor and chair of the department of emergency medicine at the University of Kentucky College of Medicine. “Those are the things we have worked on over the last year.”
For instance, the clinic is housed at the CDAR, which is about one mile from the ED at UK Albert B. Chandler Hospital, UK HealthCare’s Level I trauma facility. “It is not right next door, so that is one of the challenges,” Humphries notes. “A lot of times, social workers and others [here in the ED] can help arrange transportation for patients.”
Further, the clinic provides expedited care for patients who present to the ED with an identified OUD. “Sometimes, patients present with an OD; sometimes, they present in withdrawal,” Humphries says. “Then you’ve got all the different infections that can develop, especially from IV opioid drug use.”
Explore MAT Initiation
A relatively new practice in the ED at Chandler Hospital is the ability to administer buprenorphine to those patients who are in withdrawal from their opioid use. Similar to the process in place at UAB Hospital, the patients can be linked to care. “The goal of the First Bridge Clinic is to get patients into a situation where they can be assessed by an addiction management specialist and then, hopefully, continue on buprenorphine or some other MAT to help them deal with their OUD and get them stabilized,” Humphries observes.
Humphries cautions that emergency providers must ensure patients are at the appropriate level of withdrawal to receive buprenorphine. “The drug is such a strong binder on the opioid receptor that if patients are not at a certain degree of withdrawal, you could potentially make them feel worse [by providing buprenorphine],” he warns.
For instance, if a patient took heroin one or two hours before presenting to the ED, and he was not yet in withdrawal, providing him with buprenorphine could put him in withdrawal rather than ease his symptoms. However, when the drug is administered to appropriate patients, it can take away almost all their discomfort from withdrawal and stabilize them, Humphries notes.
The ED is wrestling with the challenge of how to best manage patients who present to the ED with an OUD on a Friday evening. The First Bridge Clinic is open only Monday through Friday.
A core group of emergency physicians has received waivers to prescribe buprenorphine. The question: Provide patients with a prescription for buprenorphine that will last until their appointment at the First Bridge Clinic on Monday, or ask the patients to come back to the ED for subsequent doses?
To smooth transitions between the ED and the First Bridge Clinic, the ED has put some electronic processes in place. “When we [input] a discharge order that the patient is to follow up with the First Bridge Clinic, the First Bridge Clinic is notified that this patient has been referred ... and then they can help contact the patient,” Humphries notes. “We have tried to break down as many barriers as possible.”
Humphries adds that while the ED does not employ peer support specialists or navigators to pair with OUD patients at this time, those resources are available at the First Bridge Clinic. “We refer patients there every day,” he says.
Provide Addiction Education
Other challenges remain. Educating emergency clinicians about the nature of addiction and what they can do to intervene is an ongoing process, Humphries notes. “We all agree that we need to relieve suffering, and we need to do whatever we can do for patients no matter what their circumstances are. There is a spectrum of acceptability among physicians to MAT,” he shares. “A lot of emergency physicians, like a lot of the public, haven’t come to understand yet that there is a difference between addiction and dependence.”
Thus, some emergency physicians continue to maintain that when providing patients with buprenorphine, one substitutes one drug for another, which is a poor option in their view, Humphries explains.
“In reality, though, you are taking a patient from an addiction disorder, which has all kinds of societal consequences [such as] stealing from family members and other types of crime and violence, to someone who is stabilized and dependent on opioids, but is not addicted to opioids,” he explains. “I don’t think there is a wide enough understanding of that difference and why it is acceptable to give somebody an opioid agonist even though [he or she] has an OUD problem.”
The goal should not be curing patients with OUD, but rather stabilizing them, Humphries stresses. “What you are doing is giving them a chance to re-enter society, be a productive member, have relationships with their family members, and to contribute,” he says. “That stabilization in itself is a huge goal and a huge win for the patient, for the healthcare system, and for society.”
Humphries adds that from a pragmatic standpoint, it should be clear to emergency providers that the opioid epidemic is not improving; a different approach is needed to achieve a better outcome. “For so long, we have had so few resources that there was a learned helplessness,” he says. “We told people that opioid withdrawal was not a life-threatening problem, but it actually is life-threatening if you look at ODs that happen when patients are in withdrawal.”
Humphries’ advice to other EDs that may not be as far along in developing their own solutions for managing patients with OUD is to realize that any barrier one puts in front of patients will decrease the chances that they arrive at a designated treatment provider. “You have to look at your process and make it as streamlined as possible,” he says.
1. 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.