EXECUTIVE SUMMARY

While frontline providers have their hands full with COVID-19, overdose deaths (OD) are surging across the country, in part, because of pandemic-related barriers. Some experts argue now is the perfect time to implement needed reforms in care for patients with opioid use disorder (OUD). In particular, they say it is time to fully leverage emergency departments (ED) in the quest to initiate these patients on treatment and connect them with ongoing care.

 • With many treatment clinics and doctor offices closed, it is harder for patients with OUD to access treatment or harm-reduction techniques.

 • Without access to needle exchange programs, clinicians fear there will be a rise in cases of hepatitis C and HIV.

 • Considering EDs are accessible 24/7, they are well-positioned to address many pandemic-related barriers, including initiating medication-assisted treatment and making referrals to ongoing care.


While COVID-19 rages across much of the country, capturing the full attention of clinicians and policymakers, there is growing evidence that America’s other epidemic, opioid use disorder (OUD), is getting worse.

Data show that after briefly decreasing in 2018, drug overdose (OD) deaths surged to nearly 72,000 in 2019, up almost 5% from the year before, and experts note OD deaths are continuing their upward climb this year.1

Gail D’Onofrio, MD, professor and chair of the department of emergency medicine at the Yale School of Medicine, notes there are “two epidemics colliding, making everything worse in many ways.”

She points to data from the Overdose Detection Mapping Application Program, a federally funded effort that collects OD data with the aim of improving both law enforcement and treatment approaches to the U.S. drug use problem. “It has actually generated more alerts from January to April [this year] than ever before, an increase of almost 200% compared to last year at that time,” D’Onofrio says.

Furthermore, in a recently published commentary, D’Onofrio and colleagues made a forceful case that the adverse effect of COVID-19 on people with OUD underscores the need and presents the opportunity for EDs to assume a central role in initiating these patients on treatment.2

Tackle the Barriers

There are multiple ways the COVID-19 pandemic is contributing to worsening conditions related to treatment for OUD and OD deaths, D’Onofrio argues. For example, with many clinics and doctor offices closed to normal business, it is harder for patients to access medications or harm-reduction tactics. Further, fear of COVID-19 is making bystanders less likely to use naloxone if they witness someone in trouble.

D’Onofrio also fears that without access to needle exchange programs, clinicians could see more cases of hepatitis C and HIV. “All of these things are horrific consequences of COVID-19 in this population,” she says, noting that a significant number of patients with OUD come from highly vulnerable groups.

Plenty are homeless and lack access to the internet, cutting them off from even telehealth services. “Many also tend to smoke or vape, and that is a risk factor for worsening COVID-19. For all of these reasons, we are very worried,” D’Onofrio says. “We have all seen overdoses more lately than we have in the past, and we are concerned there are more deaths that we have not seen.”

However, considering EDs are accessible 24/7, D’Onofrio stresses they are well-positioned to address many of these barriers through a screening, brief intervention, and referral to treatment (SBIRT) approach like the one she pioneered at Yale-New Haven Hospital several years ago.

Using SBIRT, patients with OUD who were initiated on buprenorphine in the ED and then referred to a treatment provider for ongoing care were much more likely to be engaged in treatment for their addiction after one month than patients who only received a treatment provider referral.3

With data proving the efficacy of the approach, other EDs have implemented similar techniques. Still, considering the scope of the problem, not nearly enough EDs are engaging, according to D’Onofrio.

“[Emergency medicine clinicians] do so many time-sensitive interventions for people who have other things wrong with them,” she states.

For example, D’Onofrio notes EDs devote significant resources to ST-elevation myocardial infarction (STEMI), including. “We are huge here [in New Haven, CT]. We have three sites, and we probably see 20 [STEMI cases] per month. Most EDs will probably see 10 [STEMIs] in a month,” she explains. “We probably see that many patients [with a nonfatal OD] in half a day.”

D’Onofrio points to a study out of Massachusetts showing the one-year mortality rate for patients presenting to the ED with a nonfatal OD was 5.5%.4 Nevertheless, EDs across the country routinely discharge such patients without initiating treatment. She argues a STEMI patient never would be discharged without aggressive treatment.

“It just doesn’t jibe,” she says. “We are ignoring all of these deaths, and I don’t understand it.”

Require Waivers

D’Onofrio acknowledges regulatory barriers are hindering progress in this area. For instance, the requirement that providers obtain a Drug Addiction Treatment Act (DATA) 2000 waiver to prescribe buprenorphine is onerous and should be discarded, she says.

Nevertheless, she urges ED leaders to require providers to obtain the waiver. It is a step she has taken in her own ED at Yale-New Haven Hospital, where she serves as physician-in-chief of emergency services.

“It is not a discussion. [Emergency physicians] have to take the class, and they have to get their waiver,” D’Onofrio says.

If there is a silver lining from the COVID-19 pandemic, it is that some regulatory obstacles standing in the way of providing treatment for OUD have been eased, making it easier for clinicians to obtain the waiver. “We have been able to train people for these DATA 2000 waivers over Zoom, which we were never allowed to do before,” she explains. “Everyone had to show up, and it was difficult to get everybody in the same room. But now ... I have run three classes on Zoom, and we have trained hundreds of emergency practitioners.”

Regulations also have been loosened to enable patients to connect with addiction treatment providers via telemedicine. This was a needed move since many treatment clinics have closed. Also, telemedicine removes transportation barriers. “When we refer patients, they can [connect to treatment] by phone or by telemedicine ... and that has never happened before,” D’Onofrio shares.

Further, patients are receiving take-home doses of methadone, a drug that must be taken every day. Requiring patients to visit clinics daily to receive this medication can be difficult.

“If you have a job or lack transportation, that can be a problem. But right now, [treatment providers] are supplying larger amounts of [methadone] to take home ... and the vast majority of these cases have gone well,” D’Onofrio reports.

Indeed, some are calling for at least some loosened regulatory changes to be made permanent.5

Contact Local Clinics

Another barrier to OUD treatment: a lack of community-based resources for ongoing care. In D’Onofrio’s experience, treatment resources are available, it is just a matter of connecting with these resources and establishing a working relationship. “That might take a little bit of work in some places, but it is doable,” she says.

For three years, the 24-bed ED at Marshall Medical Center in Placerville, CA, has been initiating patients on OUD treatment and then referring them to ongoing care at community clinics.

“The reason we were an early adopter was because I looked at the evidence, and I streamlined it into what I do with every other medical problem,” explains Arianna Sampson, PA-C, a physician assistant in the ED. “I saw there is a better medication for a medical problem that I treat all the time, it is more efficient ... and there is decreased mortality with it.”

Sampson had to ensure there was a clinic in the community that would accept her patients for follow-up. She connected with a clinic and “cut a deal” to ensure they would see patients the day after ED-initiated buprenorphine. The arrangement was appealing for both sides.

“For outpatient clinics, sometimes they have to book longer appointments for people when they are starting them on medication, whereas this is just easy for us to do the ED,” Sampson shares. “We are happy to start patients [on treatment] 24/7 as long as [the outpatient clinic] sees them the next business day ... it has been consistently successful. We have just been an open door.”

In addition to serving as a clinician in the ED at Marshall Medical Center, Sampson is a regional director for the California Bridge Project, a program that has helped dozens of EDs across the state implement medication-assisted treatment (MAT) programs. She notes a key step in this process is normalizing the treatment of OUD in the emergency setting.

“The reason I didn’t do this for a long time is we were told this is a specialty thing ... you send [patients] to another place where they get help,” Sampson observes. “That is something that has made clinicians feel like this is more complex than it is ... like it is a bit scary.”

It also adds to the stigma that patients with OUD feel, Sampson notes. She stresses it is possible to eliminate that stigma just by normalizing treatment, and then observing its efficacy. “I see people who I may have started on [buprenorphine] two or three years ago, and I can see how well they are doing. It is incredibly meaningful in terms of our staff, our clinicians, and decreased burnout,” she says. “For me, it has been very transformative for my career.”

Use Telemedicine

The COVID-19 pandemic has affected case numbers at Marshall Medical Center, Sampson acknowledges. “Our volume of people seeking treatment [for OUD] went down 50%,” she says, referring to the early days of the pandemic when shelter-in-place orders were in effect. “That was very striking.”

While much of the usual patient volume has returned, it is unclear how the pandemic has affected OD deaths. Sampson fears those numbers could be higher.

“I made a connection with our county coroner to see if we saw an increase in OD deaths, and it wasn’t really clear yet because we had double the [usual] number of suicides ... it takes a couple of months for toxicology results,” she says.

Early in the pandemic, Sampson contacted her referral sites to make sure they were continuing to accept patients and had developed telemedicine capabilities to facilitate access. “We were able to make that happen overnight with the two places we now refer to,” she says.

Also, since most clinicians who work in the Marshall ED have obtained DATA 2000 waivers, they have provided patients with longer prescriptions for buprenorphine when access to next-day follow-up care is a problem.

Considering the enhanced focus on COVID-19 and the burdens placed on frontline caregivers, is now really the time to push for reform in the way EDs manage patients with OUD? Sampson agrees with D’Onofrio: The answer is absolutely yes.

“This is the perfect time to make sure we are advocating for marginalized populations and people who otherwise don’t have access to care,” Sampson says. “This is an incredible time to address this because it is the call of medicine. I see it as advocating for people who ... have historically been treated poorly, and not with the same kind of treatment that we provide to people with other medical conditions.”

REFERENCES

  1. National Center for Health Statistics. Vital statistics rapid release. Provisional drug overdose death counts. Last reviewed July 15, 2020.
  2. D’Onofrio G, Venkatesh A, Hawk K. The adverse impact of COVID-19 on individuals with OUD highlights the urgent need for reform to leverage emergency department-based treatment. NEJM Catalyst, June 12, 2020.
  3. 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.
  4. Weiner SG, Baker O, Benson D, Schuur JD. One-year mortality of patients after emergency department treatment for nonfatal opioid overdose. Ann Emerg Med 2020;75:13-17.
  5. Springston J. Senators call for permanent expansion of telehealth. ReliasMedia.com, June 17, 2020.