How ED providers can start treating patients experiencing opioid addiction – TODAY

Sarah Windels – Bloomberg Fellow, Bloomberg American Health Initiative; Special Advisor, California Bridge Program

A recent report from the Legal Action Center identifies potential legal liability for hospitals that do not provide addiction treatment in the emergency department. Yet thousands of hospitals still do not provide this life saving therapy.  In my work, I help providers and administrators design and activate effective access to addiction treatment. Here are some key tips from successful programs to address barriers1 inhibiting treatment access in EDs nationwide.

1. 

   Make a commitment. Medication alone saves lives, even absent a referral for ongoing treatment.^{3, 4} Even one dose improves outcomes for patients experiencing opioid use disorder,³ decreases the impact of withdrawal,⁵ increases rates of successful follow-up3, and minimizes illicit opioid use.^{5, 6} Ideally there is a next-day follow-up for ongoing treatment, though sometimes that is not available – particularly in the early phase of an ED program. Alternatives to local ongoing care include high dose buprenorphine,⁷ a bridge prescription, partnering with a telehealth provider, or developing other novel partnerships between the ED and ongoing addiction services.⁸ Not every community has access to ongoing treatment, but don’t let this gap keep you from getting started.

2. Start treating patients with buprenorphine today. Some clinical champions have led months-long efforts to perfect the details ahead of day-one, while others begin an iterative learning process by starting with just one patient. The reality is that any licensed provider (MD, DO, PA, NP, CNM, CNS, CRNA) can immediately start a patient on buprenorphine, an effective medication for opioid use disorder, in the ED. And prescribing buprenorphine is as easy as filling out an online form – thanks to the recent changes to the DATA 2000 X-waiver.² A clear plan may ensure your team has a unified approach, while perfecting that plan may delay access to treatment for patients who need it now. Find a balance in your hospital, knowing that every plan will need iterative improvements along the way. Every minute of delayed treatment is opening up enormous risk for patients who may walk out the door and use an illicit substance today.
3. Deny the myths. Offering addiction treatment will not ‘open the flood gates’ of patients seeking care from the ED; patients needing treatment are often already lining the hallways to address health concerns related to illicit use.^9,10 Providers are eager to help, but just don’t know how.¹ In California’s 133 hospitals now offering buprenorphine, providers have reported increased job satisfaction11 with a new-found ability to use an effective tool to help patients address their addiction. Offering medications for addiction treatment may not only be a benefit to both patient and provider satisfaction, but also may be seen as a value-added service¹² that can, in fact, be cost-effective.^13,14,15
4. Find support. Guidance for providers is rapidly growing. Many providers with experience offering buprenorphine are eager to share the ease and satisfaction of treating patients with opioid use disorder and impact the growing overdose crisis. Virtual synchronous and asynchronous assistance for providers is available through a growing number of organizations such as the California Bridge Program, American College of Emergency Physicians, and Providers Clinical Support System, to name a few.  In California, the Poison Control System hotline offers 24/7 support for providers¹⁶ while the National Clinical Consultation Center Warmline offers daily specialized expert consultation in substance use evaluation and management. State and hospital administrators can similarly seek support for setting up effective programs and determining appropriate funding. A robust network of early champions of SAMHSA’s State Opioid Response funding is blossoming into impactful mentors that can share lessons learned. Ultimately, we all want our communities to thrive, and access to effective emergency treatment can happen today – particularly with the support from those with experience making it work.   

References:

1. Hawk K, et al. Barriers and Facilitators to Clinician Readiness to Provide Emergency Department Initiated Buprenorphine. JAMA Network Open. 2020;3(5):e204561. doi:10.1001/jamanetworkopen.2020.4561
2. Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder A Notice by the Health and Human Services Department Vol. 86, No. 80 (April 28, 2021) Pages 22439-22440. Retrieved on July 26, 2021 from https://www.federalregister.gov/d/2021-08961 
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(16):1636-1644. doi: 10.1001/ jama.2015.3474. 
4. Rachel P. Winograd, Ned Presnall, Erin Stringfellow, Claire Wood, Phil Horn, Alex Duello, Lauren Green & Tim Rudder (2019) The case for a medication first approach to the treatment of opioid use disorder, The American Journal of Drug and Alcohol Abuse, 45:4, 333-340, DOI: 10.1080/00952990.2019.1605372
5. Liebschutz JM, Crooks D, Herman D, et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern Med. 2014 Aug;174(8):1369-76. doi: 10.1001/jamainternmed.2014.2556. 
6. The SAMHSA evaluation of the impact of the DATA waiver program. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/ evaluation-impact-data-waiver-program-summary.pdf. Published March 20, 2006. Accessed August 24, 2020. 
7. Herring AA, Vosooghi AA, Luftig J, et al. High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder. JAMA Netw Open. 2021;4(7):e2117128. doi:10.1001/jamanetworkopen.2021.17128                    
8. Martin, A, Butler, K, Chavez, T., Herring, A., Wakeman, S., Hayes, B. D., & Raja, A. (2020). Beyond Buprenorphine: Models of Follow-up Care for Opioid Use Disorder in the Emergency Department. The western journal of emergency medicine, 21(6), 257–263. https://doi.org/10.5811/westjem.2020.7.46079
9. Aitken, C, Kerr, T, Hickman, M, Stoové, M, Higgs, P, Dietze, P. A cross-sectional study of emergency department visits by people who inject drugs. Emerg. Med. J., 30 (2012), pp. 421-422
10. Merrall E, Bird, S, Hutchinson, S. A record linkage study of hospital episodes for drug treatment clients in Scotland, 1996-2006. Addict. Res. Theory, 21 (2013), pp. 52-61            
11. California Bridge Program. Blueprint for Hospital Opioid Use Disorder Treatment. September 2020. pg 23. Accessed July 26, 2021 from https://cabridge.org/resource/blueprint-for-hospital-opioid-use-disorder-treatment  
12. Bernstein E, Bernstein J, Levenson S. Project ASSERT: an ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Ann Emerg Med. 1997 Aug;30(2):181-9. doi: 10.1016/s0196-0644(97)70140-9. PMID: 9250643.
13. Colorado Hospital Association. Business Considerations for Induction of Medication for Addiction Treatment in Hospital Settings. October 2020. Accessed July 25, 2021 from https://cha.com/wp-content/uploads/2020/10/MAT-Business-Considerations_final.pdf
14. Mohlman MK, Tanzman B, Finison K, Pinette M, Jones C. Impact of medication-assisted treatment for opioid addiction on medicaid expenditures and health services utilization rates in Vermont. Journal of Substance Abuse Treatment. 2016 Aug 1;67:9-14. doi: 10.1016/j.jsat.2016.05.002. 
15. Baser O et al. Cost and Utilization Outcomes of Opioid-Dependence Treatments. Am J Manag Care. 2011 Jun;17 Suppl 8:S235-48.
16. LeSaint, K.T., Ho, R.Y., Heard, S.E. et al. California Poison Control System Implementation of a Novel Hotline to Treat Patients with Opioid Use Disorder. J. Med. Toxicol. 17, 190–196 (2021). https://doi.org/10.1007/s13181-020-00816-1