https://jamanetwork.com/journals/jama/fullarticle/2681835?resultClick=1

Rita Rubin, MA

Until recently, when people came to Massachusetts General Hospital’s emergency department (ED) desperate to stop using heroin or prescription painkillers, physicians could only hand them a list of phone numbers for treatment programs, numbers many of them had already called, only to be told they couldn’t get in.

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“That was so frustrating for all of us,” recalled Ali Raja, MD, executive vice chair of the department. “We weren’t trained or equipped to dispense buprenorphine,” 1 of 3 approved drugs used to treat opioid use disorder.

Buprenorphine, approved by the US Food and Drug Administration in 2002, relieves opioid withdrawal symptoms and minimizes cravings for opioids without producing euphoria. Unlike methadone, which must be dispensed in highly structured clinics, buprenorphine can be prescribed or dispensed in physician offices.

In December and January, however, 38 of the 43 physicians in Raja’s department completed the 8-hour training course required by federal law to qualify for waivers to prescribe and dispense buprenorphine. Shortly afterward, the Massachusetts General ED became the first one in that state to begin dispensing the drug.

“It’s the beginning of a tidal wave,” Raja said, referring to plans by EDs in Massachusetts and nationwide to begin offering buprenorphine to people with opioid use disorder. “This is answering a need.”

Emergency medicine physicians at hospitals such as Massachusetts General see the need daily. Emergency department visits for opioid overdoses rose 30% from July 2016 through September 2017, according to a recent report from the Centers for Disease Control and Prevention.

“Educating ED physicians and staff members about appropriate services for immediate care and treatment and post-overdose protocols are important to preventing future overdoses among their patients,” the report’s authors concluded. At a press briefing about the overdose data, then-Acting CDC Director Anne Schuchat, MD, called initiating “medication assisted treatment” of opioid use disorder in the ED “an innovative and exciting strategy.”

Gail D’Onofrio, MD, physician-in-chief of the Yale-New Haven Hospital ED, pioneered the strategy. In a 2015 JAMA article, D’Onofrio and her coauthors reported the results of a randomized trial that found patients with opioid use disorder who started buprenorphine treatment in the ED were more likely to be engaged in addiction treatment and report fewer days of illicit opioids use per week a month after randomization than those who received only a referral to community-based treatment. In a follow-up article in 2017, D’Onofrio and her coauthors reported that their finding held up 2 months after randomization.

“I probably get 2 calls a week: Send me your protocol,” said D’Onofrio, founding chair of the department of emergency medicine at the Yale School of Medicine. “We have to do something, and this is a place to start.”

Broaching the Subject

It’s often easy to identify patients who are candidates for starting buprenorphine in the ED, D’Onofrio said. They might flat-out ask for it, or they might exhibit withdrawal symptoms or obvious complications associated with opioid use, such as an injection site abscess, she said. “Or you’re talking to the patient, and something clicks that this could be a problem.”

Broaching treatment with patients whose opioid use isn’t obvious is trickier. D’Onofrio will ask whether they use opioids and show them a list of the drugs. If they say they use prescription opioids, she’ll ask whether they need to take more than what they were prescribed.

But ED physicians less-experienced in dealing with opioid use disorder often don’t recognize it, said Aimee Moulin, MD, an associate professor of emergency medicine and president of the California chapter of the American College of Emergency Physicians (ACEP).

“I think we’re missing a lot because we’re not asking the right questions,” said Moulin, whose ED began initiating treatment with buprenorphine in January. Instead of simply treating the patient’s wound or the injury, she and her colleagues need to dig deeper for its cause, she said.

That’s easier said than done, though. “How do you start the conversation? What words do you use?” Moulin said. To help ED physicians ask the right questions about opioid use disorder, the California ACEP chapter is developing a script that it plans to post on its website by early summer, she said.

However, patients who have just had an overdose reversed with naloxone usually won’t accept treatment for opioid use disorder right away, D’Onofrio said. In those cases, ED physicians should discuss harm reduction, advising the patients not to use opioids when alone and providing naloxone nasal spray that a friend or relative could administer if they overdosed again.

Getting Treatment After the ED

Dispensing buprenorphine and brief counseling in the ED is only the first step in addressing opioid use disorder. However, EDs are not equipped to handle the next step—providing ongoing treatment for opioid use disorder. That is why physicians must be able to refer patients to a clinic or a physician’s office where patients can be treated with buprenorphine for as long as necessary, possibly for the rest of their lives, D’Onofrio said. “You can’t just start this [in the ED] and say, ‘Go!’” she said. “You have to send them some place.”

In New Haven, Connecticut, “we’re lucky that we have all these options,” D’Onofrio said, referring to clinics and physicians in the community that can pick up where her ED leaves off in treating opioid use disorder. However, many towns and cities are not as fortunate. A 2015 report by researchers from the FDA, CDC, and Substance Abuse and Mental Health Services Administration (SAMHSA) concluded that “significant gaps between treatment need and capacity exist at the state and national levels,” due in part to the limited number of physicians who have been waived to prescribe buprenorphine as well as their underuse of the drug.

Faced with a lack of places to refer patients, Massachusetts General established its own treatment clinic in 2015. Instead of having to wait weeks or even months to begin treatment in the community, patients who receive buprenorphine in the ED for opioid withdrawal symptoms can go to the hospital’s 7-day-a-week clinic the next day, Raja said.

Like Massachusetts General, Cooper University Hospital in Camden, New Jersey, established its own addiction clinic in 2015 because of a lack of treatment programs in the city. Cooper University Hospital could not have begun offering buprenorphine in its ED without having a place to refer patients afterward, said Rachel Haroz, MD, an assistant professor of emergency medicine at Cooper Medical School of Rowan University.

But, “word spreads very, very fast on the street,” Haroz said, so now most patients who come to the ED in search of opioid use disorder treatment must wait 4 to 6 weeks to get into her hospital’s addiction clinic. Between the time they get a dose of buprenorphine in the ED and the time a spot opens for them in the clinic, “a lot of people just buy Suboxone [a brand of buprenorphine plus naloxone] on the street,” which costs less than a packet of heroin, Haroz said.

Andrew Herring, MD, an ED physician at Highland Hospital in Oakland, California, who also runs an addiction clinic at the same hospital, questions the need to forgo dispensing buprenorphine in the ED due to a lack of follow-up care. “People are getting a little too worked up about the big picture,” said Herring, whose ED began dispensing buprenorphine in early 2017.

By administering buprenorphine to ED patients with opioid use disorder, “you’re trying to give them 2 or 3 days of clarity,” he said. “You’re trying to prevent the development of severe withdrawal,” which drives behaviors in heroin users that increase the risk of an overdose, such as injecting in unfamiliar locations.

Overcoming the Stigma

The 5 physicians in the Massachusetts General ED who have not yet completed the 8-hour buprenorphine course probably never will, Raja said. “They know it’s an option, and they haven’t approached me,” he said. “I haven’t actually probed why.”

Sandra Schneider, MD, ACEP’s director of emergency medicine practice, suspects she knows. For one, finding 8 hours to take the required course is a hassle. “People did not go into emergency medicine to become addiction specialists,” Schneider said. “I can prescribe all the narcotics I want, but if I want to prescribe buprenorphine, I have to jump through 400 million hoops. Why does it have to be so complicated?”

D’Onofrio called the required course “onerous.” “I’m trying to make it as easy as possible,” she said, noting that physicians in her ED can complete half of the course on a computer instead of in a classroom. In addition, community physicians in her ED get credit for a shift when they complete the training. By April, three-fourths of the Yale ED physicians were trained, she said, and eventually all will be. “I make it an expectation,” D’Onofrio said.

Herring pointed out that physicians do not have to complete the buprenorphine course to use the drug to treat withdrawal symptoms in the ED. The Drug Enforcement Administration (DEA) makes an exception called the “3 day rule”: Physicians who have not been registered to prescribe buprenorphine can administer a day’s worth of the medication to relieve withdrawal symptoms for up to 3 days while the patient awaits placement in a treatment program. The problem is that half of the states don’t recognize that exemption, Schneider said.

Perhaps an even bigger problem, though, “is that somehow, substance use disorder is not being treated as the medical emergency that it is,” Schneider said. The ACEP is working with its members to lessen the stigma surrounding substance use disorder that prevents proper treatment of the condition in the ED, she said. “Emergency physicians see only the failures of the system. We become very cynical because it’s so frustrating. We’ve never seen [patients with opioid use disorder] get better.”

A recent survey of emergency physicians in the Johns Hopkins Health System found that they “had lower regard for patients with substance use disorders than other medical conditions with behavioral components.”

‘’I think there’s so much baggage around addiction,” Herring said.

The stigma around their disease in the ED contributes to patients’ reluctance to admit that they have opioid use disorder, which could save a lot of time and expense, Herring said. Instead, he said, they’ll come in feigning illness, triggering a costly medical workup that doesn’t uncover what’s really wrong with them.

Emergency department physicians who do screen patients for opioid use disorder and initiate buprenorphine treatment when appropriate say that the work helps fulfill their mission. “Substance use disorder is one of the main things we see in the emergency department,” Moulin said. “We’re there to save lives, and this is an important tool.”

Comment;

When I was an ED physician, early in my career, I used to hate seeing routine problems that should have been cared for in a primary care office—I’m a Board-Certified Family Physician.  These folks needed to have a good PCP and not fragmented care in ED’s.  I was upset at the patient initially, then realized that they were mere pawns in the “game” of having a “health care non-system” in this country–they usually had no real choice!  Opioids are an emergency, crisis situation.  Unfortunately, our culture treats the ED as the “first stop” in medical care.  We may as well have ED’s able to handle these increasingly more common “emerging emergencies”

Dr. Raymond Oenbrink
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