Emergency Department Treatment of Opioid Addiction: An Opportunity to Lead

Opioid use disorder (OUD) is the fastest growing substance use disorder in the United States and the main reason for seeking addiction treatment services for illicit drug use throughout the world.1 The emergency department (ED) is an important point of care for patients with OUD as these patients are often marginalized from traditional primary care services.2 EDs often serve their primary health care needs and also offer overdose reversal, attention to injuries related to substance use, and entry points into OUD treatment. Unsurprisingly, ED visits for problems related to opioid use have risen by nearly 100% in the past decade compared to opioid-related inpatient stays, which increased by 64%.3 As a result, emergency physicians are uniquely positioned to intervene and help patients with OUD at a critical moment in their lives. There is a considerable gap in many EDs between evidence-based research and common practice. Currently, the American College of Emergency Physicians (ACEP) guidelines related to opioids focus on opioid prescribing which is helpful but offers limited direction with respect to treatment.4 In the absence of national-level guidance, most EDs refer patients to abstinence-based methods such as detoxification programs or intensive psychosocial treatment programs.5 Neither, in the absence of medication therapy with buprenorphine or methadone, has been shown to be effective in the treatment of OUD.6 Evidence from systematic reviews demonstrates that maintenance treatment with either methadone or buprenorphine is effective across a range of outcomes, including reducing all-cause mortality, improving physical and mental health, and decreasing illicit drug use.7 A study of 33,923 Medicaid patients diagnosed with OUD in Massachusetts found that patients treated with buprenorphine experienced a 75% reduced mortality versus patients treated with three psychosocial interventions alone.8 Another study of patients randomized to individual counseling and either buprenorphine maintenance or detox found that 0% of the detoxification group was in treatment at 1 year compared to 75% of the buprenorphine maintenance group. Tragically, 20% or four of the sixteen patients in the detox group died during follow-up and none remained in treatment after 50 days.9 In addition, Schwarz et al.10 found retention on buprenorphine maintenance therapy had a strong and significant effect on reducing ED use. Their results suggest that there is, on average, a 17.5% decrease in ED usage per subject over a 1-year period. Referring patients to medication therapy would save lives and also decrease ED utilization. While referring patients to medication therapy for OUD would represent a step into line with evidence-based recommendations, our specialty can and should go even further to advance care for patients with OUD. Medication therapy with buprenorphine has been shown to increase persistence in treatment when initiated in the ED. D'Onofrio et al.11 conducted a randomized clinical trial involving 329 patients with OUD who were treated at an urban teaching hospital. They found among patients with OUD, ED-initiated buprenorphine treatment, compared to brief intervention and referral, significantly increased engagement in addiction treatment, reduced self-reported illicit opioid use, and decreased use of inpatient addiction treatment services. Seventy-eight percent of patients in the buprenorphine group (89 of 114, 95% confidence interval [CI] = 70%–85%) versus 37% in the referral group (38 of 102, 95% CI = 28%–47%) were engaged in addiction treatment on the 30th day after randomization (p < 0.001). Building on the success of these results at Yale-New Haven Hospital, investigators established a similar ED-initiated buprenorphine referral pathway at Sacred Heart Medical Center in Spokane, WA. They found that when patients deemed appropriate for medication therapy with buprenophine were initiated into treatment with a single dose of buprenorphine while in the ED, more than 70% of patients were still engaged in treatment at 30 days.12 EDs commonly initiate treatment for other chronic and relapsing medical conditions such as hypertension, diabetes, and asthma, and OUD should be no different. We offer a clinical case to illustrate how such a pathway to treatment might be used in the ED: A 34-year-old woman with anxiety and recent bimalleolar ankle fracture, status-post open reduction/internal fixation, presents requesting detoxification from opioids. Eighteen months ago, she was started on a short course of oxycodone after undergoing a minor operation to repair a fractured ankle she sustained during a trip and fall down a short stairwell at her daughter's day care facility. She finished her prescription and continued to feel pain, tactile chills, and mild nausea. Her PCP felt uncomfortable prescribing her additional opioids, so she began using leftover Percocet from her husband's previous injury. After these ran out, with persistent pain and seeking feelings of “normalcy,” she started seeking prescription opioids from friends and family and eventually began to buy them from a drug dealer in the town where she grew up. As the cost of her addiction rose, she transitioned to intranasal heroin use one week prior to presentation. After she sobered from this experience, she realized she needed help overcoming her addiction. Accompanied by her husband, she presented for evaluation in the ED requesting “detoxification.” She told the triage nurse, “I didn't know where else to go … ” “Seeking detox” for OUD is an increasingly common chief complaint in EDs, particularly those in regions most affected by the opioid epidemic. In our experience, a typical ED would offer this patient assistance in accessing detoxification from opiates in a variety of settings, including nonhospital addiction or mental health treatment facilities, intensive outpatient and partial hospitalization programs, and acute care inpatient settings.13 Some EDs may offer a social worker, recovery coach, or case manager to help her find a facility able to accept her. Others may allow her to make phone calls from the ED waiting room. Unfortunately, these options either refer the patient to non–evidence-based care, as in the case of referral to detox facilities, or discharge the patient with high risk of relapse, without offering immediate treatment with buprenorphine that has a proven benefit. Consider, on the contrary, the treatment this same patient received when she presented to this ED for her ankle fracture. She was seen by a provider in the ED who performed diagnostic testing, offered her initial treatment with a splint, and ensured that she had close follow-up for more definitive treatment with an orthopedic surgeon the next day. It would be unimaginable for a provider in this scenario to diagnose the fracture, forgo splinting it (initial treatment in this case), and discharge her with a list of orthopedic surgeons and ask the patient to keep calling until one could see her within a few days. This is analogous to what is happening to patients with OUD in most EDs currently. We propose that this patient, upon arrival to the ED, should have undergone brief screening and counseling to determine her eligibility for and interest in medication therapy with buprenorphine. If she were a good candidate, and were in mild to moderate withdrawal, she would have been administered 8 mg of sublingual buprenorphine in the ED and scheduled for follow-up in a partnering specialized addictions clinic the next morning where she could be maintained on buprenorphine. She could then be discharged home already receiving appropriate treatment, with a plan in place for close follow-up. Emergency Departments can implement such a treatment pathway with relatively few barriers. ACEP already offers guidelines for OUD screening and counseling, which would enable clinicians to assess a patient's candidacy for treatment. Although medication therapy with buprenorphine is highly regulated under the federal DATA 2000 law, emergency physicians are permitted to administer up to 72 hours worth of medication treatment without needing to obtain the DEA waiver required for other providers. As such, no additional licensing is required, although obtaining a waiver offers optimal flexibility by allowing providers to discharge patients with a short prescription to link into community based care. This leaves only one major institutional barrier to ED induction of buprenorphine, which is the need for next-day evaluation in clinic by a licensed buprenorphine prescriber. This presents an important opportunity for EDs to collaborate with our colleagues in internal medicine, family medicine, and psychiatry. These professions are rapidly training their clinicians to prescribe buprenorphine to increase treatment capacity. At our institution a “bridge” clinic was established to fill the many gaps in the current treatment system by offering walk in addiction services including on demand medication treatment. Such clinical models with capacity for same or next day referrals should be considered a standard of care for EDs, particularly those in academic centers. Just as an ED patient can typically be guaranteed timely orthopedic follow-up after a fracture, they should have the same assurances when requiring OUD treatment. The increasing toll of overdose deaths due to the opioid epidemic amplifies the urgency to offer evidence-based services, and to decrease barriers, such as the delays that can occur with referrals to treatment services. While changing ED treatment pathways can be challenging, we believe that ED initiation of buprenorphine will save lives. Training clinicians in these new procedures is relatively straightforward and builds on existing screening and referral interventions. We believe that, with ED champions creating linkages to next-day addiction treatment, these pathways can be implemented in most EDs. This is a critical opportunity to make evidence-based practice the new standard of care in the midst of what is the most important health crisis of our time. The authors acknowledge Dr. Scott Weiner and Dawn Williamson.