By now, you would literally have to be living under a rock not to be aware of the increasing interest in emergency department–initiated medication-assisted therapy (ED MAT). Programs that initiate buprenorphine while patients are still in the emergency department are popping up all over the country and have been featured in The New York Times and elsewhere, but those are still the exception and not the rule.
Explore This IssueACEP Now: Vol 38 – No 04 – April 2019
Mid Coast Hospital is a 94-bed community hospital in Brunswick, Maine. We have a 20-bed emergency department with a three-bed ED behavioral health observation area and see about 30,000 patients annually. We are not dissimilar to any of you in terms of the impact that behavioral health emergencies, substance use, and opioid use disorder (OUD) have had on our department. At the same time that we have seen an increase in demand for substance use treatment, we seem to have experienced a decrease in community and statewide resources downstream of the emergency department.
The Mid Coast Hospital Program
In 2015, the initial D’Onofrio et al study that described ED MAT was published in JAMA. At the urging of one of our physician assistants, who was frustrated with the current state of affairs, we began to meet with our peers from the addiction resource center across town and created guidelines and protocols for ED MAT at Mid Coast Hospital. Blessed with an ED staff willing to take this on and a recovery center willing to grant quick access in follow-up, we created standard pathways so that expectations were predetermined. We provided a short educational session on buprenorphine for our ED providers. We did not require an X-waiver.
We introduced our program in the fall of 2017. It was a slow start, and we did not see very many patients the first few months. Much to everyone’s surprise, the floodgates did not open. We did not, in fact, become a substance use treatment center first and an emergency department second. Over time, however, the program took hold. Our early-adopter providers led us through the process, and now even our late adopters have begun to get involved and embrace the program.
Over the first 14 months, we initiated buprenorphine on 35 patients. Most (94 percent) of these patients arrived at their initial intake appointment, and 70 percent remain engaged in therapy at our addiction recovery center at 30 days, while others have been referred to methadone or other residential programs.
These are low-volume but high-risk and high-impact situations. Compare this to stroke. In our emergency department last year, we gave tissue plasminogen activator 15 times. Like many of you who are medical directors in emergency departments, I have spent an amazing amount of time working on systems of care for our stroke patients, with perhaps much more doubtful impact than addiction recovery can have on a life.
One of the first patients enrolled in our program was a young woman in her second trimester of pregnancy, with a 3-year-old child at home, who was using heroin daily. She remains in treatment, delivered her child, and is successfully parenting both children while holding down a job.
Another gentleman was offered the program after an opioid overdose. Like many patients after overdose, he declined treatment. However, a week later, he re-presented to the emergency department, asking for help, largely because he knew of our program.
ED MAT is based on taking advantage of an opportunity to intervene. Every day, we see patients who have either suffered an overdose, experienced a medical complication of their use, or are simply asking for help. The emergency department can extend access to treatment and relief from withdrawal 24 hours a day seven days a week. We should be positioned to seize the opportunity when it presents, as it may not present again. A request for help should be viewed as an emergency medical condition, with the proper stabilization and referral.
Even if patients are not interested in treatment at the time of their ED visit, our program sends the message that the medical system is here to help, which unfortunately is not the message that many of these patients hear in the traditional emergency department. This is a patient population that is extremely sensitive to judgment, stigma, and bias. Sometimes an eye roll or a glance at your watch is all it takes to alienate a patient, steering them from medical care. Patients who leave the emergency department should know that when and if they are ready for treatment, we are ready to assist them.
EM-Specific MAT Waiver Training Offered at LAC19
The Leadership & Advocacy Conference (LAC) is coming up May 5-8 in Washington, D.C., and it’s a great chance for emergency physicians to advocate for the profession, engage with members of Congress, and connect with other EM leaders. It’s also the first time ACEP is offering EM-specific MAT Waiver Training and the ED Acute Pain Management Bootcamp at the tail end of LAC.
Sign up for the MAT waiver training.
Benefits for Patients and Physicians
Programs like these can be transformative for OUD patient interactions with the health care system, but perhaps more important, they may be transformative for clinicians as well. Most emergency physicians who I know like to be given problems that they can solve. While patients with OUD can sometimes be “difficult,” I would argue that much of the stigma and bias surrounding these patients comes from our own frustration with the situation. Programs of this kind provide clinicians with the tools necessary to intervene beyond handing out a phone number.
Too often, physicians are asked to simply work harder or do better. To get physicians to accept and embrace change, we need to create systems that make it easier, rather than harder, to do the right thing. These systems require an emergency department willing to engage and also a recovery center willing to grant access. Partnerships with a local recovery center should be predetermined. Standard protocols for screening, dosing, and referral should be in place so that, in the moment, the ED clinician does not have to create a treatment plan on the fly.
The evidence for MAT is clear. From a harm reduction standpoint, interventions such as Suboxone and Narcan can save lives, even if 100 percent sobriety at 30 days is not achieved. MAT and engagement with treatment give patients a way to interact with the medical system as a partner, rather than an adversary, creating the framework to achieve full recovery.
On a higher level, we need to move past thinking about buprenorphine as “substitution therapy” and instead toward the preferred treatment model for this problem. This is a disease that, by nature, includes relapses, much like smoking and chronic obstructive pulmonary disease and carbohydrates and diabetes, and is associated with an extraordinarily high mortality rate.
This will take you more time than simply handing out a phone number. Physicians are being given new tasks to perform during their shifts. However, most emergency physicians will accept the extra time that it takes to screen, administer medications, and make a referral if they believe in the impact.
We have shown at Mid Coast Hospital that you do not need to be in a large urban center to create these programs. In fact, in the under-resourced rural areas of the country, we need the emergency department to participate even more. In the emergency department, we are particularly well positioned to intervene in a way that will change not only your patients’ perception of the health care institution but also your providers’ engagement with these patients. I hope that you consider starting a program in your emergency department.
Dr. Advani is medical director at Mid Coast Hospital Emergency Department, president of the medical staff at Mid Coast–Parkview Health, and on the board of managers at BlueWater Emergency Partners.