I am a residency-trained, American Board of Emergency Medicine–certified emergency physician and proud of it. I have enjoyed a broad and rich clinical practice. Truthfully, as much as I enjoy a challenging trauma or critical care case, no other part of my clinical practice gives me as much professional satisfaction as the work I do running an opioid addiction treatment clinic.
Explore This IssueACEP Now: Vol 36 – No 10 – October 2017
How Did I Wind Up Working with Opioid Addicts?
For years, in my emergency department it seemed that the number of patients seeking opioids through the emergency department was growing exponentially, so in 2012, we implemented a very successful opioid-seeking recidivism reduction program, which dramatically cut ED opioid-seeking visits. However, the rapid rise of heroin abuse and opioid overdose in our community continued.
I then realized that the better way to keep an opioid addict from frequenting the emergency department for drug seeking or dying from an overdose would be to enroll that patient into opioid addiction treatment.
I signed up for a buprenorphine class and obtained the “X” license required to be able to prescribe “bupe” for addiction or detox. I started using bupe to treat acute opioid withdrawal in the emergency department and saw how rapidly my patients improved. It was like magic! With no IV medications, just a single sublingual tablet of bupe, the withdrawal symptoms abruptly stopped, and my patients, who just minutes before were vomiting and writhing, suddenly became calm and appropriate. However, even if I prescribed a course of bupe to bridge the patient to an addiction clinic, the patient would sometimes have to wait for two months to see the only reputable physician treating opioid addiction in our community. Thus, I remained frustrated with the inability to make a lasting difference with this challenging patient population.
Great news came in the fall of 2014: A methadone clinic was opening. Unfortunately, the clinic sputtered, and after a few months, the doctor who opened the clinic quit. By the end of 2015, the clinic was on the verge of closing. The clinic was sold, and the new managing company approached me about filling in as the doctor; I laughed. However, as I thought about how desperate I was to have a place to send patients from the emergency department with opioid addiction, I had to consider it.
I was sure that I was going to regret this decision. I was both depressed and nervous. I had never prescribed methadone before, so I needed to learn about this medication, the pharmacokinetics, induction, titration schedules, drug interactions, QT prolongation, peak and trough levels, etc. However, to be candid, I was far less nervous about working with this medication than I was about working with this patient population in a much more intimate, personal setting in contrast to the bright, loud, open emergency department, which helps us maintain the distanced relationship we have with our patients. After all, for me, avoiding intimate, ongoing doctor-patient relationships is one of the draws of emergency medicine.