The last decade has witnessed a brutal toll of opioid-related suffering and deaths. Opioid addiction has shifted from a perceived moral failing confined to urban slums to one of accepted neurobiological disease pathology observed across geographic, racial, and socioeconomic lines. Medication-based treatment of opioid addiction reduces mortality and improves lives. Buprenorphine is safe and effective and can be initiated in the emergency department for patients with opioid use disorder (OUD).1 Significant barriers to treatment remain, however.
While buprenorphine can reduce mortality by two-thirds, only one out of three patients with OUD have access to this medication.2 Opioid use disorder has the highest short-term mortality of any acute disease we routinely treat in the emergency department, and it often occurs in young, otherwise healthy patients who, if moved to recovery, will go on to live long and productive lives. Due to stigma, however, addiction and addiction treatment have been siloed away from the rest of medicine. While we can have a substantial impact on our patients with OUD, we are much more comfortable treating heart disease, stroke, and sepsis. The work to bring OUD recognition and treatment into the purview of emergency medicine starts with the way we teach it to emergency medicine residents.
New Paradigm for a New Generation
Residency training is structured to systematically address the pathology and treatment of disease encountered in the emergency department. Residents are trained to make lifesaving diagnoses and perform complex procedures. This training gives little consideration to where the resident will eventually practice; the prevailing paradigm is that all emergency department doctors should be able to treat all life-threatening diseases in any acute care setting.
As opioid deaths have skyrocketed over the last decade, emergency medicine residencies have largely continued to treat addiction according to the principles espoused since the specialty’s inception: provide a referral to outpatient addiction services and discharge the patient with a slap on the back. The data supporting the initiation of buprenorphine in the emergency department are clear and compelling, but most current EM residents have not received training on its use. This omission is a disservice to residents, patients, and the community at large.
Changing established behavior in practicing physicians is harder than learning a new concept in an unchartered space. Residents do not harbor the accumulated negative experiences from patient interactions resulting from poor addiction treatment of years past and can approach these challenging and stigmatized patients more easily, focusing on the disease rather than the behaviors. Today’s residents came of age during the opioid epidemic and are eager to be given the tools to manage it. They do not harbor the biases we developed and inherited from generations past and are less likely to develop stigmatized attitudes if trained to appropriately manage patients with substance use disorder.