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.
We Can Make a Difference
Emergency physicians, by virtue of their daily interactions with the most vulnerable patients, are natural agents of social change. We bear witness to the daily pain and suffering of marginalized and disenfranchised populations, the gaping holes in our social system, and the gross inequities of medical care and treatment. We understand the patients’ inherent mistrust of the medical system fueled by addiction’s underserved, stigmatized place as a failure of willpower rather than a disorder of brain chemistry. And yet, by failing to incorporate evidence-based addiction training as a skill firmly within an emergency medicine physician’s scope of practice, we continue the sad tradition of inadequate access and perpetuate stigma. We convey the message that OUD as a disease is not worth our time or effort.
Addiction training should start with equipping all emergency department residents with a Drug Enforcement Administration (DEA) X-Waiver so they can prescribe buprenorphine, and this should be incorporated into the standard curriculum of emergency medicine residency training. This training can be easily incorporated into weekly didactics, and the certification never expires. Equipping our future emergency department physicians with the ability to treat the life-threatening disease of opioid use disorder is just good medicine. We must be part of the solution.
Dr. Haroz is a physician at Cooper University Healthcare in Camden, New Jersey. Dr. LaPietra is a physician at St. Joseph’s Health in Paterson, New Jersey. Dr. Holtsford is a physician at Northwestern Medicine Delnor Hospital in Geneva, Illinois. Dr. Strayer is a physician at Maimonides Medical Center in Brooklyn, New York.
References
- D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.
- Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Ann Intern Med. 2018;169(3):137-145.
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2 Responses to “Improve Opioid Use Disorder Management by Changing Resident Training”
November 1, 2020
TirEDocIt’s difficult to “change physician behavior” on this issue because a lot of us who are more seasoned have seen the repeated failure of using an opiate based medication to treat OUD. Frankly it’s a bit suspect that this is being pushed as “a new trend” just because a pharmaceutical company has come up with a new drug that is “less addictive” than the industry’s previous formulations. I and many like me remain of the mindset to minimize patient exposure to opiate medications whenever possible, and support non-opiate detox programs which don’t support promulgation of some new drug now on the market.
November 1, 2020
John HerrickI am all for this treatment, evidence based medicine, and harm reduction. Please just get rid of the waiver. Another merit badge in order to practice evidence based medicine is counter productive and further stigmatizes and limits buprenorphine’s use. I would not expect it to become standard of care until this hurdle is removed.