A 32-year-old female with anxiety and recent bimalleolar ankle fracture presents requesting help with her addiction to opioids. She was started on a short prescription of oxycodone after undergoing a minor operation to repair her fractured ankle. She finished her prescription and continued to feel pain, so she went to her primary care physician, who felt uncomfortable writing her a prescription for additional opioids. She initially resorted to using leftover Percocet from her husband’s previous injury. Once these were gone, she started seeking pain medications from friends and family and eventually began to buy prescription opioids from a drug dealer in the town where she grew up. As the cost of her addiction rose and she was unable to support her habit with prescription opioids alone, she resorted to snorting heroin for the first time one week prior to presentation. After she sobered, she realized she had a problem. “I never signed up for this” was the refrain she gave to the triage nurse as she told her story. She called her dealer to state she wanted to sever contact between the two of them, and the dealer agreed that her habit was escalating and that she was right to consider quitting. An hour later, this same dealer came to her apartment with a “parting gift.” It was another dozen oxycodone “on the house” because she had been “such a good customer.” Her husband intervened before she used them, and together, they presented for evaluation.
The rising death toll from our nation’s opioid epidemic has been rivaled in modern medical history only by that at the peak of the AIDS epidemic in the early 1990s. Consider, in 1995 at the peak of the AIDS epidemic, 51,000 Americans died from the disease. In 2015, 52,000 died from drug overdoses.
Emergency departments have stood at the front lines of both crises. Walk into any of our nation’s emergency departments and you’ll find no indications that we are reaching a plateau in rate at which lives are lost to opioid use disorder (OUD).
You’ll also find limited utilization of solutions that work.1
In the early days of the AIDS epidemic, emergency departments often served as the entry point of care for those patients who presented with sequelae of the deadly disease. During that time, emergency physicians served as primary providers for vulnerable HIV patient populations, diagnosing critical AIDS-defining illnesses and treating patients suffering from the maladies of those conditions.
However, it wasn’t until the widespread utilization of medication-assisted therapies in the form of antiretroviral drug therapies that the crisis began to subside. Aided by the Ryan White CARE Act, which provided funding for these drug therapies for patients and resources for intensive physician education on the initiation of those therapies, the public health community orchestrated a multilateral response.2
Physicians nationwide adapted their practices to include initiation of antiviral therapies. Within two years of the introduction of antiretroviral drug therapy, the annual number of lives lost to the AIDS epidemic had been halved.3
Again, we find our specialty at the forefront of another national epidemic. That’s because many patients with OUD utilize our emergency departments as an entry point into the treatment system. In 2011 alone, there were 5.1 million drug-related ED visits.4
The AIDS crisis was difficult for emergency providers because making definitive diagnoses in the emergency department was often impossible. Further, with rapidly evolving resistance patterns, it was often impossible to start appropriate treatment in the emergency department.
“I did my training in Brooklyn through the late ’80s, and what I remember most was how sick these HIV patients were. They were coming in with diseases that we’d only read about in medical school—tuberculosis, pneumocystis, pancytopenias. Of course, we felt powerless because we didn’t have any idea what was going on—couldn’t even test for it in our department. And even after we theoretically could, we didn’t because we didn’t have ready access to medications we could start them on. It could be very demoralizing.”—Massachusetts General Hospital emergency department attending
As the death toll rises year after year in the OUD epidemic, we are fortunate to have solutions to both these issues for the current crisis. In the emergency department, we can make a definitive diagnosis of OUD, and we can begin treatment that has been shown to be effective.
Despite this opportunity, research shows that nearly 80 percent of people with OUD don’t receive any treatment, and those who present to our emergency departments for treatment often get referred to short-term detoxification or abstinence-based “rehab,” both of which have extremely poor outcomes, with more than 80 percent of patients returning to opioid use.5
A Different Course
Similar to the AIDS epidemic, advancements in medical therapies may play a role in changing the tide in this current crisis. And emergency departments, where many of these patients present, may be an optimal place to initiate this therapy.
Consider that the most effective treatment for OUD is long-term management with medication treatment. Decades of research show that these medications reduce overdose death, drug use, and health care costs while improving health and the likelihood of remission.
After buprenorphine became an accepted treatment in France in the mid-1990s, other countries began to treat people addicted to heroin with the medication. In the time since buprenorphine was adopted as part of public policy, it has dramatically improved the chances that those addicted to opioids will stay clean and has lowered overdose death rates.6
The use of buprenorphine in the emergency department in coordination with outpatient prescribers is promising. At Yale New Haven Hospital in Connecticut, a randomized controlled trial tested whether prescribing buprenorphine to ease withdrawal symptoms in combination with a counseling intervention and a referral for help improved the chance people would continue with addiction treatment. The study points to early success in buprenorphine’s role in the emergency department.
Seventy-eight percent of patients in the buprenorphine group were in treatment 30 days later. By comparison, 37 percent of people who received only a referral were in treatment after 30 days, and 45 percent of patients who received a brief counseling intervention and a referral were in treatment after 30 days.7
It should be noted that follow-up at six and 12 months showed fewer people still in treatment. While we may not yet know what is the best long-term strategy for these patients, we still should celebrate the evidence that an ED intervention can dramatically increase follow-up for these vulnerable patients.
Another study, performed at MedStar Union Memorial Hospital in Baltimore, suggested that buprenorphine started in the hospital prior to discharge could help those suffering from opioid addiction. It showed that patients who received buprenorphine therapy had an overall decrease in return hospital and ED visits and an improvement in patient perception of quality of life.7
So why aren’t emergency physicians nationwide utilizing it to help patients?
In part, this is due to legislative hurdles. In 2000, Congress passed the Drug Addiction Treatment Act of 2000, a law that prohibits physicians from prescribing Suboxone unless they obtain a waiver. The waiver is granted after successful completion of an eight-hour course whose cost is often left up to the provider to cover. This additional barrier to entry makes access to medication treatment even more difficult.8
A little-known exception in that law, however, allows emergency physicians to administer this medication for 72 hours, provided that patients return to the emergency department for additional doses, when treating withdrawal as a bridge to outpatient addiction treatment.9 It was via this mechanism that the team at Yale was able to demonstrate such a powerful effect without the necessity of all prescribers obtaining a license.
As we now face what may be the largest public health crisis of this century, we must ask ourselves, what is our responsibility moving forward? Is it acceptable for us to know that there is an effective treatment we can offer and still continue to advise outdated models of treatment or, worse still, offer no treatment at all?
We would never allow patients with acute coronary syndrome, stroke, or pulmonary embolism to leave our departments on outdated treatments or with a list of centers offering treatment for those conditions. Why then would we stand by as people suffer and die of OUD?
We know medication treatment for OUD is more effective, and we have the ability to be on the front lines offering effective treatment to people in dire need. Let us seize the moment and lead at this critical juncture. Let us, as a specialty, look forward to the day when we can remember this crisis and see it as we now see the AIDS crisis: a critical public health issue that, with aggressive and early advocacy, was conquered to allow our patients to live full and happy lives.
Let us do our part to make that future arrive sooner.
Dr. Martin is an emergency medicine resident at Massachusetts General Hospital/Brigham and Women’s Hospital in Boston. Dr. Kunzler is an emergency medicine resident at Massachusetts General Hospital/Brigham and Women’s Hospital.
- Chutuape MA, Jasinski DR, Fingerhood MI, et al. One-, three-, and six-month outcomes after brief inpatient opioid detoxification. Am J Drug Alcohol Abuse. 2001;27(1):19-44.
- Williams AR, Bisaga A. From AIDS to opioids—how to combat an epidemic. N Engl J Med. 2016;375(9):813-815.
- Centers for Disease Control and Prevention. HIV surveillance—United States, 1981-2008. MMWR Morb Mortal Wkly Rep. 2011;60(21):689-693.
- Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. The DAWN Report. Feb. 22, 2013.
- Saloner B, Karthikeyan S. Changes in substance abuse treatment use among individuals with opioid use disorders in the United States, 2004-2013. JAMA. 2015;314(14):1515-1517.
- Fatseas M, Auriacombe M. Why buprenorphine is so successful in treating opiate addiction in France. Curr Psychiatry Rep. 2007;9(5):358-364.
- 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.
- Buprenorphine waiver management. Substance Abuse and Mental Health Services Administration website. Accessed Nov. 19, 2017.
- Are there exceptions when Subutex and Suboxone may be administered by a practitioner without the DATA 2000 waiver? National Alliance of Advocates for Buprenorphine Treatment website. Accessed Nov. 19, 2017.