Let’s be clear: Drug addiction is a chronic disease.¹ Sure, it’s a consequence of unfortunate life choices, as are many diseases we treat daily. Nevertheless, patients turning to the emergency department in crisis should expect to receive evidence-based treatment.

People in the United States are more likely to die from accidental opioid overdose than a motor vehicle crash.² Yet, despite its efficacy, most emergency physicians do not provide medication-assisted treatment (MAT)* for patients with opioid use disorder (OUD). This is mainly due to stigma, lack of familiarity, and competing priorities. However, choosing not to prescribe MAT in the emergency department is a missed opportunity. The emergency department is uniquely positioned to provide access 24 hours a day, seven days a week and wrap-around services, providing a true “front door” to the greater continuum of care. What’s more, patients with substance use disorders arrive in the emergency department ready and willing to accept help.³

We can literally save lives by offering MAT in the emergency department—and we should. It’s time to make MAT the standard of care for OUD in our emergency departments.

What’s Not Working

Imagine a patient with a history of heroin use arrives at your emergency department in obvious withdrawal. You give ondansetron for vomiting, perhaps clonidine. The social worker brings the patient a “resource packet” with eight grainy, overcopied pages of outdated information. The emergency department staff comments about the “junkie” in room nine, and you promise to “get ‘em outta here” to turn over that bed for a real patient. The patient is discharged, and that’s that.

Sound familiar? While this experience has been our standard emergency department approach to OUD for years, it leaves patients undertreated and dissatisfied—not to mention the lack of clinician satisfaction.

Good News: There Is a Better, Easier, Evidence-Based Way

CA Bridge is a method developed by the Public Health Institute in Oakland, California, launched in 2018 with grant funding from the California Department of Health Care Services MAT Expansion Project. In this method, any clinician at any hospital can implement its model using three core elements:

1. Provide low-barrier MAT.
2. Connect patients to ongoing care.
3. Encourage a culture of harm reduction.

1. Provide Low-Barrier MAT

Buprenorphine is a partial mu-agonist that activates the opioid receptor enough to curb cravings and help the patient exit withdrawal but not enough in standard doses to cause respiratory depression or a “high.” You can read more about it in the June 2018 ACEP Now article “Buprenorphine Explained, and Opioid Addiction Treatment Tips.”⁴

Buprenorphine is safe and easy to give in the emergency department.

• If a patient is in at least moderate opioid withdrawal, start with 8 mg sublingual or buccal buprenorphine.
• Allow it to dissolve fully.
• Wait one hour.
• Check on your patient. Are they feeling better? If so, repeat the dose Q1 hour until their withdrawal symptoms have resolved. If they’re already resolved, give an additional 8 mg to complete a loading dose.
• The patient can then go home with a prescription for 8 mg buprenorphine twice daily, until they can be seen by an outpatient clinician. (Note: No special certification is needed to do this in the hospital, but you’ll need an X-waiver to prescribe buprenorphine at discharge.)

Some words of caution: If your patient is not better after the first dose of buprenorphine, broaden your differential diagnosis. If it’s simple opioid withdrawal, the patient will get better with buprenorphine.

Make sure your patient is in at least moderate withdrawal. Use the Clinical Opioid Withdrawal Score if needed.⁵ Buprenorphine binds more tightly to the mu-receptor than full-agonist opioids, kicking off any full-agonist opioid in the patient’s system leading to precipitated withdrawal. For this reason, you should also ensure they’re 72 hours post any methadone use.

Be sure you ask about other respiratory suppressants that may be in the patient’s system. It’s not a contraindication to give buprenorphine in the setting of benzodiazepines or alcohol; it’s best to proceed with caution since the additive effects have potential for concern.

Access the full treatment protocol easily, whenever you need it.⁶

Patient not yet in withdrawal? It’s safe for patients to self-start buprenorphine. Check out those protocols with the Rapid vs. Gentle algorithms.^7,8 Resuscitated on naloxone and now in withdrawal in the emergency department? Also safe to start treatment.⁹ Now that’s a save.

2. Connect Patients to Ongoing Care:

Using the CA Bridge model, patients who arrive at the emergency department in an opioid-related crisis can expect to work with a substance use navigator, who helps the patient access insurance, pharmacies, and community services. The navigator provides support and connection to services in addition to helping the patient feel seen.

3. Encourage a Culture of Harm Reduction

Regardless of their crisis, all patients deserve dignity and respect. We must teach our teams to treat OUD like any other disease, with evidence-based MAT as the standard of care.

This three-pronged strategy incorporates the most effective treatments for substance use disorder into a model that is feasible for every hospital.³ This Blueprint for Hospital Opioid Use Disorder Treatment provides step-by-step guidance on how to set up a MAT program in the acute care setting.¹⁰

We’re involved in the overdose crisis, like it or not. Now is the time for us to step up and be a proactive part of the solution.¹¹ 

*Using MAT to mean “medication-assisted treatment” is an older version of that acronym. The newer, more accurate term is “medication for addiction treatment.” The authors of this article realize that “medication-assisted treatment” is still colloquially used by many emergency physicians.

References

1. HMA Institute on Addiction. Addiction neuroscience 101. YouTube website. Accessed October 2021.
2. Preventable deaths: odds of dying. National Safety Council Injury Facts website. Accessed November 2021.
3. Snyder H, Kalmin MM, Moulin A, et al. Rapid adoption of low-threshold buprenorphine treatment at California emergency departments participating in the CA Bridge program. Ann Emerg Med. 2021;78(6):759-772.
4. Waller RC. Buprenorphine explained, and opioid addiction treatment tips. ACEP Now. 2018;37(6).
5. Clinical opioid withdrawal score. CA Bridge website. Accessed November 2021.
6. On-shift. CA Bridge website.
7. Rapid buprenorphine home start. CA Bridge website. Accessed November 2021.
8. Gentle buprenorphine home start. CA Bridge website. Accessed November 2021.
9. Starting buprenorphine immediately after reversal of opioid overdose with naloxone. CA Bridge website. Accessed November 2021.
10. Mikolaycik Kurtz A, Snyder H, Lee S, et al. Blueprint for hospital opioid use disorder treatment. CA Bridge website. Accessed November 2021.
11. Request technical assistance. CA Bridge website. Accessed November 2021.
12. Buprenorphine hospital quick start. CA Bridge website. Accessed November 2021.
13. How to apply to get your X waiver. CA Bridge website. Accessed November 2021.