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 Is it acceptable for us to know that there is an effective treatment we can offer and still continue to advise outdated models of treatment or, worse still, offer no treatment at all?
Explore This Issue
ACEP Now: Vol 36 – No 12 – December 2017We would never allow patients with acute coronary syndrome, stroke, or pulmonary embolism to leave our departments on outdated treatments or with a list of centers offering treatment for those conditions.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.
References
- 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.
Pages: 1 2 3 4 5 | Single Page
6 Responses to “Opinion: We Have Effective Treatments for Opioid Addiction—Why Don’t We Use Them?”
December 18, 2017
Todd B. Taylor, MDOy Vey!
I am aware that ED initiated buprenorphine\naloxone (Suboxone) treatment had a positive impact on opioid treatment in a very small study in 2015.
And, I’ll bet we could also show a positive benefit in world hunger & homelessness if we decided to use our precious ED resources for that as well.
Point being, if this is so important & beneficial, then “Medication-Assisted Treatment (MAT)” programs need to be more readily available, funded and open 24/7/365.
You may be aware that ED visits for “non-medical use” of opioids has increased dramatically in recent years. Has anyone studied the untoward effect of initiating Suboxone in the ED on future visits? I could not find any. So, from a public policy perspective, one has to ask, is one small study sufficient to change decades-long practices? Is the direct result of increased use of the ED for opioid withdrawal worth this perceived benefit?
If you have to initiate treatment for acute opioid withdrawal on a regular basis, then there is something seriously wrong with your local availability of MAT programs (and all the more reason not to do it).
I thought we learned this many years ago with methadone. So I seriously doubt it is wise for EDs to become the point for entry for opioid substance abuse.
BTW: The ACEP Public Health & Injury Prevention Committee is currently working an Information Paper to include this topic.
I urge extreme caution and only consider doing this if it is in direct coordination with a substance abuse program (MAT) that is readily available (funded).
Todd B. Taylor, MD, FACEP
“Old School” Emergency Physician
December 22, 2017
Jon Miller, MD, FACEPI agree with Dr. Taylor. If there is no facility equipped and ready to accept the patient via a “warm hand off” then what’s the use of prescribing a medicine for a day? Our federal government realizes this is a crisis and yet there has been little increase in funding to create solutions (including MATs). Opiate withdrawal is not life threatening and therefore the chances of MATs becoming benevolent and taking non-payers is a pipe dream at best until grants are in place to help fund the solution.
It’s certainly a sad state of affairs and I applaud the residents for writing this, but ED’s throughout the country aren’t Harvard. We don’t have extra social support and programs that are more easily cultivated at academic centers.
I for one would love to be the entry way for treatment, but until I know that there is a system in place to continue ones care I will not initiate a new substitute in the form of a prescription. I will educate. I will support. But I will not start treatment for OUD.
January 3, 2018
Evan Schwarz, Washington University School of MedicineThank you for this very thoughtful article. We have initiated a similar program at our hospital which has had success so far. Preliminary data demonstrate a 60-70% follow up at a month. We are currently reviewing data to see if patients are still in treatment at 3 and 6 months and 1 year. I hope we have better long term results than found in the previous study. Community sites in my area are also in the process of setting up similar programs.
One key to all this is to make sure to coordinate follow up with local treatment centers. Starting treatment in the ED without arranging follow up is problematic. We were able to coordinate care with local treatment centers as well as take advantage of centers receiving federal and state funding to treat patients that lacked financial resources. We were also able to work with our State Targeted Response fund to not only pay for multiple physicians to obtain their waivers but it also actually paid the physicians for their time. I’d suggest that others interested in setting up a similar program check with those receiving federal and state opioid grants to see how they can collaborate with these groups.
With that said, arranging this did take some effort and time. Of course, many initiatives (at least at my facility) from being able to use ultrasound in the ED to getting cardiology to take patients to the cath lab in the middle of the night also took a lot of effort to set up. Now that the program is set up, it does not take a lot of resources to induce patients in the ED. Our social worker arranges follow up with one of the local treatment centers, a counselor comes in to walk the patient through what is going to happen (while nice is not absolutely necessary), and if a physician with a waiver is working, they evaluate the patient and write a prescription if they feel that it is appropriate. Yes, it does take a few more minutes of our time to do this, but if it saves a few patient’s lives, it seems like a worthwhile use of our time.
Additionally, many of the concerns that people ‘warned’ us about have not occurred. We have not become overrun by patients with opioid use disorders, at least any more than we already were. The prescriptions that we write for are generally only for a few days in duration, and given that so many are following up, it does not appear we are having a large problem with diversion. While I’m sure it is far from 0, we also do not have lines of people trying to scam buprenorphine from us. Once again, it is not adding any significant stress to our system and may save someone’s life so I’d argue the program is more than just a perceived benefit.
It’s difficult for me to imagine another patient population with such high morbidity and mortality where we’d refuse to provide the best care just because of either personal bias or due to concerns that may not actually be true. With that said, I do realize that there may be some facilities that do truly have barriers that they cannot overcome. However at least at my hospital whether we want to treat them or not, these patients are already there. As such, offering them a simple treatment that we can easily initiate in the ED makes sense to me.
January 5, 2018
Todd B. Taylor, MDJust a follow-up to Evan Schwarz (Washington University School of Medicine) comments. Medicine, including EM, is replete with presumed beneficial treatments, later found to be ineffective, even counterproductive. Steroids for spinal trauma for example.
If the WSU program is being done within a research context (as it appears to be), then maybe that is reasonable & may be the only way we will even know the actual impact of such a process.
Nevertheless, until sufficient evidence shows it works, what element are necessary for success, is worth the cost, and the BEST alternative, I urge caution outside of such a research context.
To that end, I must respond to this statement, “It’s difficult for me to imagine another patient population with such high morbidity and mortality where we’d refuse to provide the best care just because of either personal bias or due to concerns that may not actually be true.”
I agree and is what prompted my first comment. We already know the ED is clearly NOT the “best care” for individuals with opioid addiction & withdrawal. In most communities, EDs are simply the default (only available) option.
And the fact remains, we simply do not know if offering withdrawal treatment in the ED may be counterproductive. So, attempts to shame others into adopting as yet unproven treatment is not helpful.
Here is a relevant analogy, equally politically & emotionally charged. Up until the late 1990’s in Arizona, ED were the only source for sexual assault forensic exams. Not only were these a time consuming burden, criminal defense attorneys were successful at using typical ED chaos to get evidence disqualified (e.g. lack of chain of custody & witnesses, etc.). AZ ACEP (with help of other stakeholders) was able to convince the State AG that this would never improve & it was important enough to provide dedicated resources. SARN Centers were established where law enforcement could take victims 24/7 and avoid the ED. Victims received comprehensive (BEST) care & conviction success improved.
So, do we really want to prove that EDs can have a marginal impact on opioid abuse? Or would these efforts be better spent working with state & other stakeholders in establishing resources for the “BEST care”, which most would agree are funded 24/7 MAT programs. Why would we want to be complicit with a (second rate) default option which are EDs that are already over burdened with “default care”? IMO, this is the question we should be asking.
January 18, 2018
Lawrence LewisI don’t think anyone is arguing that ED initiated MAT in OUD can work without an outpatient system for referral and ongoing treatment. If you do not have that, you must advocate for it. There is considerable funding available for such efforts. But if referral centers for treatment of OUD are available, identifying and initiating treatment in an ED to allow patient’s an opportunity to stop using opioids seems a good idea. We know that widespread MAT programs in Baltimore and France reduced OD deaths as well new HIV cases. We don’t yet know how successful ED based initiated MAT will be, but early experiences show promise. Having started to do this recently in my own practice, the difference you see in patients once their overwhelming craving is controlled is encouraging. Time will tell if this translates to a good long-term outcome.
August 30, 2022
Joseph Soler MDAll of the above thoughts and ideas are excellent, BUT ….
In view of the huge amounts of Fentanyl coming through the Southern Border, it was described to me once, by a very insightful and highly educated individual, that these efforts are “like pissing into the wind.” Until the southern border is effectively closed, much of these efforts are futile. It is very discouraging.
ACEP could make a very powerful statement by demanding that the southern border be closed and drug flow into the USA minimized. Otherwise, we are like Don Quijote fighting a spinning windmill. It is very discouraging and demoralizing to Emergency Medicine Physicians.