Starting Buprenorphine in the Emergency Department

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An interesting study in the April 28th Journal of the American Medical Association (JAMA) looked at three types of intervention for opioid addiction in patients presenting to the Emergency Department for care. It found that patients were more likely to be in addiction treatment and free from illicit opioids when started on buprenorphine in the emergency department, and given a referral to buprenorphine prescriber.

This study, done at an urban teaching hospital in Connecticut, screened patients in their emergency department and uncovered 329 patients with opioid addiction. Some came for help for the opioid addiction (34%) but the others came to the ER for other medical problems.

These patients were randomized to three interventions: one group was given written information about addiction treatment programs in the area. The second group was given this information, plus a brief intervention describing the various ways to treat opioid addiction. Patients in this group were linked with the referral and transportation to addiction treatment was arranged.

The third group had the same intervention as the second group, plus they were prescribed three days of buprenorphine, dosed at 8mg on day 1, and 16mg on days 2 and 3. Patients in this group were provided free office- based buprenorphine treatment for ten weeks, with visits ranging from several times per week to every two weeks, depending on how the patient was doing.

The study’s primary outcome was to compare how many patients in each of the three intervention groups were engaged in addiction treatment thirty days after their emergency department visit.

The results were what you would expect. People in the group that started actual treatment in the emergency department with buprenorphine were significantly more likely to be in addiction treatment thirty days later. In this group, 78% were in treatment. In the group given only treatment referrals, 37% were in treatment at 30 days, and 45% of the people given referral and brief intervention were engaged in treatment at 30 days.

Also, patients in the buprenorphine group reported greater reductions in the number of days of illicit opioid use than did the referral and brief intervention groups. The groups showed no significant difference in behaviors that increase risk for contracting HIV.

These patients were fairly ill, with high rates of co-occurring mental health disorders, with more than half reporting prior psychiatric diagnoses. About a fourth of these patients required acute care for a medical problem other than opioid addiction at their emergency department visit. These patients also had the expected high rates of concurrent other drug and alcohol use. In other words, these patients were about as ill as the average patient with opioid addiction.

However, this study didn’t include patients who were so sick that they required hospitalization, which may have skewed the data somewhat. Because services were free, this likely enhanced retention in treatment, though the authors say that 80% of all patients in the study were insured.
That’s an unusually high percentage, as compared with what I see in my rural area, in a state which did not expand Medicaid access.

The bottom line is that medication-assisted treatment with buprenorphine appears to be an effective way to get opioid-addicted patients into treatment and reduce illicit drug use in these patients. That would seem common sense, but we now have a study to support that assumption.

I love the idea of treatment being started in the emergency department, with close follow-up in an office setting or opioid treatment program. As the authors of this study pointed out, starting treatment for opioid addiction in the emergency department is very similar to how other chronic diseases are treated. For example, patients with new-onset diabetes or high blood pressure are often started on medication to treat the disorder in the emergency department, with a close follow up recommended with a primary care doctor.

Why do we treat the disease of addiction any differently?

My readers know the answer, of course: stigma and lack of education and understanding on the part of health care professionals.

As the authors pointed out in the discussion section of the study, even the referral group got more intervention than the average opioid addict visiting an emergency department in this country.

My patients still report being treated with derision and rudeness by emergency department staff. Not only are their medical problems including addiction not being addressed, they are shamed for being addicted. They are given powerful verbal and non-verbal messages that they are bad people, a pain in the ass to deal with, and unwelcome in the healthcare facility.

You could not invent a better recipe for continued drug addiction and avoidance of future medical care.

This study shows how easily this could be fixed. I would require emergency department doctors to get DATA 2000 certified, and the education of other healthcare professionals too. I don’t know how to initiate this solution but it can’t be done quickly enough.

I’ll say it again: we will know we are treating addiction well when it’s no longer easier to get drugs than treatment.

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8 responses to this post.

  1. I have mixed feelings about the practicality of applying the results of this study. Even though 80% of the patients in this study were “insured” (most are not) that doesn’t mean they can find either an OTP or an OBOT program that will take them, in a timely manner. So what happens when that one week prescription runs out? I think it would only be practical if we have government sponsored (or subsidized) OBOTs with ready access, in any town that offers buprenorphine induction via the ED. And in the present political climate that is unlikely to happen. Meanwhile, the challenge among Program Directors that I have talked to is finding and holding competent medical providers (counselors, nurses, and docs) to staff their programs.

    Reply

    • Posted by Benjamin Keith Phelps on May 19, 2015 at 8:08 pm

      Amen, Dan. I agree wholeheartedly! I was on the 6th floor at George Washington University in 1996 on methadone, & they did that type of thing then that is described here – put you on methadone for a week & then send you to a clinic. Well, they knew I lived in Richmond b/c my roommate moved all our stuff while I was there that week from DC to Richmond, VA. So they didn’t bother to set me up with any clinic in Richmond, & they gave me methadone everyday, then released me after a week. Well, does ANYBODY have a clue as to what happened to me after about 36 hours or so upon being released? Oh, I did call a clinic in Richmond or two, & I was told they had waiting lists, & that they knew nothing about GWU protocol OR about me & my situation, & I couldn’t get an intake at any of them, whether through TASC or otherwise. So I was stuck. So does ANYBODY have any clue as to what I did when that 36 hour mark hit & I was suddenly in withdrawal all over again? Yeah, I stayed in the DC area in my car, buying dope & then driving it back down to Richmond (I didn’t know anybody in Richmond to buy from.) During that time, I got cellulitis in my foot, ended up in the ER twice, tried Dr. Coleman’s buprenorphine taper (I craved like hell b/c he did it over a 3-4 day period), & I FINALLY found a doc in NC from my parents’ church who was willing to Rx me methadone to taper me, at risk of his license, for which I will be eternally grateful, since there were no programs within 2 hours of my parents’ home at that time (there are more than 1 now.) So overall, what I’m saying is, if the patient isn’t GUARANTEED a spot when s/he leaves the ER, this is going to do almost NOTHING if they get unlucky, except help them out for a week & then leave them high & dry (no pun intended.) There needs to be a link between the ER & the provider of treatment so that there’s a referral to a SPECIFIC program, & there’s a slot awaiting that person upon discharge from the ER. Anything else is dangerous.

      Reply

  2. Posted by Benjamin K Phelps on May 17, 2015 at 5:42 pm

    This may not seem like that big of a deal, but think of the message behind it: I went to my PCP recently, where it’s an Urgent Care AND Primary Care facility in one, so different docs see me on different days. One particular doc came in, asked me what I came in for that day, then went over my existing meds. When we got to methadone, she said “How much do you take?” My answer was “160mg”. Her eyes got big as saucers & her reply was “And you’re coming down quickly, right?” I said “No, I’m not coming down at all. I’ve been on 160mg for a mighty long time, because that’s the stable dose that me, my doctor, & my counselor have found seems to work for me – where I don’t go home & have a fight with myself every evening about taking tomorrow’s takehome tonight – I just take my dose each morning & then don’t think anymore about it. I don’t feel it, I don’t nod or fight sleep, I just go about my day.” Now again, I’ll say it – it doesn’t seem like too big a deal, & it wasn’t. But her reaction for someone else COULD have easily sent a message of shame for needing such a dose. People are OFTEN shamed for being on a higher dose than the average patient. The assumption is ALWAYS that you’re trying to get high. And if I were sitting there in front of her with my eyes drooping, speech slurred, I’d expect she’d be right! But I don’t appear sleepy, I don’t appear on a nod or on medication AT ALL, for that matter. She based her comment SOLELY on a number that surprised her. I’m not saying she’s a bad doctor for that – she likely just has never been taught any of this, other than opioid addicts are put on methadone. Maybe she’s never seen anyone on 160mg/day… I can’t say. But I know A LOT of people at the clinics I’ve been to who are REALLY sensitive to people shaming them about needing a higher dose or for not tapering after x number of years. I’ll say this to everyone on Suboxone, methadone, Vivitrol, & any other medical treatment: DON’T JUDGE YOUR SUCCESS AT RECOVERY BY WHETHER OR NOT YOU NEED TO TAKE MEDICINE, NOR BY THE DOSE OF MEDICINE YOU NEED TO TAKE. Staying in treatment on Suboxone or methadone does NOT make you a failure, still an addict, etc. The ONLY correlation between you & an active addict is the dependency on the medication not to be ill. That’s it. You aren’t taking erratic dosages from day to day, constantly raising your dose to feel the same as you did yesterday, spending your rent money on this drug, hurting your family by using it but doing it anyway, etc… The ONLY correlation is that you need the medicine to prevent withdrawal. All the rest of the requirements for an active addiction diagnosis are not present anymore (assuming you’ve reached a stable dose & are no longer using other drugs.) If this is the case, YOU HAVE SUCCEEDED. Whether you taper or not is up to you, & if you want to, it’s GREAT if you succeed at it. HOORAY FOR YOU if you can do that!!! (And I really mean that!) But if you taper & find that you’re struggling like crazy, STOP THE TAPER, & if necessary, GO BACK UP TIL YOU’RE STABLE. Some people can eventually stop Suboxone or methadone. Some can’t. You are NOT defined by whether or not you need medicine daily. Everyday, I must take a Nexium or I will have heartburn that will drive me insane! If I skip a day of Nexium, I get sick with heartburn. Yet I don’t have the slightest feeling of guilt over needing to take it daily to avoid that heartburn. Why should addiction treatment be ANY different?

    Reply

    • Thanks for sharing that Ben. You are absolutely right and I wish all medical providers had the knowledge to understand and appreciate how methadone *helped* you get your life back. I was an OBG for 38 years and until I started working in MAT clinics I knew almost nothing about opioid addiction.

      Reply

  3. Posted by Jay Warner on May 17, 2015 at 9:31 pm

    Kudos on this article! So glad there was a study about this subject and that is proved overwhelmingly that maintenance can be started in an emergency/urgent care setting with follow through from a PCP or clinic. I really hope this takes off and it becomes general practice around the world.

    Reply

  4. Posted by RobH on May 17, 2015 at 9:47 pm

    Great study! Of course it would require almost revolutionary change among ER staff. It would be great if ER staff offered suboxone and treatment info to an obviously sick (in withdrawl) patient instead of contempt and a drug seeker label.

    Reply

  5. Posted by drew on May 19, 2015 at 12:08 am

    My thoughts exactly Ben. I didn’t stop doing street drugs to be chemical free, I stopped because I was ruining my life and everyone around me was sick of it. I have addiction issues, as well as epilepsy and a chronic anxiety disorder. I take prescribed Xanax, Suboxone, Lunesta, Lyrica and Zoloft daily. My addiction is a direct result of my mental health. Once I finally found understanding doctors who could see I wasn’t lying about these things, I was treated for my mental health issues and not my addiction. That’s been two years ago now, and I’m graduating from a nursing program next month. And have decided to go to seminary school and give God the glory for my recovery. I’m surrounded by friends, family and have a life better than I could have Imagined. The only people who don’t support me? Those in AA, most of whom consider my recovery false because I take 3 prescribed narcotics. If anyone like me reads this, don’t let others judgement your recovery decide if you recover or not. Medicine is not the enemy.

    Reply

  6. Posted by Icecutter on May 28, 2015 at 2:44 am

    This is a really good idea. People in crisis turn to ER’s and it’s a good place to help an addict in crisis. If methadone induction could be started there, then there would be two options for MAT in ER’s. Always the first issue is to stabilize the addict. Then they can be directed to the appropriate clinic or physician for maintenance.

    Reply

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