A Bridge to Treatment

 

 

 

 

 

In my last blog, I lamented the lack of communication and cooperation between medical professionals involved in the care of patients with opioid use disorders.

Opinion about medication-assisted treatment has split the field in half. Most old-school, 12-step-based, abstinence-only programs discourage patients with opioid use disorder from seeking treatment with medication like methadone and buprenorphine. Some providers at opioid treatment programs rail against the lack of knowledge and open-mindedness of these programs, yet don’t inform stable patients on buprenorphine about their office-based options, which may be more appropriate and less restrictive (an option usually not available to methadone patients). Office-based providers accept patients from opioid treatment programs without bothering to get records that could give essential information that could make treatment safer.

Hospitals lack information about appropriate referral sources to treat opioid use disorders, and emergency departments let patients leave after a near-fatal overdose with only a list of phone numbers to call for help.

It’s time to break down barriers and put the welfare of patients first.

At the American Society of Addiction Medicine (ASAM) conference this year, I heard a possible solution.

Dr. Sarah Wakeman and Dr. Laura Kehoe, both associated with Harvard Medical School, talked about their Bridge Clinic. This program is set up to be a bridge between acute hospital or emergency department care and long-term primary care for patients with substance use disorders.

This model is “low barrier” or “low threshold” care, which means eliminating obstacles between the patient and appropriate care. The clinic’s mission is to provide on-demand, compassionate care to patients in all stages of addiction.

Most of their patients have opioid use disorder, and around 77% are treated with buprenorphine products. Around 11% are treated with naltrexone. I assume the others are treated for alcohol use disorder or other substance use disorders.

The Bridge Clinic serves as an immediate access clinic for Massachusetts General Hospital patients with substance use disorders who don’t have a primary care provider. This clinic provides both drop- in and scheduled appointments for patients. It’s been in operation for the past several years and has grown quickly, indicating a need for their services. In some cases, patients elect to remain in treatment at this Bridge Clinic rather than go on to primary care, office-based medication-assisted treatment.

This clinic is opened seven days per week, from 9am to 5pm. The physicians who staff this clinic are very aggressive with starting same day pharmacotherapy for substance use disorders, not only MAT for opioid use disorder. They refer to opioid treatment programs when that level of care is most appropriate, or if the patient needs methadone rather than buprenorphine.

They also work with families, and connect patients with other needed services.

The clinic staff includes an addictionologist, family practice physician waivered to prescribe buprenorphine, recovery coach for peer support services, resource specialist who finds other programs to help patients with their needs (food, housing, etc), and administrative assistant and a patient service coordinator. Extended care in the overnight hours can be provided by the colleagues at the emergency department.

Patients are referred from Massachusetts General Hospital, where patients with substance use disorders are offered induction onto medication-assisted treatment while hospitalized.

That’s right. I said that. Patients with opioid use disorder are started on methadone and buprenorphine during hospitalizations for other medical ailments. For example, a patient with endocarditis from IV opioid use disorder can be started on treatment with methadone or buprenorphine before ever leaving the hospital, and the Bridge Clinic can take care of the patient during the gap between hospitalization and arrival at an office-based or opioid treatment program.

This is treatment nirvana!

Patients with near-fatal overdoses can be started on buprenorphine before they even leave the emergency department, and use the Bridge Clinic to link them with care.

This wonderful new idea has substantial evidence to show it works. D’Onofrio et al., [2] published results of a randomized study of patients with previously untreated opioid use disorder who presented to the emergency department. In one arm of the study, patients got treatment as usual, which was referral to treatment facilities. In the second arm, patients received brief intervention counseling and referral to care to an outpatient buprenorphine provider. In the third arm, patients were started on buprenorphine and linked directly with outpatient buprenorphine treatment, with no gap in treatment. In this last group, nearly 80% of patients followed up with buprenorphine treatment and had significantly less opioid use than patients in the other two arms.

For this reason, the Bridge Clinic wanted physicians who worked in the emergency department to get their waivers to prescribe buprenorphine, and accomplished this. When they see patients with opioid use disorder, they either do the induction onto buprenorphine in the ER, or send the patients home to do a home induction by providing a two-day pack of buprenorphine. Since the Bridge Clinic is open seven days a week, such patients can be seen quickly.

This is wonderful, since we know from studies that patients who are started on MAT while in the hospital or emergency department have much higher rates of treatment retention. We also know that higher treatment retention means fewer opioid overdose deaths.

Around half of the patients referred to the Bridge Clinic from the hospital or emergency department are seen within 24 hours of being referred.

The clinic endorses a harm-reduction model, and does not discharge patients for continued drug use. They staff attempt to build trust by offering services without attempting to control the patients’ intake of drugs. The patients are included in the plan of care. They have low no-show rates, and are aggressive at getting patients back in to treatment if they miss appointments.

The Bridge Clinic’s goal is to eventually transition care, after acute stabilization, to somewhere closer to where the patient lives. Sometimes this can be worked out easily, and sometimes there may be problems. Bridge Clinic staff attempt to work out these difficulties.

Some patients need the Bridge Clinic short-term, and others for longer. Their average length of stay is around three months. This program provides help to patients with ongoing drug use, homelessness, pregnancy with substance use disorders, chronic pain patients, and to patients leaving incarceration, eager to find help prior to a relapse.

I was so inspired by the description of this program. It was obvious that these women excelled at gaining the cooperation of their colleagues at their hospital and in the primary care practices. It really sounds like the ideal situation, with everyone working for the good of the patient, no matter what their needs are. There are no waiting lists, and no senseless obstacles for patients to surmount.

Every community needs a bridge clinic, I think. How wonderful that would be, with a warm and friendly place to send patients in crisis, open every day of the week. Patients could be assessed, stabilized, then referred to the best treatment program nearest to where they live.

However, North Carolina isn’t Massachusetts. We have a higher percentage of people with no health insurance, while Massachusetts has expanded Medicaid, which helps pay for this sort of treatment.

But at least we have a model for quick-access, low-barrier care for people in crisis with substance use disorders. If we can ever muster the cooperation and will for such a program, these people can teach us how to do it.

  1. Sordo et al., 2017, British Medical Journal
  2. D’Onofrio et al., Journal of the American Medical Association, 2015, Apr 28; 313(16): 1636-1644.
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5 responses to this post.

  1. Posted by Trudy Duffy on August 30, 2018 at 1:37 am

    We need Bridge Clinics across the country.

    Reply

  2. Unfortunate it is once again Massachusetts leading the way in access to/innovative mental health and addiction services also unfortunate the rest of the states will probably never reach that level of care. We will have to advocate for the private sector to “buy in” at this level of commitment. Then have a few dedicated teams with undying persistence to advocate and push the narrative to get with the program. Literally.

    Reply

  3. This is what can happen when you have people who are smart passionate and leaders who don’t let anything complicated stop them from doing what is patients needs to get better treatment on demand with compassion and no barriers . I waited 8 weeks to start methadone and because my urine screen was not positive I had to use to be accepted in program. When you have amazing leaders they can make the impossible work because they are truly invested in their work. Dr. Sarah Wakeman and Dr kehoe are wonderful and I am so happy they are here in Boston.

    Reply

  4. California is spreading MAT in EDs and hospitals across the state. Our websites contain tools that anyone can use to get a program started at their hospital.
    http://www.PROJECTSHOUT.org (for inpatient settings)
    http://www.ED-Bridge.org (for emergency departments)

    Reply

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