EXECUTIVE SUMMARY
The results of a study conducted in the ED at Arnot Ogden Medical Center in Elmira, NY, provide a roadmap for how EDs in smaller, less densely populated areas can help their communities address the opioid epidemic. Without taking on any additional staff, investigators found it is feasible for emergency providers in such settings to initiate patients on buprenorphine and then refer these patients to a local treatment center for continued medication-assisted treatment (MAT).
- When the study was conducted, the ED advertised that patients in withdrawal could be treated there and then linked to a treatment provider for ongoing MAT.
- Key to the approach was a good working relationship with a local treatment center that agreed to see patients started on buprenorphine in the ED within three days.
- Results from the 12-month study showed that out of 62 patients who were evaluated for the program in the ED, 53 met the criteria to receive buprenorphine in the ED and were initiated on treatment. Of this group, 46 were compliant with their initial appointment to receive MAT at the addiction treatment clinic. Forty-three of the original 62 patients who were referred to the treatment center for care still were receiving MAT at 30 days, and 33 patients still were engaged in MAT at 90 days.
There are many reasons why EDs may choose to keep patients who present with opioid use disorders at arm’s length, preferring to hand them off to an addiction or behavioral health specialist whenever possible. One of the more frequent refrains is that they simply do not have the resources or expertise to treat addictions.
However, the results of an intriguing new study suggest that not only can larger, urban EDs with plentiful resources respond to this need effectively, but EDs in more rural settings can act, too.
Investigators conducted a small, prospective, observational study at Arnot Ogden Medical Center (AOMC) in Elmira, NY. It grew out of many years of frustration experienced by Frank Edwards, MD, FACEP, emergency medicine residency director at AOMC.
“For many years working in this region, on a reasonably regular basis I would have patients come into the ED in opioid withdrawal who didn’t have any significant hookup with treatment options, [and they] were asking for help,” Edwards recalls. “Other than giving them Tylenol, Zofran, and treating their symptoms with an alpha-blocker, clonidine, or something that might help a tiny bit, there wasn’t too much else to do.”
Edwards would give these patients the phone number for a local treatment center and hope they would follow up. “We here in Elmira are one of the hotbeds for opioid use disorder,” he shares. “It is sort of a rural, economically deprived area with not enough Suboxone providers to go around, so we needed to address this.”
Edwards came across the pioneering work of Gail D’Onofrio, MD, MS, the physician-in-chief of emergency services at Yale-New Haven Hospital. She and colleagues documented the benefits associated with a new model of care for patients who present to the ED with symptoms of opioid withdrawal.1
“[They] showed you can treat these folks with buprenorphine in the ED and give them a warm handoff to a treatment center, and [these patients] have much better follow-up rates,” Edwards explains. “That only makes sense.”
To date, most EDs that have implemented the type of approach spelled out in D’Onofrio’s study are in larger urban centers where resources tend to be more plentiful.
Nonetheless, Edwards researched the issue further. He believed developing such a program at AOMC could provide not only a feasible solution for the community, it could form the basis of a good, scholarly educational project for the hospital’s residents to tackle.
“After discussions with some toxicologists about the use of buprenorphine ... we decided to [do the program] here,” Edwards says. “It also coincided with the hospital’s development of a task force to help deal with the opioid crisis as well.”
When staff initiate medication-assisted treatment (MAT) in the ED, it is important to work with a partner in the community that can continue providing Suboxone to patients once they leave the ED. Consequently, Edwards contacted CASA-Trinity of Chemung County, an outpatient drug and addiction treatment facility staffed by peer counselors, nurses, and Suboxone providers.
“We are the only substance use treatment provider in Elmira other than some private [practitioners], but we are licensed by the state. We were the logical entity to be at the table for this,” explains Ann Domingos, LCSW-R, CASAC, CADC, the CEO of CASA-Trinity, which maintains three other addiction treatment clinics in New York and two clinics in Pennsylvania. “[Edwards] called everybody together and talked about how we could address this.”
Edwards and Domingos came up with a working relationship whereby any patient who agreed to begin MAT in the ED would be seen whenever possible in the CASA-Trinity clinic within three days.
This time frame fit within Drug Enforcement Administration rules, which allow non-X-waivered physicians to administer buprenorphine for up to 72 hours, enabling the ED to continue providing the drug to patients up until their scheduled appointment at the treatment facility.
The facilities created a communication system and developed relevant paperwork. Whoever is treating a patient in the ED can call the clinic to set up a guaranteed appointment. “If this was during off hours, there would be a voicemail system plus some paperwork that the patient would take with him or her to the treatment center at the next-available time and day when it was open,” Edwards notes.
While Domingos welcomed the effort, there were some initial challenges on her end. “We had not yet developed a robust outreach and warm handoff component to our program. Systems were changing at that time to include that type of thing,” she recalls. “It was an interesting process to be able to free up staff to be able to go to the ED and meet [patients there] if at all possible.”
Domingos notes this was at a time when peer recovery specialists, individuals who are in recovery from substance use disorders themselves, were first certified by the state to provide counsel and support to new patients seeking treatment. “[Peers] can go over to the ED to meet patients and let them know they will see them when they come over to the clinic,” she says.
Nonetheless, the process was new to Domingos and AOMC ED staff. “Some of the challenge was intersecting differently both with other providers and [individuals] in our own system,” she explains.
Once all the intricacies of the process were worked out with CASA-Trinity, Edwards made sure nurses, physicians, and advanced practice providers were fully educated about how the program would work. This happened through presentations, emails, and printed materials spelling out the protocol and other relevant details, according to investigators.
During the 12-month period when the program was under study (March 15, 2018, through March 15, 2019), the ED advertised to the community that people in withdrawal could come in for immediate treatment with buprenorphine and a rapid referral for ongoing MAT services. This outreach was conducted through flyers, press releases, and interviews on local TV, according to investigators.
“One of the thrusts of the program was that if we let the community become aware of this option for getting treatment, they wouldn’t necessarily have to just call the treatment center and get an appointment at some time in the future,” Edwards shares. “If they were in withdrawal and wanted treatment right then, then they could come on in. In a nonjudgmental fashion, we would treat them and get them linked up [with a MAT provider].”
While there were some logistical hurdles, Edwards notes the study showed this type of program is feasible without the need for additional resources. “We did have a study coordinator who worked with us for one year and basically kept track of the patients’ data so we could compile our statistics,” he says.
However, other than for data tracking and collection, no additional staff members were required. Further, the results demonstrated the benefits of initiating MAT in the ED.
Investigators reported that during the study period, 62 patients were evaluated for buprenorphine criteria, 53 of whom met the criteria to receive buprenorphine in the ED, and then were referred to the treatment center for follow-up. Of this group, 46 patients were compliant with their initial appointment to receive MAT at the addiction treatment clinic.
Of the nine patients who did not meet the required criteria, or were not in sufficient withdrawal, to receive buprenorphine in the ED but were nonetheless referred to the clinic for treatment, four patients appeared for their initial MAT appointment at the treatment facility. Forty-three patients still were receiving MAT at 30 days, and 33 still were engaged in MAT at 90 days.2
While the AOMC ED no longer advertises to the community, patients in withdrawal still can be initiated on MAT in the ED and then be referred to CASA-Trinity for continued care. It is an option patients still pick, Edwards observes.
“That second piece is really key to making this [program] make sense,” he says, referring to the need to develop a working relationship with an outpatient treatment center that can take over the care of patients on MAT.
Domingos, who has since established similar relationships with other EDs, adds that another critical piece is designating a champion in the ED who is 100% behind the approach and will push for the needed changes.
“Some of it is educating the emergency physicians and nurses on addiction. It is also getting everybody around the table from the very beginning before you are going to do this to talk about how you can do it,” she says. “There is a lot of up-front work that really needs to happen before this type of project can be successful. That is really what makes or breaks it.”
REFERENCES
- D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment of opioid dependence: A randomized clinical trial. JAMA 2015;313:1636-1644.
- Edwards F, Wicelinski R, Gallagher N, et al. Treating opioid withdrawal with buprenorphine in a community hospital emergency department: An outreach program. Ann Emerg Med 2020;75:49-56.
There are many reasons why EDs may choose to keep patients who present with opioid use disorders at arm’s length, preferring to hand them off to an addiction or behavioral health specialist whenever possible. One of the more frequent refrains is that they simply do not have the resources or expertise to treat addictions.
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