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Emergency Departments as front line for opiate epidemic

There is no question that opioid use disorders are a serious problem in the United States. Increasing recognition of the scope of the problem has led to political and policy attention. While evidence-based treatments for opioid dependence are available, they remain difficult to access. Treatments that involve opiate replacement such as methadone are particularly stigmatized. The approval of buprenorphine by the FDA for office-based treatment is a step forward, as it can be administered in a non-clinic setting, enables the patient to have increased privacy and freedom within the treatment, and is felt to be safer than methadone in overdose due to its unique pharmacology. There remain barriers to access, however, including cost issues, the need for doctors to obtain additional training to prescribe, a cap on the number of patients an individual physician can treat, and the stigma attached to addiction.

Buprenorphine is an opiate that acts as both an agonist and antagonist at the opioid receptor. This is important for two reasons. First, if someone is dependent on opiates and takes a dose of buprenorphine it can induce withdrawal symptoms due to the displacement of the other opiate at the receptor. This makes it somewhat less attractive as a substance of abuse, as a patient who is opiate-dependent would prefer to avoid withdrawal. Second, it is very difficult to overdose on, due to its natural “ceiling”, as with escalating doses, the partial antagonism counteracts its cumulative effects.

Buprenorphine is typically dispensed in pill form as a combination of the active buprenorphine opiate and an inactive form of the opiate antagonist, naloxone, which becomes active if the pills are dissolved for the purposes of injection, thus further limiting its abuse potential, as injection would trigger a powerful and unpleasant withdrawal. All of these factors combined are what made it possible for buprenorphine to gain approval as a treatment for addiction that was felt to be safe enough that it could be dispensed to the patient to take at home, in up to a one-month supply, as opposed to methadone maintenance, which requires that the drug be administered as a licensed clinic with only limited potential for “take-home” doses.

Suboxone (trade name for Buprenorphine/naloxone combination). “Suboxone sublingual tablets” by Supertheman. CC BY-SA 3.0 via Wikimedia Commons.

The US Drug Enforcement Authority (DEA) did, however, put significant limits on buprenorphine prescribing. First, physicians must take an eight-hour course on the drug’s pharmacology and safe prescribing methods. Then the physician must apply for a waiver from the DEA that allows them to prescribe. For the first year of prescribing, they can only treat 30 patients, (afterwards, they can apply to treat up to 100) and must keep records that the DEA can demand to see at any time. The additional scrutiny and training does add an additional hurdle to recruiting clinicians who want to provide buprenorphine treatment.

Why is opiate replacement even necessary?  It seems more and more clear that long-term opiate users have an abysmal rate of success with therapies that involve detoxification only, and detoxification can in the actually increase the risk of overdose. Long-term opiate craving appears to have a neurologic basis, and it is more and more recognized that a harm-reduction approach keeps patients engaged in treatment and alleviates some of the physical factors that may drive patients to relapse.

So, taking all of this into account, it is actually quite remarkable that scientists recently explored the idea of emergency department (ED) physicians intervening with patients who were found to have opiate dependence during their ED visit. The study looked at a group of 329 opiate-dependent patients who were treated at an urban teaching hospital over the course of a four year period. The patients were randomized to receive either a handout about available treatment services without any motivational enhancement; a brief standardized motivational enhancement interaction, direct linkage to aftercare that the patient’s insurance would pay for, and transportation to that treatment; or the motivational interview, referral, linkage, and take-home doses of buprenorphine with a follow-up medical appointment in 72 hours for possible prescription renewal. Patients who received the third option – coming from a group in which half of the subjects had co-occurring psychiatric problems, and over half were injecting opiates – had significantly higher rates of engagement in treatment at 30 days, greater reduction in days of illicit opiate use, and used inpatient addiction services at a lower rate than the other groups. In summary, in a group that is considered very difficult and risky to treat, this intervention seemed to work, and work in a way that was more cost-effective than usual care, in that it reduced use of expensive inpatient addiction treatment.

Historically, the ED has been a place of triage and stabilization, and the focus has not been on primary prevention or public health measures. There are significant barriers to implementing such a program. Staff must be trained, prescribers must have a DEA waiver, the hospital must agree to dispense medication, provisions need to be made for uninsured patients, and simply checking someone’s insurance can be an arduous task. Immediate referral to follow-up is probably the biggest barrier, so coordination with a clinic or provider(s) willing to take these patients on would be necessary. Start-up costs are high. However, the biggest barrier is probably that of re-thinking the idea of what can or should be done in an ED setting. A significant portion of the patients in this study were people who were in the ED as a result of an opiate overdose. Opiate maintenance therapy reduces the risk of overdose, and thus, death. This alternate option for those dependent on opioids has challenged me to re-think what services we can provide for opiate users who present to the hospital where I work, and hopefully will expand other physicians’ ideas of what is possible in the emergency department.

Featured Image Credit: Pop life by frankieleon. CC BY 2.0 via Flickr

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