AN UPDATE ON THE OPIOID CRISIS:
The Case for MAT Induction in the ED By Aaron Wohl, MD, FACEP FCEP Board Member Emergency Physician, Lee Health Memorial
In 2017, opioid overdoses claimed 47,872 lives in America. This staggering number is an increase from 2016 and America’s average life expectancy fell for the second year in a row by 1.2 months as a result of opioid-related deaths, alcoholism and suicide.1 Florida’s opioid-related death rate has also increased dramatically by 109% from 2013-16.2 Opioid-related deaths continue to rise despite significant reductions in prescribing opioids because these policies have not yet adequately addressed the needs of those who have already developed opioid use disorder (OUD)—and those individuals are turning to illicit sources. Heroin use has increased an estimated 37% per year since 2010 and 4 in 5 new users start by misusing prescription opioids (often not prescribed to them).3 In Florida specifically, death rates from illicit opioids have sharply increased since 2013 and heroin is no longer the main culprit. Synthetic fentanyl analogues are now prevalent in the heroin supply and are killing with alarming efficiency.2 The consequences of this epidemic are devastating to families, communities and the economy, costing the U.S. an estimated $95.3 billion in 2016.2 Yet treatment and recovery services have been scarce, underfunded and plagued by long waiting lists, and relationships between EDs and outpatient programs offering medication assisted treatment (MAT) have been virtually nonexistent. As emergency physicians (EPs), we must expand the scope of our practice to meet the pressing needs for the epidemic of our times. ED clinicians are uniquely situated to assist in prevention and recovery efforts by offering MAT now. A study published earlier this year in Annals of Internal Medicine 14
found that treatment with buprenorphine or methadone after a nonfatal overdose was associated with a 4060% reduction in all-cause and opioid-related mortality. Yet, only 3 in 10 of these patients received medications for OUD.4 This is a travesty and ethically dubious. There is a limited number of things we can do as emergency physicians that decreases the risk of all-cause mortality by up to one-half in any disease. We would consider this a “breakthrough therapy” in any other pathologic process; we must embrace this therapy for addiction to opioids. To be successful however, ED’s must engage and build relationships with their community resources, educate patients on harm reductions strategies and offer MAT induction from the ED.
FCEP’s Position EDs can attempt to mitigate opioid-related morbidity and mortality with five main strategies: 1 Through rational opioid prescribing
2
3
4
5
practices for both acute and chronic pain (reduce supply and prevent new misuse and addiction) Use of the state PDMP prior to prescribing opioids when concerned for OUD (mandatory per H.B. 21) Educate and counsel patients on realistic pain control expectations and the dangers of opioid use as well as alternative therapies to opioids (reduce demand) Engage revealed OUD patients in harm reduction strategies and provide naloxone for overdose reversal if they are not ready for treatment Screen suspected patients for OUD and encourage patients to start induction with MAT in the ED and then enter outpatient MAT programs (a process described as a "warm handoff" or "ED Bridge") EMPULSE WINTER 2019
About MAT MAT for addiction is the most effective method EPs can suggest for patients who desire a path to recovery. This approach can help alleviate withdrawal symptoms and drug cravings while patients turn their attention towards other aspects of recovery, such as avoiding triggers and reducing harmful behaviors. A stable safe source of medication helps stem the pursuit of illegal behaviors and acquisition harms motivated by the need to obtain opioids elsewhere. MAT programs address addiction with a combination of drug and behavioral therapies. Drugs used in MAT include buprenorphine, methadone, naltrexone, or combination buprenorphine-naltrexone (Suboxone). This whole-patient approach has been shown to improve substance abuse-related disorders and psychosocial functioning. Surprisingly, evidence suggests that the counseling component adds little to the patient’s outcomes; what seems to matter most is getting them on the replacement MAT. The alternative to MAT isn’t a drug-free patient; rather, it is a continually relapsing patient, and relapse has a high association with death.
About Harm Reduction This is a philosophy and commitment to meeting patients where they are. It realizes that addiction is a medical disease and not a moral failing. It is a practical set of strategies aimed at reducing the negative consequences associated with drug use. It emphasizes evidence and education over neglect. Telling people to “just say no” has been an abject failure. The majority of IV drug users are not ready to quit on the day they see us in the ED. If our time and counseling is geared
