The Case for MAT Induction in the ED

AN UPDATE ON THE OPIOID CRISIS:

The Case for MAT Induction in the ED

By Aaron Wohl, MD, FACEP

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 found that treatment with buprenorphine or methadone after a nonfatal overdose was associated with a 40- 60% 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 practices for both acute and chronic pain (reduce supply and prevent new misuse and addiction)

2) Use of the state PDMP prior to prescribing opioids when concerned for OUD (mandatory per H.B. 21)

3) Educate and counsel patients on realistic pain control expectations and the dangers of opioid use as well as alternative therapies to opioids (reduce demand)

4) Engage revealed OUD patients in harm reduction strategies and provide naloxone for overdose reversal if they are not ready for treatment

5) 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")

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 towards getting them to quit, we’ve set ourselves up for failure.

Harm reduction teaches them to keep themselves safe until they are ready for recovery. A commonly heard criticism is that this facilitates illegal behavior. It does not. You have to do what is best for your patients. If we continue to neglect them, the death tolls will continue to rise. Does this enable people? Yes, we are enabling people who use drugs to protect themselves and their communities from HIV, hepatitis C, endocarditis, and overdose. You are enabling them to take personal responsibility for their health and their futures.

About Warm Hand-Offs

There is a small window of opportunity to act when an OUD patient in the ED expresses his or her willingness to enter a recovery program. In a perfect system, patients seeking treatment for opioid addiction will be identified in the ED, initiated on buprenorphine and referred to an MAT program—a process described as a “warm hand-off” or “ED Bridge.”

A successful warm hand-off procedure works best with the following:

• Emergency physicians initiating the first dose of treatment using specific, shared protocols: When OUD patients ask for treatment, physicians should be empowered and understand how to provide it. Administering the first dose of treatment in the ED also buys time for the hospital to mobilize its network of treatment centers, peer specialists and transportation providers while physicians can monitor the patient’s response to buprenorphine.

Administering buprenorphine in the hospital or ED setting requires no special training or waiver. To prescribe a patient for outpatient buprenorphine for addiction however, a provider must obtain their DEA X-Waiver. This requires an 8-hour online course, which takes about 5 actual hours to complete. All EPs should obtain their X-Waiver as it’s simple to do, informative, and shows the community and hospitalist physicians that they too can, and should, take on the responsibility of treating addiction. We must be the leaders that challenge other providers to change their paradigm and begin evidence-based therapy with MAT for OUD patients.

• Outpatient treatment centers expanding intake hours: At this time, most intake hours are only weekday mornings. Patients in withdrawal cannot and should not be expected to wait to begin treatment when (a) they need immediate relief and (b) know they can find that relief in the form of an opioid in their medicine cabinet or on the streets. Ideally, treatment centers should be open and accepting patients 24/7, but we are learning that this is prohibitively expensive for these facilities with scarce funding. In lieu of expanded intake hours, X-waivered EPs can write a prescription for 1-2 days until open intake hours are available.

• 24/7 access to addiction peer specialists: Peer specialists are recovered addicts who provide essential support for OUD patients who are beginning their journey to recovery. Preferably, peer specialists will be hospital-based or “on-call” at a nearby facility. The idea of implementing an EMS model, where peer specialists and EMS personnel serve full shifts and are dispatched to follow up with the patient outside of the hospital, is the most robust system and is already being utilized at one or two sites in Florida.

Many sites have care managers serving as educators and coordinators for selected OUD patients until a peer specialist can be utilized. These care managers can educate on harm reduction strategies such as safe needle injection practices and use of Narcan, and coordinate referral with the outpatient MAT clinic.

• Easily accessible transportation to treatment centers: Expecting OUD patients to coordinate their own transportation to a treatment facility is extremely risky. The route should be direct and the patient should be accompanied by a peer specialist vs. law enforcement. Some hospital systems have utilized Uber for transport with a peer or have designed transport systems utilizing hospital personnel.

Other identified needs include reducing the cost of medications associated with treatment, improving metric collections and data-sharing, and the ability to monitor OUD patients as outpatients to ensure they stay in treatment.

It's important to note that implementing a successful warm hand-off system requires significant and coordinated work. To get started, simple ED MAT induction and very close referral to outpatient MAT is still a laudable goal.

About Funding

Perhaps the most important long-term need is consistent funding to pay for operating costs associated with warm hand-offs and MAT programs. The Florida Department of Children and Families (DCF) has secured and distributed federal funding via grants for treatment providers and EDs to implement MAT programs and warm hand-offs. In the next issue, we'll highlight their efforts, financial costs of MAT and more. ■

Are you an opioid champion? We want to know what you're doing to combat the opioid crisis. Contact us at sleague@emlrc.org to join our statewide coalition list.

References

1. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Spotlight on Opioids. Washington, DC: HHS, September 2018.

2. Kasat, Sandeep. "Florida Opioid Research: Summary of Key Findings." Westat. October 22, 2018. Access at www. guidewellinnovation.com/opioids-crisis

3. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA. Psychiatry. 2014;71(7):821-826

4. Larochelle et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Annals of Internal Medicine. June 19, 2018. Access at annals.org/aim/article-abstract/2684924/ medication-opioid-use-disorder-after-nonfatal-opioidoverdose-association-mortality