Throughout the majority of my career in emergency medicine, I would have to say that the patient I dreaded the most was the patient with “drug seeking behavior.”
I didn’t dread them because they presented some novel condition that I didn’t know how to treat. I dreaded them because I believed that there wasn’t anything I could do for them except give them what they wanted, which would make matters worse. Or try to convince them that a non-opioid treatment was just as good, which would mean an argument and bad patient sat score. Or last, confront them with the truth and discharge them with nothing.
There just didn’t seem to be a good answer. In the end, my goal was often to just get them out of the
ER as quickly and painlessly as possible. And as anyone knows who has worked in this field very long, that was seldom successful.
But now, I think we have a better way. And what’s better, I think it’s a win-win-win for everyone. Let me explain. You’d have to be living under a rock to not understand that we are experiencing one of the worst epidemics in decades in the misuse of opioids. I hate to estimate the number of Americans who are currently addicted to opioids, but the number is conservatively in the millions. Over 60,000 people died last year of overdoses. We have lost the War on Drugs, not for the lack of effort or money. We lost it because it was only one leg of a three legged stool, namely interdiction, prevention and treatment.
Yes, we have to continue efforts to interdict drugs and prosecute drug kingpins. Yes, we must do everything we can to prevent young people from entering the cycle of drugs. But we must also treat those who find themselves addicted to opioids. And to do that, we need to really understand the hurdles to treatment.
First, as any clinician knows, we need a diagnosis to treat. And addiction, or its new name “substance use disorder,” exhibits an element not present in many other conditions: shame. Few other problems, especially ones as deadly as this one, are hidden or denied as vigorously as this one. People with chest pain may diminish the magnitude of the pain, but they will still admit that they have chest pain. Patients with opioid addiction/withdrawal will often actively hide their symptoms to prevent detection.
The astute clinician will, of course, see right through this ruse. But we are also often guilty of willful ignorance, because we have not had any viable positive treatment options to offer the patient. I believe that should now change. It is my firm belief that emergency physicians should take an active role in diagnosis and treatment of opioid use disorder.
That’s right, I said we should be actively involved in treatment. Before you write me off, let’s look at the problem a little more closely. When we have seen patients with opioid use disorder in the past we have routinely discharged them with a list of clinics, treatment centers, rehab centers, or sometimes outpatient providers. But this is the quintessential passing of the buck. Most rehab centers have long waiting lists that require pre-certification from insurance, assuming the patient has insurance. Many don’t. This leads to having the patient lost to follow-up until the next time they show up in the ED with a drug-related medical problem.
Outpatient programs are often not much better. Does anyone really expect the patient to follow up on their own when their desire for getting clean gets overwhelmed by their need for their next fix? But what would happen if the patient could get started on the road to medically-assisted treatment right in your emergency department?
You might argue that medically-assisted treatment is not right for everyone. Some can get straight with counseling and support like a 12-step abstinence program. While I’m all for programs like this,studies show that 80% or more will fail on abstinence alone. Patients should be very carefully screened before referral to such programs so that they have the highest possibility of success. Most patients will, however, require some sort of medical assistance to blunt their compulsion for illicit drugs.
The two drugs that have been studied the most are methadone and buprenophine. Methadone is a pure, long-acting agonist that has a proven track record of suppressing withdrawal and the urge to return to illicit drugs. But because it is a pure agonist, it is subject to abuse itself and requires close supervision. Methadone is federally regulated and its dispensing is restricted to sites controlled by the DEA, like the one I work for in Baltimore. We treat over 3000 patients each day with methadone. Some have been coming daily for decades. This clearly has its limitations for patients who work or simply have a life that doesn’t conform to coming to a clinic everyday.
That’s where buprenorphine comes in. While an agonist itself and subject to abuse, when it is combined with naloxone, the oral form can no longer be crushed and snorted or injected without triggering the naloxone reversing agent.This makes it safe to be prescribed by physicians in private practice. It requires an 8-hour course to add an X waiver to your DEA number in order to prescribe. But it is relatively easy to get.
So what would happen after you have given the patient their first dose of buprenorphine/naloxone in the emergency department? They will still need to get it daily. Plus,they’ll need to get into some type of counseling support.This is where I would like to issue a challenge to emergency physicians and the hospitals where they practice. Begin a separate substance abuse practice within the group of emergency physicians. The required hours are about 30/month maximum for the first year and 100/month for the second. It is a practice that should be supported by your hospital or community. It is fully reimbursed by Medicaid and Medicare.
Expanding your group to include such a service allows you to include family practitioners, nurse practitioners and others who could be a resource in your ED as well. Finally, it is a track that fits in nicely into the careers of emergency physicians who are aging out of the rigors of emergency medicine.
This is just the beginning of this conversation and I would welcome your comments and feedback. I’d be happy to come to your hospital, state ACEP chapter, or group and discuss the process and financials of this important community response.
In 2003 I had the privilege of serving in Iraq in a forward deployed Marine Corps Shock Trauma Platoon. We were always within just a few miles of enemy contact. For our service, the Health Services Battalion of the First Marine Division was awarded the Presidential Unit Citation, the highest unit award in the military. We received that award because we went as far forward as possible to save as many lives as possible.
Emergency medicine has always been on the front lines of medicine. The opioid epidemic may be the largest and most brutal war we will face in a lifetime in this country. Emergency physicians are in the right place to make the diagnosis of this often fatal condition. We are also in the right place to initiate what is most likely to be lifesaving treatment, not just for overdoses, but for successful treatment of the chronic disease. And continuing to meet the needs of these patients is good for emergency physicians.
Hospitals will rejoice that their emergency medicine group has tackled this problem head on and will reward them appropriately with their loyalty and support. And the community will see the emergency physicians for what they truly are, heroes, for stepping up to address this considerable challenge.