Stretching our scope to save lives in the midst of an epidemic.
Like many clinicians practicing in the midst of the present epidemic of opioid addiction and overdose, we in emergency medicine have expanded the scope of our practice to reduce opioid-related morbidity and mortality, across three broad strategies.
Those strategies are judicious opioid prescribing to prevent new cases of addiction, harm reduction practices (such as take-home naloxone) in existing misusers who are not yet ready to transition to recovery, and initiation of the most effective treatment for opioid use disorder, buprenorphine, at the time and opportunity of emergency care.
All three elements of an emergency medicine-driven opioid stewardship program represent a significant departure from existing EM paradigms, if not a departure from the EM mindset itself. Many emergency providers have particular concerns around ED-initiated and ED-prescribed buprenorphine. Let’s discuss them.
This is not our purview. The treatment of opioid addiction is not an emergency.
“A great part of the tragedy of this opioid crisis is that, unlike in previous such crises America has seen, we now possess effective treatment strategies that could address it and save many lives, yet tens of thousands of people die each year because they have not received these treatments.” (Volkow 2018)
Opioid overdose is now the #1 cause of accidental death in America with an annual toll of over 50,000 dead. Every one of them is preventable. I have seen hundreds, likely thousands of patients with opioid use disorder over the course of my career. I treated them with irritation or derision, tried to get them out of the department as quickly as possible, and discharged them, even as they were experiencing active withdrawal symptoms, with a piece of paper listing a few phone numbers, a slap on the back, and a good luck to ya.
This was always an inadequate, stigma-based approach, but until recently most of us didn’t know better and didn’t have a lot of tools to help. This has changed. The ED sees more complications of opioid use disorder than any other speciality, because for many opioid use disorder (OUD) patients, the ED is their only available access to healthcare. The reason it is essential that emergency clinicians expand their practice to include the treatment of opioid addiction is that the emergency department is where these patients are. And the history of medicine tells us that we will stretch the scope of our practice, because right now, it’s what our patients need.
Using buprenorphine to treat OUD is just replacing one addiction with another.
This fallacy is misunderstanding the difference between addiction and dependence, which is everything. Opioid addiction is living entirely in the service of a desperate need to avoid withdrawal, characterized by constant debilitating cravings and perpetual cycling of highs and lows that make normal functioning impossible. Addiction leads to acquisition harms: frantic behavior to acquire a continuous supply of opioids — poverty, crime, lying to physicians or selling sex on the street. It leads to injection harms: local infections, HIV, hepatitis C and the devastating consequences of bacteremia such as endocarditis. It leads to street drug harms arising from the unpredictable, unregulated substances purchased illicitly from dealers who are often equally desperate. In 2019, the most important street drug harm is overdose and death.
These harms disappear when an opioid-dependent person has reliable access to prescribed daily opioid therapy. This transition from addiction to dependence allows the return to a much more normal life people effectively transitioned to buprenorphine maintenance return to their jobs, families and health in the most important sense of that word.
The last thing we need is more difficult patients coming to the ED for buprenorphine. We do not want to be a suboxone clinic.
Emergency providers are dissuaded from initiating and prescribing buprenorphine by their experience with methadone. Methadone is a very effective treatment for opioid addiction, but is far more dangerous and abuse-prone than buprenorphine. Patients on methadone who frequently come to the ED are the ones who aren’t succeeding with methadone.
Emergency departments that have begun buprenorphine programs have not seen spikes in volume or “bup seekers,” in fact the prevailing sentiment is how rewarding it is to finally be able to offer this population an effective treatment and watch many of the patients who had caused so much trouble in the department while in the throws of addiction return to health and functioning.
Buprenorphine is less likely to be abused than full agonist opioids as it is less euphoriant than the street drugs it replaces, can precipitate severe withdrawal in opioid-habituated people not in spontaneous withdrawal, and blocks the action of other opioids. However, buprenorphine has street value, and prescribed buprenorphine can be diverted. Diversion is illegal, but illicitly purchased buprenorphine is used for the same purpose as prescribed buprenorphine — to treat withdrawal and replace dangerous street opioids — so the black market for buprenorphine actually represents a failure to make MAT available to many OUD patients who want to move to recovery. (Cicero 2018, Carroll 2018)
I don’t know if my patients are going to follow up. It makes no sense to start or prescribe buprenorphine if they don’t follow up with outpatient care.
The goal for all OUD patients is sustained outpatient comprehensive addiction treatment. The development of a departmental buprenorphine program should include links to clinic-based care. However, psychosocial counseling does not provide benefit over buprenorphine treatment alone, and the decision to treat with buprenorphine should proceed independent of how likely that patient is to successfully link to ongoing addiction care. (Amato 2011, Martin 2018) Every hour an OUD patient is therapeutic on buprenorphine is an hour that person is safe from withdrawal, cravings, and overdose. This is an hour that person can contemplate recovery. One of the predictors of sustained successful treatment is prior exposure to buprenorphine. (Cunningham 2013)
Alternatives for an opioid-dependent patient in withdrawal are no longer adequate. Non-agonist treatments of opioid withdrawal syndrome may blunt symptoms, but do not address cravings. Due to the lethality of street opioids in 2019, sending a patient to the street in opioid withdrawal is a more dangerous discharge than any emergency clinician would contemplate in any other context.
I’m not x-waivered, so I can’t initiate buprenorphine therapy.
All DEA-registered providers can administer buprenorphine in the emergency department for patients in opioid withdrawal. Though a DATA-2000 (X) waiver is required to prescribe buprenorphine for addiction, the law allows patients to return to the emergency department on days #2 and #3 to receive further doses of buprenorphine for up to 72 hours. Three days is long enough to link the patient to a buprenorphine clinic or prescriber in most settings.
I didn’t learn how to use buprenorphine. It’s complicated and too time-consuming for emergency care.
Although there are a variety of questions and controversies around ED-initiated buprenorphine, treating spontaneous opioid withdrawal with buprenorphine is straightforward, safe and has the potential to turn someone’s life around. There are numerous ED-specific pathways and guides to provide decision support. Many withdrawing patients treated with buprenorphine require no IV, no tests and can be discharged in 60-90 minutes.
Contrast this with non-agonist treatment of opioid withdrawal, which may require difficult IV starts and often multiple rounds of (largely ineffectual) medications over many hours, only to be discharged in no better shape than when they came in, susceptible to using incredibly dangerous street opioids.
Emergency clinicians are uniquely positioned to make an impact in the opioid addiction and overdose epidemic because of the breadth of our skillset and the breadth of our patient population, many of whom seek care only with us, because we see anyone, anytime, for any problem. Feel free to contact me with any concerns you have on your way to developing an OUD treatment map for your department.
“The history of medicine is, in part, the history of physicians stretching the scope of their practice to answer the pressing needs of their times.” (Rapoport 2017)