But the COVID-19 pandemic has significantly limited outpatient treatment for opioid use disorder (OUD), highlighting how important it is for the ED to provide 24/7 treatment and links to ongoing care, says Gail D’Onofrio, MD, chair of emergency medicine at Yale Medicine.
At most hospitals today, ED patients diagnosed with opioid use disorder (a physical and psychological reliance on opioids found in certain prescription pain medications, or in illicit drugs such as heroin, and synthetic opioids like fentanyl) are referred to life-saving, medication-based treatment outside the hospital or, in some cases, rehabilitation programs without medication—if any referral is made at all.
But that approach isn’t working, Dr. D’Onofrio says. More than 130 people die each day from an opioid overdose in the United States. In 2018, there were nearly 47,000 opioid overdose deaths in the U.S., the Centers for Disease Control and Prevention (CDC) reports. While slightly decreased overall last year, the numbers are continuing to rise in many states, including Connecticut.
Dr. D’Onofrio is determined to encourage hospitals throughout the country to adopt new and better treatment standards for this deeply challenging form of addiction. In 2015, Dr. D’Onofrio and Yale researchers published a groundbreaking study in JAMA showing the effectiveness of starting ED patients on a proven medication called buprenorphine and continuing treatment in a primary care setting.
Still, even before the coronavirus, many medical professionals were reluctant to adopt the use of buprenorphine, she says. One reason is because doctors must receive a special waiver to prescribe it. This, as mandated in the Drug Addiction Treatment Act of 2000 (DATA 2000), includes an eight-hour course. And even those who have the waiver aren’t always prescribing it to patients who would benefit, she says.
A recent survey of emergency providers from April 2018 to January 2019 published in JAMA Open Network, led by Yale emergency physician and addiction specialist Kathryn Hawk, MD, reported that 20% of the 268 providers surveyed across four geographically diverse academic EDs felt ready to prescribe buprenorphine, and only 3% had obtained their waivers to do so.
To help overcome this, Dr. D’Onofrio liberally dispenses her cell phone number to physicians and encourages them to call her—to provide support or to troubleshoot with doctors who want to use it.
“I give my phone number out to every emergency department in the state and everywhere I go around the country,” Dr. D’Onofrio says. “If they don’t feel comfortable or have questions, I can walk them through it. Better yet, they can call Yale New Haven Hospital and ask for any of our ED doctors around the clock. They’ve all been trained to prescribe.”
Emergency medicine physicians play a pivotal role in the opioid crisis. It’s common for people who struggle with opioid use disorder to not have a primary care physician, lack medical insurance, or feel too ashamed to see a doctor about their addiction, Dr. D’Onofrio says. So, they end up in the ED when there is a crisis, often an overdose.
Visits to EDs for suspected opioid overdoses increased about 30% from 2016 to 2017, according to the CDC, and preliminary data for May 2020 indicate a rise in fatal and nonfatal opioid overdoses in some areas of the country.
It’s part of the reason Dr. D’Onofrio and colleagues are advocating for the accelerated adoption of quality measures for ED-initiation of buprenorphine and referral for ongoing treatment.
“We have a pandemic and an epidemic colliding right now, and we are very concerned about those with opioid use disorder. Treatments are interrupted, and because of social isolation, people may be more likely to be using alone and could overdose alone,” says Dr. D’Onofrio, who outlines these and other issues in an article published in NEJM Catalyst Innovations in Care Delivery. “This really highlights how emergency departments can step in and help by initiating treatments with buprenorphine and discussing harm reduction strategies.”
The pervasive stigma of opioid use disorder
Buprenorphine is a partial opioid agonist, meaning that it tightly binds to certain opioid receptors in the brain without fully activating them, effectively stopping cravings and opioid withdrawal. A partial opioid agonist is therefore less likely to lead to complications, including respiratory depression and overdose, which can happen with full agonist opioid medications such as methadone.
Buprenorphine has been found to decrease overdoses, cravings, illicit opioid use, and transmission of infectious diseases, and it increases retention in treatment. Importantly, says Dr. Hawk, patients with opioid use disorder who are started on buprenorphine often describe the sensation of starting it as “finally feeling normal again.”
Effective as it has proven to be, a stigma still surrounds opioid use disorder, even among medical professionals. This limits access to the treatment, despite the large number of people affected, says Dr. Hawk.
"Educating healthcare professionals, patients, and the community about how these medicines work is one of the first steps to addressing the stigma,” Dr. Hawk says. “The second is to expand access to the now millions of Americans that we know have opioid use disorder.”
However, many people inside and outside the addiction treatment world believe using medication such as buprenorphine to treat opioid use disorder is just replacing one drug for another, says Jeanette Tetrault, MD, a primary care physician and addiction medicine specialist.
“This is misinformation. The most important thing to recognize is that addiction, by definition, is a disease with a neurobiologic basis,” she says. “People with opioid use disorder can’t just stop using opioids. And that's not a behavioral phenomenon, that's the result of a neurobiological change. There are differences in the brain between someone who does not have opioid use disorder, or addiction, and someone who does.”
Dr. D’Onofrio agrees, and takes umbrage when physicians tell her they don’t believe in using buprenorphine.
“There is a huge quality gap when it comes to addiction,” she says. “We have evidence-based treatments for opioid use disorder, and we must adopt them into practice. Individual doctors are deciding whether or not they believe in such treatment. But treatment of opioid use disorder is not a belief system. You don’t ask people whether or not they believe in giving tetanus immunization or whether they believe in treating a stroke or heart attack.”
At a conference about overcoming stigma hosted by the American College of Emergency Physicians (ACEP), Dr. D’Onofrio says the most powerful statement came from an ED doctor whose daughter died of a heroin overdose. “He made a passionate plea for emergency departments to be part of the solution and initiate treatment,” Dr. D’Onofrio says. “He asked, 'If not us, then who?’”
Research supporting buprenorphine in the ED
Ten years ago, Dr. D’Onofrio never pictured herself taking on the cause of buprenorphine treatment in the emergency department. Back then, doctors in the ED were regularly treating overdoses from prescription painkillers and heroin and then discharging patients once they were stabilized.
Similarly, people with opioid use disorder were encouraged to seek follow-up care at an outside clinic that offered methadone or urged to see a physician who could prescribe buprenorphine. Through Yale’s Project ASSERT—a motivational program aimed at helping people with substance and alcohol use disorders—a trained health promotion advocate would even schedule the appointment for the patient.
However, actually going to the clinic or doctor’s office was left up to the patient, and many wouldn’t go and would relapse after leaving the hospital. In 2008, Dr. D’Onofrio, along with fellow Yale researcher David Fiellin, MD, applied for a National Institute on Drug Abuse (NIDA) grant to test screening and interventions for drug use in the emergency department. She was familiar with the work Dr. Fiellin and Patrick O’Connor, MD, were doing in the primary care setting with buprenorphine and thought, “Why not test starting this medication in ED patients?”
“At the time, this was considered incredibly innovative. No one had heard of using this medication in the ED, but now it seems so basic,” Dr. D’Onofrio says. Patients often use the ED as their only source of health care, which meant that the ED visit was an opportunity to intervene. “We had already instituted Project ASSERT, using health promotion advocates to screen, offer motivation, and provide direct community referrals and services—which was unique. And we had very good engagement rates, with close to 60% of patients following up with a direct, facilitated referral to treatment.”
Drs. D’Onofrio, Fiellin, and O’Connor, as well as other Yale colleagues, designed a clinical trial to test the idea. Conducted at Yale New Haven Hospital between 2009 and 2013, it randomized patients into three groups: a referral alone to outpatient treatment depending on patient preference (and insurance) after discharge; the Project ASSERT model, which included a 10- to 15-minute interview motivating patients to accept treatment and a facilitated referral to care; and the motivational interview with ED-initiated buprenorphine and referral to primary care for 10 weeks of medical management.
The findings were robust, Dr. D’Onofrio says. Seventy-eight percent of patients in the buprenorphine group remained engaged with addiction treatment 30 days later, compared to 37% in the referral only group, and 45% in the referral and motivating interview cohort.
“I was surprised that the buprenorphine group—with nearly 80% engaged with treatment at 30 days—was so high,” Dr. D’Onofrio says. “I thought it would be as good as Project ASSERT, but not higher. That was a game-changer.”
Since then, Drs. D’Onofrio, Fiellin, and Hawk, along with other Yale researchers, have embarked on several more NIDA-funded studies in EDs around the country.
“In our first implementation study, we collected data on an ongoing basis. We certainly know that more ED clinicians have obtained their waiver to prescribe buprenorphine and are administering and prescribing much more buprenorphine for their patients with opioid use disorder then at the start of the study,” Dr. D’Onofrio says. “Whether or not that equates to improved patient outcomes regarding engagement in treatment, we don't yet know.”
A bridge to long-term care for opioid use disorder
Dr. Fiellin, a primary care physician and addiction medicine specialist, who directs the Yale Program in Addiction Medicine, has participated in much of the Yale opioid research and speaks of the rewards of treating opioid use disorder with buprenorphine. “You see patients quickly transition from a period of uncontrolled use, often spending upwards of $100 or more a day and having burned bridges with family and friends,” he says. “Within three days, they come back and are engaging with their family and work; they’re saving money and feeling normal.”
Another way to make patients feel normal, Dr. Fiellin says, is to deliver care where patients would normally be going for routine health care.
“We want to move those effective treatments from specialty settings where patients may not feel comfortable going or may be infrequently visiting to medical settings such as emergency departments, HIV clinics, and primary care clinics where patients often have long-term relationships or are visiting on a regular basis,” Dr. Fiellin says. “We have the opportunity to initiate and continue a long-term and effective treatment in those settings.”
As for Dr. D’Onofrio, she’s still working on her research and dispensing her phone number to any medical provider who may have a question about buprenorphine in the emergency department.
“This isn’t optional. We need urgent reforms to require adoption of quality and accountability measures, mandatory residency education, and institutional, regulatory, and legislative support,” says Dr. D’Onofrio. “There’s no excuse not to offer this life-saving treatment.”