Learn more about initiating MAT in the ED to accelerate recovery and improve patient lives.
On a recent emergency department (ED) shift, a young and otherwise healthy 20-year-old patient presented with a chief complaint of “opioid dependence.” As I walked into the room, the patient and her family immediately recognized me. “You’re the doc who started her on buprenorphine last year!” they exclaimed.
I instantly remembered her and her family as well, as she had originally presented to the ED the very week we had launched our ED Medication-Assisted Treatment (MAT) clinical pathway nearly one year prior. After returning to her parents’ home for support, she had tried to quit using intravenous heroin. Her parents brought her into the ED after she experienced two days of withdrawal and agony, and they had run out of options to control her symptoms. I gave her one dose of sublingual buprenorphine and returned in 60 minutes to find a completely different person — no longer clutching her abdomen, sweating and anxious: “I can’t remember the last time I felt this normal.”
She left the ED and continued treatment with an organization that treats opioid and other substance use disorders 24 hours a day via telemedicine. However, after nearly a year of successful treatment, she attempted to wean herself off the medication completely and ultimately relapsed. Because she remembered our ED was a place she could go for treatment at any time, she returned shortly after that to start treatment. Fortunately, we were able to restart her medications and reconnect her with follow-up. Because opioid use disorder is a chronic and often relapsing condition, it is even more critical that we expand access and entry points into treatment that meets the needs of our patients.
As the opioid epidemic continues to impact our patients and communities, providers across Vituity are demonstrating their passion and commitment to patient care by implementing programs to address this crisis. One specific area where we are leading the way is by bringing MAT into the ED. By initiating treatment within the ED, Vituity providers are improving outcomes and linking patients to ongoing care for opioid use disorder.
My path to championing MAT in the ED began during residency when one of my attending physicians introduced the topic and encouraged many of us to obtain our DEA X waiver. I subsequently went on to pursue a fellowship in healthcare management and administration with Vituity, and in doing so I had the opportunity to work with passionate ED leaders across California and the U.S. who were eager to do more to combat the opioid epidemic. In the time since, we have seen growing evidence supporting the feasibility, efficacy, and cost savings associated with the initiation of MAT out of the ED, which have been matched by increasing grant opportunities to implement programs aimed at combating the opioid epidemic. As a result, we’ve seen providers across Vituity seizing the opportunity to build ED-based MAT programs and translate evidence into action.
A Primer on Medication-Assisted Treatment (MAT)
MAT refers to the concept of using medications to help treat substance abuse disorders by reducing cravings or combating side effects associated with withdrawal. It’s a concept many providers are already familiar with. For example, when we prescribe a nicotine patch to an inpatient, we’re actually providing a form of MAT.
For opioid use disorder, there are currently three FDA-approved medications: methadone, naltrexone, and buprenorphine. In outpatient settings, MAT is a common approach used by community-based substance abuse programs. Buprenorphine is increasingly being initiated in the ED and inpatient settings for a variety of reasons, including a favorable safety and efficacy profile combined with its simplicity of use.
Both clinical professionals and lay people have asked me why we don’t just wean patients off opioids entirely (i.e., detoxification). Well, data consistently demonstrates that relapse rates with detox and abstinence measures are incredibly high, with one study reporting the majority of detox patients relapsing within 30 days of discharge. Medications such as buprenorphine, on the other hand, help minimize the cravings that drive patients back toward opioid use and have consistently shown much stronger results with a variety of outcomes, including retention in treatment, return to work and family obligations, and ultimately, reduced mortality.
In the face of a growing opioid epidemic and substantial data on the efficacy of medications for treating opioid use disorder, many providers are beginning to initiate treatment in the ED. In a 2015 randomized control trial published in JAMA, researchers at Yale University randomized ED patients presenting with opioid withdrawal to one of three treatment arms: (1) referral to outpatient treatment, (2) referral and brief counseling intervention, and (3) referral, counseling, and initiation of buprenorphine in the ED. The results were impressive: Receiving buprenorphine in the ED increased a patient’s likelihood of 30-day retention in treatment to 78%, a near-doubling relative to the group receiving brief counseling and referral alone.
Over the last year, many organizations have developed free open-access clinical pathways and educational materials to help guide buprenorphine use in the ED and inpatient settings. Organizations like the California Bridge Program have led the way by developing a simple buprenorphine guide and other educational materials that can be easily deployed in any ED.
Expanding the use of MAT in EDs
As director of MAT for Vituity, my ultimate goal is to combat the opioid epidemic by expanding access to MAT for our patients with opioid use disorders. We seek to achieve this goal by helping ED leaders implement ED-based MAT programs and build relationships with outpatient and telemedicine-based treatment programs for aftercare. Because buprenorphine is still a relatively new medication that many ED providers are unfamiliar with, we have built educational tools, including online modules and in-person workshops, to train our frontline providers. Because many communities across the country have little or no access to outpatient treatment for opioid use disorder, we have build a partnership with Bright Heart Health, a telemedicine-based provider of treatment for opioid and other substance use disorders, to meet this need and ensure ongoing access to care after discharge regardless of geography.
I am thrilled that 14 Vituity practices were selected to receive grants to implement MAT programs with dedicated Substance Use Navigators as part of the federally funded California Bridge Program. Additionally, there are many more EDs both within and outside of California doing this important work of expanding access to MAT in the acute-care setting — and it does not require external funding to implement. Between 2018 and 2019, Vituity saw a fourfold increase in the number of practices that reported having a buprenorphine program or actively developing one.
I collaborated with our Chief Medical Officer, Gregg Miller, MD, on a white paper about setting up a MAT program in your ED, including best practices for providers and administrators as well as a resource list for continued training, education, and funding. You can download it here.