Several years ago, a young woman arrived at the Swedish Edmonds hospital emergency department (ED) near Seattle with severe withdrawal symptoms from heroin. She had recently dropped out of school and was in danger of losing her job, her house, and her three-year-old daughter. While severely sick and depressed, she was most desperate not to lose everything she had. Luck was on her side that day. The ED clinician who evaluated her was compassionate, and after confirming her desire to get clean, she stabilized the patient with a dose of buprenorphine to relieve her withdrawal symptoms for 24 hours. Next, she connected her with our ED’s behavioral health specialist, who arranged for the patient to get to a clinic for an outpatient prescription for buprenorphine to manage her substance abuse disorder long term.
A few weeks later, the woman returned to the ED to thank them for their care. She was drug-free, in a treatment program, and working. She had paid her rent, was starting to save money, and had enrolled in school for the next semester. She was so grateful that she could see a way to give her daughter the life she deserved.
This example of an effective and compassionate approach to handling opioid use disorder is called Medication Assisted Treatment (MAT), an emerging solution for EDs to treat patients with opioid addiction.
MAT, which combines counseling with one of the FDA-approved opioid agonist medications — methadone, buprenorphine, or naltrexone — empowers clinicians to handle opioid use disorder as the chronic disease it is. This is not a moral failing but a medical condition: Just one week of opioid use can cause neurochemical changes that lead to increased tolerance and the likelihood of addiction. Using MAT in the ED, clinicians can help willing patients move forward on their journey to recovery.
Studies have proven that patients who start buprenorphine in the ED are twice as likely to stay in a 30-day treatment program as those who don’t. This protocol is not only a more humane approach to our opioid crisis, but it has the potential to reduce healthcare costs by $20,000 per patient.
At Vituity, where we have pioneered the use of MAT in EDs at dozens of hospitals, clinicians are now experiencing improved efficiency and morale by witnessing the positive effects on patients ready to fight addiction. Their success is encouraging dozens more Vituity EDs to adopt the protocol over the coming year.
While MAT is an evidence-based strategy for handling opioid withdrawal in the ED, implementing the protocol can be challenging. With only a few minutes to diagnose and treat each patient, ED clinicians typically focus on caring for the immediate issue, not the underlying ones. They often don’t have time to incorporate a new practice into their workflow, especially if they don’t have the outpatient resources to support continued treatment. Additionally, some clinicians still view those with substance abuse issues as having a mental failing and don’t see the ED as the right place to treat their addiction. We must drive a cultural shift that ensures that patients struggling with substance use disorder get the best possible treatment.
Change and innovation happen when clinicians and staff are open to trying new things to improve quality of care. Even the most open-minded care team requires additional commitments to implement a MAT program successfully, including education, access to medication, social service support, and outpatient treatment partners:
To eliminate any biases that might affect their quality of care, physicians, advanced providers, and nurses need to understand that opiate addiction is a treatable chronic condition. Consistent education and training are necessary to teach the full range of treatment options and how to include them into workflows until the new protocol becomes part of the clinical routine.
Buprenorphine needs to be on your hospital formulary. If it’s not, you may need to educate the hospital’s pharmacy and therapeutics committee about a MAT protocol and the fact that any clinician can directly administer this medication to any patient without a DEA-X waiver. To develop a best-in-class MAT program, having clinicians on your team with DEA-X waivers enables your ED to prescribe buprenorphine for outpatient use, giving patients more time to get an appointment with a behavioral health specialist or treatment clinic.
Getting social service support inside the ED is critical and can free up your clinician’s time so they can practice medicine. This can be in the form of a patient care navigator, social worker, case manager, or peer counselor who can provide patients with warm handoffs to clinics and follow up to ensure they are getting appropriate care. Every program can be different depending on the hospital’s resources and abilities.
EDs can’t just administer buprenorphine without a clear follow-up plan. ED leaders need to establish linkages with outpatient DEA-X–waivered clinicians. Ideally, these partners would be low-barrier clinics that are willing to see any patient regardless of insurance status and are open to walk-in visits the day after an ED encounter. Surging grant money has supported the growth of such clinics in many communities, and telemedicine can also increase access to outpatient treatment.
The numbers from the opioid epidemic can seem overwhelming. But as clinicians and administrators, we can make a difference through small but significant changes to how our EDs care for these patients. I encourage all EDs to take these four simple steps to start a MAT program and help patients begin the road to recovery.