Many ERs fail people who struggle with addiction. These new approaches might help
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Kayla West has watched for years the opioid epidemic ravage her community in eastern Tennessee. She was a psychiatric nurse practitioner and treated patients with mental illness, but felt that she had to do more to help those suffering from addiction.
West jumped at the chance to improve the care of patients in emergency rooms by helping hospitals with addiction in 2020.
She was aware that many people with substance abuse disorders end up in the ER. That starting opioid medications like buprenorphine, often known as Suboxone, could increase a person's chances of staying in treatment for a month can double a person’s chance of being in treatment.
But she knew that the practice of providing medication was not common.
Recent research from the Legal Action Center, Bloomberg American Health Initiative, found that many hospitals fail to screen patients for substance abuse, prescribe opioid treatment, or connect them to appropriate follow-up care.
The report states that many patients who do not receive these services are dead within a year or less of discharge.
However, a growing number emergency rooms and health professionals are working to correct this problem by developing new ways to treat missed opportunities in ERs.
Sika Yeboah Sampong, an attorney at Legal Action Center and coauthor of this report, said that "we know it's possible" because other people have done it. There are many ways to make these practices more popular in different places, states, and counties.
She says that these models have been implemented in a variety of hospitals: large and small, in rural areas, urban centers, and in hospitals with limited resources.
West consulted several experts in Tennessee when she was developing a pilot program for one of the hospitals she advises. She says, "It's almost like looking at a buffet of possibilities for where you can implement changes." These are just a few examples of the many strategies that are emerging from ERs in the United States.
California patient advocates:
Daniel Browne began using prescription opioids and drinking alcohol at the age of 14. He was 24 years old when he began using prescription opioids and drank alcohol.
He says, "I didn’t know where else I could go for treatment than the ER."
Browne drove for 15 minutes from his house to Adventist Health Howard Memorial Hospital, Willits, Calif. in May 2020. Mary Anne Cox Gould met him there. Cox Gould, a substance-use navigator for the program CA Bridge, was present at that time. Cox Gould championed addiction treatment at the hospital and helped patients connect from the ER to clinics in their community. (Cox Gould supervises other navigators at Adventist Health hospitals.
Clayton says that this doesn't need to be a single story about a special hospital. It can be done at scale.
Browne recalls that Browne met Browne in the parking lot before she took me to the ER.
He received his first dose buprenorphine. His withdrawal symptoms were immediately relieved by her presence. Browne states, "Once you don't have to deal with the severe detoxification, it is much easier not to relapse."
Cox Gould took Browne to the outpatient clinic at the hospital and helped him set up recurring appointments. Browne was unable to fill his buprenorphine prescription in a local pharmacy due to technical difficulties. Cox Gould made arrangements to have it delivered by the hospital pharmacy.
Browne, who is now more than a full year into his recovery, says that he has become more reliable in his job and has reconnected to his family. Browne also credits the consistent support and medication he received.
These are the hallmarks of CA Bridge, according to Serena Clayton, executive director. Treatment includes medication. A navigator can help patients connect with others for long-term recovery. She says that navigators in the ER make it more welcoming for patients and give staff an opportunity to learn more about addiction.
California has approximately 130 hospitals using the model, and the state has allocated $40 million to expand it to more than 100 other facilities. These funds are used to pay the salaries of substance abuse navigators and training for ER staff in prescribing buprenorphine.
Clayton states, "This doesn’t have to be about one hospital." It can be done at scale.
New York: Removing obstacles for doctors and patients
Dr. Joshua Lynch, associate professor of emergency medicine at University at Buffalo, says that patients with addiction face many obstacles to their recovery. He says doctors who are trying to help patients with addiction face many obstacles.
ER doctors are often short on time and lack the training to treat addiction-related problems. They also don't know where they can refer patients for further care. Lynch states that both doctors and patients need to be aware of the obstacles.
This was the goal of New York MATTERS. It provides patients with buprenorphine access and links them to treatment facilities. Through an electronic referral system, it also offers pharmacy vouchers for 14 days and Uber vouchers for transportation to the clinic.
Lynch states that doctors are most likely to use this service because they can offer it all without making phone calls.
Partly funded by the state Department of Health in New York, the program includes 38 hospitals and 95 clinics. They are all vetted to make sure they can provide buprenorphine to patients who need it. Patients can choose to be referred to any clinic on the map that providers in participating ERs can display on a tablet.
Lynch states that the patient population is used a lot to hearing 'no', 'that's impossible' or you must go to this place'. We want to encourage them by offering them these options.
Lynch states that most patients choose a clinic near their home or where they know someone who has had a positive experience.
According to him, 55% of the patients who enroll in the program reach their first appointment. They can then receive treatment and medication. According to national statistics, less than 10% of opioid-dependent patients receive the same treatment.
Lynch claims that the cost to join the program for any hospital or clinic is minimal as it mainly leverages existing resources and the state hosts data for the referral platform. He estimates that expanding the program to include facilities throughout the state would cost less $4 million per year.
All North Carolina health care professionals should be trained
Dr. Blake Fagan, chief education officer at Mountain Area Health Education Center, Asheville, N.C., has heard the same refrain when approaching hospitals ERs to provide addiction training.
He said that doctors had told him that there was no place for patients to go afterward.
The doctors were reluctant even to prescribe opioids to patients without a place to keep them occupied. Fagan and his fellow colleagues realized that their training needed to go beyond hospitals.
They reached out federally qualified health centres, which can treat anyone regardless of their insurance status. These centers are able to treat many addicts in a state that does not have Medicaid expansion or has large rural areas.
The Mountain Area Health Education Center received grant funding of just over $1million from two foundations. It has trained staff at 11 local health departments and two health centers in the Mountain Area to administer opioid abuse disorder medications. These centers have treated over 400 patients with the disorder between March 2020 and May 2021.
Dr. Shuchin Shukla heads the program along with partners from the University of North Carolina Chapel Hill. He says that the centers are now obvious referral points for doctors who prescribe medication in the ER.
Shukla states, "We consider ourselves to be a model for what it takes to do this in a Medicaid state that is not expanding."
North Carolina has programs that train residents, medical students, and physician assistants in addiction treatment.
Dr. Sara McEwen is the executive director of Governor's Institute. She said that students who view addiction prevention and treatment in medicine as a part of their daily practice will be able to apply it when they go to the ER or any other clinical setting.
A Wake Forest School of Medicine study found that 60% of medical students who had received the education used it during their internships.
Paige Estave is a coauthor and candidate for joint doctoral-medical degrees at the school. It will encourage doctors to think, talk and find resources by students bringing this up. ... We hope that these little bits of improvement will eventually add up to more.
These programs are effective.
These models all have their strengths and weaknesses, but one thing remains constant: Do they work?
It's one of the most difficult to answer according to both addiction researchers and program managers. Many projects are still in their early stages and will not be able measure success until later. Others struggle to collect long-term data necessary for evaluation.
McEwen in North Carolina knows that more than 500 medical students are trained in addiction. However, until they have completed residency and become independent practitioners, it is difficult to predict how many will be able to prescribe buprenorphine. Lynch in New York can estimate the number of patients who make it to their first appointment at clinics. A recent study by CA Bridge tracked the number of patients given buprenorphine in 52 hospitals. These numbers do not indicate the number of patients who have achieved long-term recovery. This would mean that patients must be tracked for many months or years.
People like West, who look to these models for guidance, must continue to operate in uncertainty. She says that she would rather start now than wait for the perfect solution.
West states that any movement in this direction is a good thing. "I have learned that regardless of your resources, there are still options for improvement in your ER."
Kaiser Health News is an independent national newsroom that publishes editorially and is a non-profit program of the Kaiser Family Foundation. Kaiser Permanente is not associated with KHN.