For people who overdose in Kentucky, getting taken to the emergency room doesn’t necessarily mean starting treatment to help their addiction. Now, a new study says that if ERs could prescribe medicines to help people quit, more people would likely enter treatment.
Paramedics in Kentucky administered 10,000 doses of the anti-overdose drug Naloxone in 2016, and many of these people given the drug ended up in the emergency department. For the most part, emergency rooms stabilize them but don’t offer to help them start treatment for opioid use disorder – prescribing rules for doctors in ERs often say they can’t, and hospitals often don’t have the administrative bandwidth to coordinate care for patients once they leave the ER. In these cases, a new literature review recommends that emergency departments start prescribing medication-assisted treatment themselves instead of just making referrals to outpatient treatment and hoping the person with substance use disorder goes.
Medication-assisted treatment [MAT] is providing medications, like buprenorphine, to people to treat substance use disorders in addition to providing behavioral counseling. There’s strong evidence that people who use MAT in addition to traditional counseling are more likely to not use drugs again. Dr. Herbie Duber, an assistant professor of emergency medicine at the University of Washington, said emergency rooms haven’t widely used MAT.
“Traditionally [emergency medicine] stayed out of a lot of these things, but the reality is if you can initiate someone on appropriate therapy in the emergency department, there’s a better likelihood that they’ll stay on treatment,” Duber said.
“To say, ‘I saw this patient, they’re 34, they’ve an opioid use disorder, I gave them a dose [of MAT], they’re interested in engaging in care.’ The provider on the other line says, ‘Yes,’” and says they have a spot for that person within three days after ER discharge, said Duber.
The University of Louisville Hospital, one of the region’s safety-net hospitals that sees many people who’ve overdosed, doesn’t give patients MAT in the ER, according to Dr. Martin Huecker, an emergency room physician at the hospital and an assistant professor.
In order to start giving MAT to patients, doctors like Heucker would have to get a special license to prescribe these MAT drugs that patients could get filled at a local pharmacy. It sounds easy enough, but physicians can only prescribe these drugs to a set number of patients at one time.
“I could theoretically, if I got the license, but the first year you can only have 30 patients, and after the first year you get to increase your patients,” Heucker said. “I could prescribe it out of the ER, a week’s supply to an ER discharge patient and they could follow up with any clinic in town, and continue on the MAT.”
Just since November, the U of L Hospital has seen hundreds of patients with opioid use disorder, so implementing an ER program for MAT prescriptions wouldn’t just take Heucker getting his license, but almost every ER doctor. The license takes around eight hours to complete, which is an investment in time and money from the hospital.
And in addition to that hurdle, it’s generally accepted as best practice to make sure a patient will have a place to go within three days of leaving the ER in order for MAT to be successful. Emergency rooms can dispense MAT to patients for three days, but patients have to be at an ER in-person, which means a costly hospital bill for treatment they could have received at a lower-cost clinic. Giving patients a short-term prescription for MAT while they wait for an appointment means that that patient is more likely to be in treatment for up to two months after ER discharge, according to the literature review.
For such a program to be successful here, ERs would need to build infrastructure to make sure patients get into treatment within three days, which would take coordination between area emergency rooms and opioid treatment providers.
“You have to have the infrastructure in getting them into outpatient treatment,” Huecker said.
Heucker said his team at U of L is in talks to create some sort of system to prescribe MAT. In the meantime, they’ve partnered with Centerstone, a MAT and substance abuse disorder provider, to send some people who want treatment straight into it when they leave the ER. The project started last November.
“A peer support specialist comes – usually someone who is sober and was dependent on opioids – and that person counsels the patients, offers to escort them a couple blocks over to Centerstone, and we’ve had a good amount of people take them up on it,” Heucker said.
So far the peer support specialist has talked to 334 people since November who were experiencing opioid withdrawl; about 100 of those people decided to go to Centerstone. Funding from a federal grant for the U of L partnership with Centerstone runs out in 2019.