Advocates eye increased ER addiction treatment
Programs test ways to provide patients with follow-up care
For years, Kayla West watched the opioid epidemic tear through her eastern Tennessee community. As a psychiatric nurse practitioner, she treated people with mental illness but felt she needed to do more to address addiction.
So in 2020, when the state created a position to help hospitals improve addiction care in the emergency room, West jumped at the opportunity.
She knew that many people with substance use disorders land in the ER, and that starting medications for opioid use — like buprenorphine (brand name Suboxone) — could double a person’s chance of staying in treatment a month later. Yet she also knew that providing the medication was far from standard practice.
A recent report from the Legal Action Center and the Bloomberg American Health Initiative found that despite widespread consensus on the importance of addiction treatment in the ER and an unprecedented rise in overdose deaths, many hospitals fail to screen for substance use, offer medications to treat opioid use disorder or connect patients to follow-up care.
Many patients who don’t receive those services die shortly after discharge or within a year of their ER visit, the report said.
But a growing number of emergency rooms and health professionals are trying to change that by developing new approaches to address the missed treatment opportunity in ERs.
“We know it’s possible because others have done it,” said Sika YeboahSampong,
an attorney with Legal Action Center and co-author of the report. “You have a combination of levers and kinds of structures of how different cities, counties, states and even independent hospitals adopt these practices.”
These models have already been put in place in some big hospitals and small hospitals, rural areas and urban centers, those with ample resources and those on tight budgets, she said.
In Tennessee, West looked to several of them for helpful guidance as she developed a pilot program with one hospital she advises. Here are a few of the strategies emerging from ERs across the U.S.
Advocating for the patient:
Daniel Browne started drinking alcohol and using prescription opioids at age 14. By the time he was 24, he was on the verge of losing his job, his car and his apartment.
“I didn’t know where else to go to get treatment other than the ER,” he said.
In May 2020, Browne drove to Adventist Health Howard Memorial Hospital
in Willits, California, where he was immediately met by Mary Anne Cox Gould. At the time, Cox Gould was a substance use navigator for a program called CA Bridge. She championed addiction treatment in the hospital and helped connect patients from the ER to clinics in the community.
She stayed with him as he received his first dose of buprenorphine, which provided immediate relief from withdrawal symptoms. “Once you’re not facing the crippling detoxification, it’s much easier to not relapse,” Browne said.
Cox Gould then walked him over to the hospital’s outpatient clinic and helped him schedule recurring appointments. When Browne ran into obstacles filling his buprenorphine prescription at a pharmacy, she made all the necessary arrangements for him to get it from the hospital.
Now more than a year into recovery, Browne said he’s become a more reliable employee and has reconnected with his parents and younger brother — successes he credits partly to the medication and
consistent support he has received.
Those are hallmarks of the CA Bridge program, said executive director Serena Clayton. Medication is considered a key element of treatment. Connecting patients with a navigator helps them in long-term recovery. And having navigators in the ER creates a more welcoming environment for patients, and gives ER staff a chance to learn more about addiction, she said.
Removing obstacles:
Patients with addiction face many barriers to recovery, said Dr. Joshua Lynch, an associate professor of emergency medicine at the University at Buffalo in New York. But doctors who want to help them also encounter hurdles, he said.
ER physicians are short on time, often lack training for addiction-related issues and don’t know where to refer the patients for follow-up care. To improve the situation, both sets of barriers — for patients and for doctors — must be addressed, Lynch said.
That was his goal in creating New York
MATTERS, a program that gives patients access to buprenorphine and links them to addiction clinics to continue treatment. It also provides pharmacy vouchers that cover 14 days of medication and Uber vouchers to cover transportation to the clinic — all through an electronic referral system.
Lynch estimated about 55% of patients in the program make it to their first appointment, where they can receive medication and therapy. National figures suggest fewer than 10% of patients addicted to opioids receive similar treatment.
Dr. Blake Fagan is chief education officer at the Mountain Area Health Education Center in Asheville, North Carolina. For years, when he approached hospital ERs to offer addiction training, he heard a common refrain. “We don’t have any place to send patients afterwards,” he said doctors told him.
Without a clear place for patients to continue treatment, the doctors were reluctant to even start medications for opioid use. That’s when Fagan and his colleagues realized their training had to extend beyond hospitals.
They reached out to federally qualified health centers, which treat people regardless of insurance status. Using just over $1 million in grant funding, the Mountain Area Health Education Center trained 11 health centers and two local health departments to provide medications for opioid use disorder. From March 2020 to May 2021, those centers treated more than 400 patients with the disorder.
North Carolina also has programs to train medical students, residents, nurse practitioners and physician assistants in addiction care.
Dr. Sara McEwen,
Training everyone:
executive director of the nonprofit Governor’s Institute, which has helped to incorporate the training into medical school curricula, said students who see addiction prevention and treatment as a routine part of medicine will naturally apply that when they reach the ER or other clinical settings.
Measuring success: Across these varied models, one essential question remains: Do they work?
Unfortunately, it’s also one of the most challenging to answer. Many projects are still in the early phases and won’t be able to measure success for another few years. Others are struggling to gather long-term data that’s necessary for evaluation.
In North Carolina, McEwen knows more than 500 medical students receive the addiction training each year, but until they complete residency and practice on their own, it’s difficult to gauge how many will prescribe buprenorphine to their patients.
In New York, Lynch can estimate how many patients make it to their first appointment at a clinic, and a recent study of the CA Bridge program tracked how many patients were given buprenorphine across 52 hospitals. But those numbers don’t indicate how many patients achieved longterm recovery. That would require tracking patients for months and years.
In the meantime, people like West who are looking to these models as guideposts must operate with a level of uncertainty. But she said she’d rather get started now than wait for the perfect solution.
“Any movement on this is a step in the right direction,” West said. “I’ve learned that no matter how varied your resources are, there are options for change in your ER.”