Emergency Medicine Providers

 

A hospital or emergency department may be the only place a patient with substance use disorder (SUD) receives health care. In some instances, this will be for an overdose, and in other cases, it may be for an injury or infection related to their substance use. This makes the hospital a critical intervention point for engaging people with SUD and linking them to treatment.

 

 

The opioid epidemic has resulted in rapidly escalating utilization of health system inpatient and emergency medical services. Between 2005 and 2014, the national rate of opioid-related inpatient stays increased 64.1 percent and the national rate of opioid-related emergency ED visits increased 99.4 percent. Recent data from the Centers for Disease Control and Prevention (CDC) show that this trend has continued. In sixteen states reviewed by the CDC, ED visits for suspected opioid overdoses increased 30 percent from July 2016 through September 2017.

 

We know that patients who have had a non-fatal overdose are at heightened risk for fatal overdose and need treatment for SUD. Recognizing the critical need for ED interventions for patients with SUD, the Addiction Policy Forum launched its Emergency Medicine Initiative to support health systems and patients. With the necessary protocols, assessment tools, and referral paths, a non-fatal overdose can become an intervening opportunity for connection with treatment and recovery.

 

6 Principles for Emergency Departments to Respond to Addiction

  • Electronic Health Record

    For Patients with Suspected Opioid Overdose or Opioid Addiction

    Purpose


    This language can be incorporated into Epic, Cerner, or MEDITECH electronic health records to provide patients with important information about opioid addiction, harm reduction, and substance use disorder treatment.


    Patients who may benefit from this information include:


    1. Patients who come to the ED for treatment of a suspected opioid overdose,

    OR

    2. Patients who screen positive for potential opioid misuse or addiction,

    OR

    3. Patients who inform clinical staff that they are addicted to opioids.

    Language for EHR

    “Everyone should carry naloxone (Narcan), which reverses opioid overdoses and saves lives. You can get naloxone in pharmacies in [jurisdiction] without an individual prescription [if your jurisdiction has a standing order.]

     

    Learn more about naloxone and ways to stay safe and healthy at AddictionResourceCenter.org

     

    Please call [local crisis line number] if you are concerned about your substance use or addiction.”
  • Discharge Protocol

    For Patients with Suspected Opioid Overdose or Opioid Addiction

    Patient Criteria

    This discharge protocol applies to patients who meet the following criteria:


    1. Patients who come to the ED for treatment of a suspected opioid overdose,

    OR

    2. Patients who screen positive for potential opioid misuse or addiction,

    OR

    3. Patients who inform clinical staff that they are addicted to opioids.


    Discharge Protocol

    Upon discharge, patients meeting the above criteria should receive the following 3 items:

    1. Overdose reversal instructions,

    2. Two doses of naloxone if available,

    3. Flyer with information about addiction, treatment, and locally available services.

 

Initiating Medication Assisted Treatment

Patients are at heightened risk of overdose following a period of abstinence and loss of tolerance, and any course of detoxification should always be followed by ongoing treatment.

 

Medication Assisted Treatment (MAT) with behavioral counseling and buprenorphine (Suboxone®, Subutex®), methadone, or extended-release naltrexone (Vivitrol®) is an evidence-based best practice for treating opioid use disorder. MAT has been found to decrease opioid use, opioid-related overdose deaths, criminal activity, and infectious disease transmission. When patients and physicians were surveyed by SAMHSA about the effectiveness of buprenorphine, they reported an average of an 80% reduction in illicit opioid use, along with significant increases in employment and other indications of recovery.

 

Buprenorphine treatment can be initiated in the Emergency Department. Physicians, nurse practitioners, and physician assistants who have obtained DATA 2000 waivers can prescribe or dispense buprenorphine on an ongoing basis, while the “3-day-rule” under Title 21 C.F.R. § 1306.07(b) allows an un-waivered physician to administer (but not prescribe) buprenorphine to a patient for the purpose of relieving acute withdrawal symptoms while arranging for the patient’s referral for treatment, under the following conditions: no more than one day’s medication may be administered or given to a patient at one time; this treatment may not be carried out for more than 72 hours, and this 72-hour period cannot be renewed or extended.

 

A 2015 randomized clinical trial conducted by researchers at the Yale School of Medicine tested the efficacy of three interventions for patients with opioid use disorder: screening and referral to treatment; screening, brief intervention, and facilitated referral to treatment; and screening, brief intervention, ED-initiated buprenorphine and referral to office-based buprenorphine treatment within 72 hours. Depending on the level of severity of their opioid withdrawal symptoms as indicated by the Clinical Opiate Withdrawal Scale, patients in the buprenorphine group either received their first dosage while in the Emergency Department or were provided medication and instructions for at-home induction. 78% of patients in the buprenorphine group were engaged in treatment 30 days later, a significantly higher rate than the other two groups.

 

Resources:

 

Sample ED Workflows

Mosaic Workflow ED Workflow