Addiction is an emergency: end waiting for services and expand access to life-saving drugs
The pandemic landscape has exacerbated the scale of the opioid crisis and challenged the responsiveness of our health infrastructure. More than 93,000 people died of an overdose in 2020, 30 percent more than in the previous year and the highest number since the federal government declared a health emergency in 2017. 2021 is well on the way to being the deadliest year for the opioid crisis in the United States.
When a patient seeks help in the fight against addiction, it can be a fleeting moment on the scale of an emergency. A groundbreaking 2015 study identified visits to the emergency room as ways to significantly expand access to buprenorphine treatment for opioid use disorder (OUD). Buprenorphine is a highly potent Food and Drug Administration-approved drug that blocks food cravings and withdrawal symptoms, and helps prevent relapses and overdoses. Currently, the 5,000 emergency rooms operating in acute hospitals nationwide are a critically missing part of the addiction treatment infrastructure. Treatment is not the current standard of care for patients with OUD in emergency rooms; However, it works and can be replicated in any hospital setting – rural, urban, small, large, academic, critical access.
California used its first round of federal opioid response grants in 2018 to invest in expanding access to treatment for OUD through ED visits through a program called CA Bridge. An evaluation of the program found that of 12,000 people diagnosed with OUD in emergency rooms across the state, 60 percent were receiving evidence-based addiction treatment (MAT) and 40 percent were in follow-up appointments, compared to studies that found follow-up rates for participants control groups range from 7.6 percent to 37.0 percent. Aside from the impact of the program on patients, all 52 participating hospitals reported continuing the model eight months after completing formal funding.
We believe that California’s ED-based approach to expanding access to OUD treatment could be rolled out to emergency rooms nationwide with some significant changes to policy and payment practices.
Addiction as an Emergency: Breaking the Status Quo
Addiction is a treatable chronic disease, and like other chronic conditions, addiction if left untreated is life-threatening. Similar to myocardial infarction, the risk of death increases in the days, months, and years after a non-fatal overdose. But we often don’t treat addiction with the same urgency.
Wherever we work in California, the overdose epidemic has reached unprecedented proportions, with 5,000 deaths related to opioid overdose in 2020. Almost 75 percent of these deaths are attributed to increased fentanyl levels in drug supplies. In particular, at the start of the pandemic in the eighth month of 2020, the city of San Francisco recorded 537 deaths from drug overdoses and only 169 from COVID-19.
Central research has found that when the drug buprenorphine is administered in the emergency room and continued through primary care, patients have a 74 percent chance of receiving treatment after two months, compared to only about 50 percent who only received psychosocial treatment Intervention remain in treatment. No other setting is able to replicate the 24/7 access and services of an emergency room. Emergency rooms are increasingly the entry point for vulnerable populations and have developed strategies to address social determinants of health through social workers and other connections, provide acute psychiatric stabilization, and offer case management – in addition to same-day treatment for OUD with buprenorphine. However, this life-saving, evidence-based MAT is only now becoming widely available in California while the rest of the nation is lagging behind. Providers, hospital systems, and government leaders in more than 30 states have consulted with CA Bridge, but no other state has introduced such widespread access to treatment directly from the emergency room.
To make matters worse, access to this treatment can be expanded, the federal government is still requiring a special buprenorphine prescription waiver known as the “X-Waiver” that providers fill out on an opt-in basis. Although the Drug Abuse and Mental Health Authority lifted an eight-hour mandatory training course in May 2021 to get the X exemption, this regulatory move still acts as a barrier.
A nationwide representative observational study found that between 2014 and 2018, the number of visits to the emergency room for both alcohol and substance use disorders generally increased, totaling 1 in 11 emergency rooms and 1 in 9 hospital stays. The increase in addiction-related emergency visits, coupled with the growing evidence base for the effectiveness of MAT, means that addiction treatment can no longer be a niche industry operating on the edge of the broken health system.
Treatment should begin in the emergency room
Without a MAT program, many patients presenting to the emergency room after an overdose or seeking help with an addiction are turned away or faced with the “treat them and the streets” approach. A recent study shows that fewer than 20 percent of patients in need are receiving drug treatment for an opioid use disorder, although there is strong evidence that drugs can be effective in reducing overdoses and all-cause mortality in OUD.
The integration of patient navigators in an emergency room to work with substance use patients is also a successful strategy for initiating treatment in this environment. The CA Bridge model has successfully implemented the large-scale use of navigators to connect ED patients to outpatient treatment options.
Evidence invalidates myths about addiction treatment
Research on CA Bridge’s large-scale MAT implementation breaks down common but incorrect assumptions about the implementation of addiction treatments in the hospital setting, including:
Myth 1: Emergency rooms don’t have the bandwidth
CA Bridge hospitals quickly adopted new protocols to initiate treatment for addiction. Nearly 80 hospitals with significant differences in ED volume, urbanity, racial / ethnic demographics, and payer mix submitted applications to implement a CA Bridge program in 2018, 334 eligible EDs applied – even though the application was in the middle of the first COVID-19 Rise in the state was due. And that interest isn’t limited to California. In less than two years, CA Bridge has received interest from hospitals and public health authorities in more than 30 states looking to also start MAT programs from emergency physicians.
Myth 2: Feasibility depends on the type of hospital
The CA Bridge program study concluded that there were no significant differences between participating hospitals based on hospital location (rural versus urban) or teaching status (clinical teaching hospital versus community hospital). This seems to suggest that attitudes towards MAT and related drugs are becoming less stigmatized in all hospital settings and that programs can be successful in hospitals of all resource levels.
Myth 3: Patients Don’t Choose MAT
CA Bridge’s implementation of MAT in emergency rooms resulted in 12,009 patients being identified between May 2019 and June 2020. Of these, 59 percent (7,179) received buprenorphine before leaving the emergency room. In other words, more than 7,000 people chose treatment when given the option of an emergency room.
Myth 4: MAT has nothing to do with equity concerns
Despite the fact that MAT is recognized as the standard of care in addiction care facilities, previous studies have shown that access to buprenorphine is uneven among demographic groups of people seeking MAT. Patients treated with buprenorphine are unlikely to be black, have statutory health insurance, live in low-income zip codes, or have concurrent mental disorders. Giving patients the opportunity to seek direct treatment for OUD in an emergency room, whether as initial treatment, resumption of treatment, or prevention of drop-out, creates a level playing field for access to medical care and reduces the likelihood of inequalities in access and poor outcomes due to structural racism that affects patients have access to MAT.
Further research shows that many patients will actually seek addiction treatment from a hospital emergency room if they can. The ED-based model for MAT can traditionally reach underserved patients and makes MAT easier for those with socio-economic disadvantages. Patients with unstable housing and Medicaid coverage were also more likely to get MAT in a hospital than wealthier populations who have more options for that care.
As overdose rates continue to rise in the United States, treatment models like CA Bridge offer a scalable strategy to reach those at highest risk who cannot receive drug treatment in a traditional setting. We urge policymakers to consider the following recommendations:
1. Obtain Disclaimer X in order to receive hospital staff privileges
As long as an X-Wavier is required to prescribe buprenorphine, we believe that obtaining the X-Waiver license to prescribe buprenorphine should be required for emergency physicians seeking privileges in acute hospitals, rather than remaining a voluntary act . Doctors seeking privileges to work in hospitals already go through a thorough licensing process. Rather than adding to the paperwork, this request only takes a few minutes and ensures the doctor is ready to provide evidence-based treatment.
2. Link the induction of buprenorphine to the hospital quality metrics
Currently, quality metrics for ED visits for substance use disorders group all types of drug use diagnoses into one HEDIS metric. We call on the National Committee for Quality Assurance to add quality metrics that measure opioid use disorder patients who start on buprenorphine, who leave the hospital on a buprenorphine prescription, and who are co-prescribed with naloxone.
3. Add reimbursement mechanisms for screening, brief intervention and referral to treatment (SBIRT) from the emergency room and for dedicated substance use counselors and peer support
SBIRT is currently only billable in the basic service. We urge Medicaid government programs to reimburse SBIRT services provided in the emergency room as the number of patients receiving treatment there is being used. We encourage further reimbursements for peer support services and care navigation provided by emergency department staff at levels that support fair wages for those staff.