The emergency department may be, for many patients, a last-resort source of care. But the ED is showing potential as a starting point for people to receive coordinated treatment for opioid-use disorder.

Medication-assisted treatment (MAT) is initiated in the ED at Washington University Medical Center (WUMC) in St. Louis, where emergency physicians can write an initial buprenorphine prescription and then link patients to local treatment programs via an established referral network.

The WUMC program was implemented in January. The most important part, and maybe also the hardest, was establishing the relationships needed to build the referral network, said Evan Schwarz, MD, assistant professor of emergency medicine at the Washington University School of Medicine.

“The first step for emergency departments and hospitals is to figure out what facilities are in your area and establish that connection,” said Dr. Schwarz, who is also WUMC’s medical toxicology section chief.

Yale program provides model

WUMC’s program is patterned after the one started at Yale New Haven Hospital in 2009. At Yale, ED patients exhibiting signs of opioid withdrawal were referred to a treatment program and given enough buprenorphine to last until they could schedule an appointment with the referred program.

A study published in 2015 in JAMA showed a positive outcome. In a randomized trial involving 329 patients between 2009 and 2013, 75 percent of those who received buprenorphine and a referral were still engaged in treatment after 30 days, compared with 37 percent who were referred to a program but not given a prescription.

“It’s a model people can copy or change to meet their needs and be successful,” Dr. Schwarz said.

The early results at WUMC show promise, Dr. Schwarz said. He noted that pairing buprenorphine with counseling is a winning combination, in part, because it removes a reason for patients to self-medicate.

“If patients are not treated and they’re in withdrawal, their motivation is to get out of withdrawal,” Dr. Schwarz said. To do this successfully, a combination of providing physical relief and easing psychological fears is required, he added.

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Another opioid-reduction strategy at WUMC was to develop order sets and order bundles that include non-opioid pain-treatment choices such as Lidocaine or nerve blocks.

“It doesn’t do any good to tell others not to use opioids, but then don’t say what the alternatives are,” Schwarz said. “This gives a nice list of options.”

One challenge to establishing a successful ED program to initiate MAT may be having enough physicians certified to provide ongoing treatment, Dr. Schwarz said. That problem exists despite a dramatic increase in the number of certified physicians nationwide, with more than 37,000 as of this year, according to the Substance Abuse and Mental Health Services Administration.

The AMA favors ending this federal regulatory barrier to buprenorphine. In an Oct. 25 statement provided to the U.S. House Committee on Energy and Commerce, the AMA told Congress that removing the certification requirement would provide patients with new access to treatment. “The safety and effectiveness of MAT is well-established, and we need to do all we can to encourage more qualified clinicians to care for patients with an opioid-use disorder,” the AMA said.

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