The Only Wrong Door to Treatment Is a Revolving Door

Stories that caught our attention this week

: Dr. Andrew Herring of Highland Hospital in Oakland, Calif., left, gave a dose of buprenorphine, a drug that eases the symptoms of opioid withdrawal, to a homeless man who collected cans to pay for bus fare to get to the hospital.
Andrew Herring, MD, of Highland Hospital in Oakland, left, gives a dose of buprenorphine to ease the symptoms of opioid withdrawal for a homeless man who collected cans to pay for bus fare to get to the hospital. Photo: Brian L. Frank/The New York Times/Redux

We begin with a sobering statistic: The US Centers for Disease Control and Prevention estimates that more than 72,000 people died from drug overdoses in 2017, up from 64,000 people in 2016.

As German Lopez writes in Vox, that would mean “drug overdoses in 2017 killed more people than guns, car crashes, or HIV/AIDS ever killed in a single year in the US. As with the previous year, the 2017 death toll is higher than all US military casualties in the Vietnam and Iraq wars combined.”

Experts say that the increase in overdose deaths can be attributed to two major factors: the rise of fentanyl, a synthetic opioid thatEssential Coverage is 50 to 100 times stronger than morphine, and the growing number of Americans using opioids. At least two-thirds of drug overdose deaths in 2016 and 2017 were related to opioids. With this increase in usage comes an increase in visits to emergency departments (EDs), which are on the front line of the opioid crisis.

Every day, EDs treat people who have overdosed on opioids or are suffering from withdrawal symptoms. For the latter group, EDs focus on relieving patients’ symptoms before referring them to addiction treatment services and then discharging them. But this strategy doesn’t address the underlying disease of addiction, which can make EDs a revolving door for people with opioid addiction. What if EDs took these patient encounters one step further and worked to prevent future visits by initiating addiction treatment before patients leave the facility?

EDs Promote a “No Wrong Door” Approach

The ED in Oakland’s Highland Hospital is doing just that. In a New York Times feature, Abby Goodnough profiles Andrew Herring, MD, an emergency medicine specialist who runs Highland Hospital’s innovative buprenorphine program. The California Health Care Foundation funds this program, known as ED-Bridge. It’s among the first in the country to provide buprenorphine, a Food and Drug Administration-approved medication that treats withdrawal and cravings, at a critical point of intervention. When patients in withdrawal show up at Highland Hospital’s ED, Herring’s team offers them a dose of buprenorphine and refers them to an addiction treatment clinic for monitoring and to a primary care clinic for ongoing care.

Not all patients who are offered buprenorphine accept it, but for those who do, this intervention is a vital first step toward recovery. Herring told Goodnough, “With a single ED visit we can provide 24 to 48 hours of withdrawal suppression, as well as suppression of cravings.” It can take many tries to get a patient started on treatment, but those who try buprenorphine in the ED are more likely to follow up with further treatment.

Herring was inspired to establish the program at Highland after he read a 2015 study out of Yale-New Haven Hospital that found “addicted patients who were given buprenorphine in the emergency room were twice as likely to be in treatment a month later as those who were simply handed an informational pamphlet with phone numbers.”

Appointments are the enemy of homeless people.

—Barry Zevin, MD

ED physicians are uniquely positioned to initiate medication-assisted treatment with patients because, unlike clinicians practicing in other settings, they are exempt from the special training that the Drug Enforcement Administration (DEA) requires physicians to obtain prior to prescribing. The DEA permits ED physicians to administer buprenorphine “to a person for the purpose of relieving acute withdrawal symptoms when necessary while arrangements are being made for referral for treatment. . . . Such emergency treatment may be carried out for not more than three days and may not be renewed or extended.” (Emphasis added.)

Clinicians who prescribe buprenorphine (i.e., writing a prescription to be filled at a pharmacy) as opposed to administering it (i.e., giving the medication in a setting like an ED) must complete an eight-hour buprenorphine waiver training program. There is a national shortage of buprenorphine prescribers, in part because of the strain the training time places on busy physicians. Furthermore, some doctors are reluctant to treat patients who are addicted to opioids because they fear they may attract too many patients with addiction, though this has proven not to be the case for EDs starting this practice. Goodnough reports in another New York Times article that only about 5% of the nation’s doctors are licensed to prescribe buprenorphine, despite substantial evidence that it works for opioid addiction care. These California county snapshots show the treatment gap across the state.

California Prioritizes Funding for Medication-Assisted Treatment

California is trying to address this crisis by embedding addiction treatment in all points of care — primary care, hospitals, jails, residential treatment, mental health clinics, maternity care, and EDs. ED-Bridge is already operating in eight California hospitals, and the state recently announced $4 million to expand the program to 24 new EDs as part of a $138 million addiction treatment funding package.

There is growing recognition that jails can help address the broader opioid crisis by getting inmates started on addiction treatment while they are still incarcerated. The Justice Department estimates that one in five jail and prison inmates has used heroin or opioids, and Anna Gorman writes in the Washington Post that “some research has shown that providing [medication-assisted treatment] is effective at reducing both the likelihood of relapsing on drugs and returning to jail.” California recently launched a program to embed medications for addiction treatment — including methadone and buprenorphine, both of which have proven to cut overdose mortality by 50% or more — in 23 of its county correctional systems.

The City and County of San Francisco is spending $6 million over two years to find homeless people with opioid use disorder and offer them buprenorphine prescriptions on the street. This is the city’s attempt to meet patients where they are. “Appointments are the enemy of homeless people,” Barry Zevin, MD, medical director of Street Medicine and Shelter Health for the San Francisco Department of Public Health, told Goodnough. “On the street there are no appointments, and no penalties or judgments for missing appointments.”

As California implements these medication-assisted treatment programs in diverse settings, it is sending a message that it hopes other states will learn: When it comes to addiction treatment, there is no wrong door.

How is your community responding to the opioid crisis? Tweet at me with #EssentialCoverage or email me.