Every contact with a medical provider is an opportunity to help someone address their addiction. And so, it is important for everyone who works in a healthcare setting to recognize addiction, understand the neurobiology, know the standard treatments and be familiar with the resources available through the addiction specialty system. Many people who share their experiences of addiction with me tell me that it was one person, who was there at a critical time, who influenced them to better understand their addiction and to take steps to change. The current opioid epidemic is highlighting the problems that occur when medical staff do not have this training and the opportunities when they do.
People in crisis often present to emergency departments for an overdose or for medical complications of using substances. Early in the opioid epidemic, emergency room staff were not trained in the use of buprenorphine to treat withdrawal and not aware of the success that it has in helping initiate people to longer term care (2017 D’Onofrio). Because of this, people who were successfully revived from an overdose with the lifesaving medication (naloxone) were often discharged in serious withdrawal without a referral to a treatment provider. Without training in identifying and understanding addiction, it is easy to understand why people could blame the patient for the very likely continued opioid use, seeing the patient as unmotivated and choosing a dangerous and destructive lifestyle.
There were several efforts happening around the country and in New York Work that influenced care in emergency settings. Work done at Yale by Kathryn Hawk, Md MHS and Gail Donofrio, MD, showing that initiating buprenorphine in the emergency department is effective at engaging people into care and this work was noticed by several emergency rooms in New York State, as well as, early adopters, including Ross Sullivan, MD, at Upstate Medical in Syracuse NY, who championed the development of ED protocols. The state passed legislation in 2019 requiring emergency rooms to provide treatment directly or by referral to people in an opioid crisis and support a transition to ongoing care. Families and patients advocated for appropriate treatment and OASAS funded four emergency room and treatment provider collaborations with State Opioid Response funding. Through other initiatives, OASAS supported peers from community providers to meet with people in emergency departments and in other community settings. These forces helped drive innovations in the delivery system and to move us to where we are today. In many emergency rooms a person in withdrawal from opioids can expect to be treated by a medical professional who understands the neurobiological power of addiction, the neuroprotective effects of buprenorphine and the importance of peer supports during an addiction crisis for both families and patients. The goal is to have this type of care available in all emergency and medical settings.
We still have a long way to go. The crisis has spurred many physical health settings to better recognize and understand opioid addiction and its treatment, but stigmatizing beliefs remain. Not all settings have a champion and I still hear stories of people in painful withdrawal minimally treated and misunderstood in some emergency and primary care settings. Until addiction is as easily identified and medical professionals are as comfortable treating addiction as they are taking blood pressure, we have work to do.
I believe the experiences we have had in this effort, can help move us closer to better integration for all forms of substance use, even when the specific substance has less clear medical treatment protocols. Relationships between addiction experts, recovery support providers and medical providers have become stronger and these relationships can serve as a foundation for improving integrated care across all settings. Now that peers from community providers are available in medical settings, to assist with treatment engagement, real-time scheduling solutions are being developed to better connect treatment providers, and there are ECHO-like learning models for sharing expertise, they can be used to better integrate screening and brief intervention models for alcohol use disorder and engagement strategies for people who have a crisis related to cocaine misuse. The crisis has caused so much pain to our communities and the people we serve. Let’s build on the opportunities that it has brought to provide better, more integrated care.
D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA. 2015;313(16):1636–1644. doi:10.1001/jama.2015.3474