The opioid crisis in the United States continues to take center stage as the National Institute on Drug Abuse says more than 115 people die of an opioid overdose every day.
MADISON, Wis. — It happens every day: Emergency clinicians administer life-saving care to patients suffering from opioid overdoses.
Now physicians, counselors and agencies in Wisconsin are considering anti-addiction drugs as a first response in emergency rooms. Most emergency clinicians want to expand such medication-assisted treatment (or MAT), according to Wisconsin’s chapter of American College of Emergency Physicians.
“It weighs on you driving home after a night shift and someone didn’t make it, knowing society could have intervened and helped,” said Bobby Redwood, an emergency and preventive medicine physician.
Medication-assisted treatment is a proven method for successfully treating substance abuse disorders by combining anti-craving medicines such as buprenorphine or methadone with supportive counseling and behavioral therapy.
Anti-addiction drugs such as buprenorphine, a narcotic also referred to as suboxone, can diminish withdrawal symptoms for a patient in detox — an otherwise uncomfortable and challenging experience.
“A lot of the work we’re doing is figuring out: What does a community need to become buprenorphine ready and medication-assisted treatment ready?” said Redwood, a former president of American College of Emergency Physicians’s Wisconsin chapter.
More overdoses than ever
More people died nationwide of drug overdoses in 2017 than ever before — a staggering 10 percent increase in deaths compared to 2016. A high concentration of those deaths occurred in mid-Atlantic states and Midwestern ones like Wisconsin.
Wisconsin saw a 35 percent increase in fatal opioid overdoses between 2015 and 2016. Emergency department visits for overdoses were the highest in the nation, with an astounding 109 percent increase between 2016 and 2017, according to the Centers for Disease Control and Prevention.
But tough obstacles and many miles often separate those suffering with opioid addiction from reaching outpatient programs that provide medication-assisted treatment or a clinician who can prescribe buprenorphine.
For those vulnerable and in underserved areas, the ER is often the only access to health care, said Gail D’Onofrio, a professor of emergency medicine at Yale School of Medicine, in a statement.
D’Onofrio and her team received a grant of nearly $820,000 last year to develop a way for ERs to administer buprenorphine and overcome “bureaucratic and medical barriers to implementation.”
In a landmark study in 2015, D’Onofrio found patients who started on buprenorphine out of the emergency room were twice as likely to stick with treatment — and therefore twice as likely to avoid overdose —compared to those who received only references to local clinics.
Too few clinicians
Wisconsin also has a significant shortage of substance abuse disorder counselors, which has resulted in treatment programs and clinics unable to fill jobs, according to the Pew Charitable Trusts, an independent research organization.
Prior to 2017, only physicians could prescribe buprenorphine and similar MAT drugs.
To close this gap, Gov. Scott Walker signed a measure into law allowing physician assistants and nurse practitioners to prescribe buprenorphine if they completed additional training.
Opponents of medication-assisted treatment point to the controversy of treating drug addiction with other drugs. The extra training is required to ensure prescribers understand the anti-addiction drug, the addiction process and how to treat it.
“It’s different than prescribing for pain,” said Toni Simonson, executive director of HSHS Western Wisconsin and Prevea Behavioral Care. “It’s prescribing for addiction.”
These physician assistants and nurse practitioners have a unique opportunity to identify people with substance abuse disorders who come into their primary care offices or emergency rooms, according to Sam Spencer, a PA working in addiction medicine.
“There’s a lot of little towns and physician assistants in the ER who understand addiction and want to do the best for their patients, which is starting them on suboxone,” Spencer said.
Although some states are experimenting with buprenorphine as an emergency service, implementing something similar in Wisconsin may take longer.
To administer medication-assisted treatment, emergency departments must follow clinical protocols to ensure patients receive the behavioral or counseling component of treatment.
On its own, buprenorphine is not as effective at treating addiction if a patient can’t follow up with a behavioral health counselor.
“I think a lot of our workforce feels hamstrung because they don’t have those behavioral health and primary care follow up resources,” said Redwood, the emergency and preventive medicine physician.
“Not because they’re not motivated, but because it doesn’t exist in their county.”
Emergency room providers are also concerned that incorporating addiction services could draw more people detoxing to an already crowded ER.
One idea: Require a follow-up
Melissa Malloy, PA at Waukesha Memorial Hospital and an ardent supporter of such treatment, says it can take hours to treat patients in withdrawal, which fills up beds needed by patients suffering heart attacks or strokes.
“In general, we try everything we can to keep people out of the ER,” Malloy said. “Because we see so many non-emergent situations in the ER and, truth be told, opioid withdrawal isn’t a life-threatening issue.”
Malloy suggests ER providers adopt a policy requiring patients to follow up with an addictionologist for further MAT within a set number of days to discourage coming back to the ER for additional prescriptions.
In December, the ER at ProHealth Oconomowoc Memorial Hospital did just that.
A patient in withdrawal at Oconomowoc’s ER was assessed and started on medication-assisted treatment with a dose of suboxone. He was referred to a program at Rogers Memorial Hospital the next day.
Though other hospitals may operate on the similar model, there is currently no cohesive state-wide plan for implementing MAT.
Redwood cites the need to secure funding and create a unified strategy.
“Our workforce is ready and willing and anxious to adapt a statewide plan,” he said.
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