We treat chronic disease in the ED; sometimes it's life-threatening; more often, it's not. No matter, we need to know which ED treatments, if any, improve long-term outcomes.
Consider a recent study on ED interventions for diabetes. Patients with type 2 diabetes and isolated hyperglycemia not on insulin and not followed by a diabetes clinic were randomized to one of three interventions: Patients were provided with contact information for a diabetes clinic (referral group), underwent a 15-minute interview and had an appointment made at a diabetes clinic (intervention group), or underwent a 15-minute interview, had an appointment made at a diabetes clinic, and were started on insulin in the ED (treatment group).
The authors found at two months that patients in the treatment group reported going to the diabetes clinics at a greater rate and consuming fewer carbohydrates than the other groups, but those differences vanished by six months. The treatment group was never more likely to engage in cardiovascular risk reduction and there were no differences in glycemic control as measured by HbA1c, the primary clinical outcome. Another negative study.
This study doesn't sound familiar? That's because it never happened.
But substitute opiate use disorder for diabetes, buprenorphine/naloxone for insulin, and urine drug screens for HbA1c, and it might sound more recognizable, like work done by the group led by Gail D'Onofrio, MD, at Yale on ED-initiated buprenorphine/naloxone for opioid use disorder. Despite press coverage to the contrary, this study never demonstrated any impact of ED-initiated buprenorphine on the only objective measure used to assess sobriety, the urine drug screen, nor were any other outcome differences sustained at six months. (JAMA 2015;313:1636; http://bit.ly/2PBwYWd; J Gen Intern Med 2017;32:660; http://bit.ly/2Cj0lbY.)
Despite this, I'm convinced that within the next five years buprenorphine will be routinely administered in EDs for opioid use disorder. Four drivers, the same ones that drove opiate prescriptions for chronic pain, risk forcing EDs to participate in the next opiate crisis, a crisis of substitution therapy. Properly harnessed, however, these same drivers could make small but important contributions to sustained sobriety.
- Research: No studies have demonstrated that ED-administered buprenorphine promotes sustained sobriety, but the practice has been embraced by the press, administrators, and community leaders.
- Finances: Insurance companies created financial incentives in the 1980s and 1990s to abandon multidisciplinary treatment for chronic pain and rewarded medication-only care. Insurance companies will likely reimburse ED buprenorphine but not the long-term medical and social care that sustain sobriety.
- Ease: Withdrawal medications (comfort packs) are complex, potentially dangerous, and a challenge to administer and prescribe. It's much easier to use buprenorphine to treat-and-street opiate use disorder patients.
- Legislation: Politicians often practice medicine through laws that restrict or compel elements of practice. Given the outcry about the opioid crisis, some legislators will support almost any solution. Influential groups that misapply research will lobby for legislators to compel EPs to provide buprenorphine.
But these factors could also positively influence care so that ED buprenorphine is an appropriate and effective practice.
- Research: Good research is needed to determine the most effective methods and locations for initiating buprenorphine. We also need research that proves that there aren't unintended consequences to ED buprenorphine.
- Finances: Health care payers should reimburse care demonstrated to sustain sobriety. Reimbursement for therapy, peer coaching, sober housing, and other nonmedicinal interventions coupled with the appropriate use of substitution therapy will keep us from falling into a pill-mill approach to Suboxone.
- Ease: Systems of wraparound care could make it more appropriate to give a patient in withdrawal a single dose of buprenorphine in the ED and get him into ongoing treatment than to use a comfort pack, but we need commitment from our continuity care colleagues to ensure timely access to full-spectrum medication-assisted therapy, preferably within 24 hours.
- Legislation: We physicians have tremendous power to influence legislation through direct contact with legislators, op-eds, and lobbying efforts by our professional organizations. We must promote laws that require insurers to pay for the full range of care that substance use disorder patients need. We should also support evidence-based legislation that eases administrative burdens for developing and maintaining these systems of care.
Opiate use disorder is a life-long disease. Treatment must prioritize sustained sobriety. Just as opiates alone were not the right solution for chronic pain, substitution opiates alone are not right for this disorder. Suboxone is only one element of sustained sobriety. We must not let it be a distraction from finding the best role for emergency departments in caring for these patients.