Addiction Is An Emergency: End Wait Times For Services And Expand Access To Life-Saving Medications - Health Affairs
The pandemic landscape has exacerbated the magnitude of the opioid crisis and challenged our health care infrastructure’s ability to respond. More than 93,000 people died from an overdose in 2020, 30 percent more than the previous year and the highest number since the federal government declared a public health emergency in 2017. Fueled by a rise in non-prescription opioids, namely heroin and illicit fentanyl, 2021 is on track to be the deadliest year on record for the opioid crisis in the United States.
When a patient seeks help in battling addiction, it can be a fleeting moment with the magnitude of an emergency. A ground-breaking 2015 study identified emergency department (ED) visits as opportunities to greatly expand access to opioid use disorder (OUD) treatment with buprenorphine. Buprenorphine is a highly effective Food and Drug Administration-approved medication that blocks cravings and withdrawal symptoms and helps to prevent relapse and overdose. Currently, the 5,000 EDs operating within acute care hospitals nationally are a critical missing piece of addiction treatment infrastructure. Treatment is not the current standard of care for patients with OUD in EDs; however, it works and can be replicated within any hospital setting—rural, urban, small, large, academic, critical access.
California used its first round of federal State Opioid Response grants in 2018 to invest in expanding access to treatment for OUD through ED visits through a program called CA Bridge. An evaluation of the program found that of 12,000 people identified with OUD at EDs across the state, 60 percent received evidence-based medication for addiction treatment (MAT), and 40 percent attended follow-up appointments, compared to studies that found follow-up rates for participants in control groups range from 7.6 percent to 37.0 percent. Beyond the program’s patient impact, all 52 participating hospitals reported that they had continued the model eight months after the conclusion of the formal funding.
We believe that California’s ED-based method of expanding access to OUD treatment could be expanded to emergency departments nationally with a few substantial changes in policy and payment practices.
Addiction As An Emergency: Interrupting The Status Quo
Addiction is a treatable chronic disease and like other chronic ailments, untreated addiction is life-threatening. Similar to myocardial infarction, the risk of death increases in the days, months, and years following a non-fatal overdose. But we often don’t treat addiction with the same urgency.
Where we work in California, the overdose epidemic has reached an unprecedented level, with 5,000 deaths in 2020 related to opioid overdose. Nearly 75 percent of these deaths are attributed to increased fentanyl in the drug supply. Notably, the city of San Francisco recorded 537 deaths from drug overdoses and only 169 from COVID-19 during an eighth-month period of 2020 during the beginning of the pandemic.
Pivotal research has found that when the medication buprenorphine is administered in the ED setting and continued via primary care, patients have a 74 percent chance of remaining in treatment after two months, compared to only about 50 percent who remain in treatment after psychosocial intervention only. No other setting is able to replicate the all-hours access and wrap-around services of an ED. EDs increasingly are the access point for vulnerable populations and have developed strategies to address social determinants of health through social workers and other linkages, provide acute psychiatric stabilization, and offer case management—in addition to same-day buprenorphine treatment for OUD. Yet, this lifesaving, evidence-based MAT is only just now becoming widely available in California, with the rest of the nation lagging behind. Providers, hospital systems, and state leadership in more than 30 states have sought guidance from CA Bridge, but no other state has yet to implement such widespread treatment access directly from the ED.
Compounding the difficulty of expanding access to this treatment, the federal government still requires a special waiver to prescribe buprenorphine, known as an “X waiver,” which providers complete on an opt-in basis. Although the Substance Abuse and Mental Health Services Administration removed an eight-hour education requirement to obtain the X waiver in May 2021, this regulatory step still functions as a barrier.
One nationally representative observational study found that visits to the ED increased for both alcohol use disorder and substance use disorders more generally between 2014 and 2018, making up 1 in 11 ED visits and 1 in 9 hospitalizations overall. The increase in addiction-related ED visits coupled with the growing evidence base for the effectiveness of MAT, means that addiction treatment can no longer be a niche industry operating on the fringes of the fractured health care system.
Treatment Should Begin In The Emergency Department
Without a MAT program, many patients who present to the ED post-overdose or seek help for addiction are turned away or faced with a “treat them and street them” approach. One recent study shows that fewer than 20 percent of patients in need receive medication treatment for opioid use disorder, despite strong evidence that medication can be effective in reducing overdoses and overall mortality for OUD.
Incorporating patient navigators into an ED to work with patients with substance use is also a successful strategy for initiating treatment in this setting. The CA Bridge model has successfully implemented the use of navigators at scale to link ED patients to outpatient treatment options.
Evidence Busts Myths About Addiction Treatment
The research on large-scale MAT implementation by CA Bridge breaks down commonly held but incorrect assumptions about implementing addiction treatment within the hospital setting, including:
Myth 1: Emergency Departments Don’t Have The Bandwidth
CA Bridge hospitals rapidly adopted new protocols to initiate treatment for addiction. Nearly 80 hospitals with significant variation in ED volume, urbanicity, racial/ethnic demographics, and payer mix submitted applications to implement a CA Bridge program in 2018. When funding to sustain the program was released in 2020, more than two-thirds of the state’s 334 eligible EDs applied—despite the application being due in the middle of the state’s first COVID-19 surge. And this interest is not limited to California. In less than two years, CA Bridge has received interest from hospitals and public health agencies in more than 30 states that also want to begin MAT programs from EDs.
Myth 2: Feasibility Depends On Hospital Type
The CA Bridge program study concluded that among the participating hospitals, there was no significant variation based on hospital location (rural versus urban) or teaching status (clinical teaching hospital versus community hospital). This seems to indicate that attitudes regarding MAT and the associated medications are becoming less stigmatized in all hospital settings and that programs can succeed in hospitals of all resource levels.
Myth 3: Patients Won’t Choose MAT
Implementation of MAT through CA Bridge in EDs resulted in 12,009 patients being identified between May 2019 and June 2020. Of these, 59 percent (7,179) were provided buprenorphine before leaving the ED. In other words, more than 7,000 people chose to begin treatment when given the option in an ED.
Myth 4: MAT Is Unrelated To Equity Concerns
Despite the fact that MAT is considered the standard of care in addiction services, prior studies have shown uneven access to buprenorphine across demographic groups of people seeking MAT. Patients treated with buprenorphine are unlikely to be Black, have public insurance, live in low-income ZIP codes, or have co-occurring mental health disorders. Allowing patients to directly seek treatment for OUD within an ED, whether as initial treatment, treatment restart, or lapse prevention, levels the playing field for access to care and reduces the likelihood of disparities in access and poor outcomes due to structural racism that impacts which patients have access to MAT.
Additional research shows that many patients will indeed seek addiction treatment in a hospital ED if given the chance. The ED-based model for MAT can reach traditionally underserved patients, facilitating MAT for those with socioeconomic disadvantages. Patients with unstable housing and Medicaid coverage also had higher odds of getting MAT in a hospital than more affluent populations who have more options for this care.
Implications For Policy
As overdose rates continue to rise across the United States, treatment models such as CA Bridge provide a scalable strategy to reach individuals at the highest risk who cannot access medication treatment in a traditional setting. We urge policy makers to consider the following recommendations:
1. Require The X Waiver To Obtain Hospital Staffing Privileges
As long an X wavier is required to prescribe buprenorphine, we believe that obtaining the x-waiver license to prescribe buprenorphine should be required for emergency physicians seeking privileges at acute care hospitals, rather than remaining a voluntary action. Physicians seeking privileges to work in hospitals already undergo a thorough credentialing process. Far from increasing the paperwork burden, this requirement takes only a few minutes and will ensure that the physician is ready to provide evidence-based treatment.
2. Link Buprenorphine Initiation To Hospital Quality Metrics
Currently, quality metrics for ED visits for substance use disorder roll all types of substance use diagnoses into one HEDIS metric. We urge the National Committee for Quality Assurance to add quality metrics measuring patients presenting with opioid use disorder who are started on buprenorphine, leave the hospital with a buprenorphine prescription, and who are co-prescribed naloxone.
3. Add Reimbursement Mechanisms For Screening, Brief Intervention, And Referral To Treatment (SBIRT) From The ED And For Dedicated Substance Use Counselors And Peer Support
Right now, SBIRT is only billable in primary care settings. We urge state Medicaid programs to reimburse for SBIRT services provided in the ED because of the numbers of patients who access care there. We encourage further reimbursement for peer support services and care navigation provided by ED staff at levels that support fair wages for this workforce.