Medication Assisted Treatment for Opioid Use Disorder in the Emergency Department

The COVID-19 pandemic has overshadowed other prevalent and growing public health concerns, notably the opioid use disorder (OUD) crisis. Opioid use disorder is the leading cause of overall death of Americans under the age of 50.

The new cohort of trainees is just a few months from their medical school education and their degree gives them the authority to prescribe various drugs, including morphine, fentanyl, and oxycodone- notorious contributors to the opioid crisis in our country. Conversely, the same group are, legally, unable to prescribe lifesaving Medication Assisted Treatment (MAT) such as buprenorphine and methadone for addiction treatment. This mandate stems from the Controlled Substances Act of 1970 which defined such prescription drugs as Schedule III narcotics, indicating abuse potential.¹

In response to growing OUD prevalence in the 1990s, The Drug Addiction Treatment Act of 2000 (DATA 2000) created a mechanism for clinicians to treat opioid addiction prescribe buprenorphine and other similar medications. It required DEA registration, course completion, and patient panel size limits. Progressive at the time, DATA 2000 initially expanded access to opioid agonist therapy. However, the consistent growth of the opioid epidemic requires we reevaluate previous efforts to stem the tide of overdose mortality. While increasing the number of physicians who can prescribe MAT, DATA 2000 introduced additional barriers into MAT prescription, including requiring providers complete an additional training course and gain certification via an "X Waiver." These barriers contribute to a major treatment gap, with only 10% of patients seeking long-term OUD treatment able to receive it.²

Only a third of the over 2 million Americans diagnosed with OUD each year receive substance use treatment.³ As a result, many patients with OUD will end up receiving repeat care in emergency departments for overdose, injection related infections, and other sequelae of chronic or hazardous opioid use.^4,5 A 2015 study found only 2.2% of American physicians are waivered to prescribe controlled substances, such as BUP. Psychiatry comprises the specialty with the most waivered physicians comprising 40% of all waivers. An X Waiver is not required to administer BUP treatment acutely in the ED. However, the X Waiver and mandated training from the Substance Abuse and Mental Health Services Administration (SAMHSA) is required for a physician to write a prescription for take home doses. The "72 Hour Rule" does allow patients seeking opioid withdrawal related treatment to return to the ED for BUP doses every day for up to 3 days after they were initially seen; however, evidence suggests this 72-hour interval is insufficient to stabilize a patient with OUD on the road to long term maintenance and to avoid remission of hazardous opioid use.⁸ Additionally, this short time interval decreases the ability of the ED team to effectively bridge the patient to long-term outpatient or inpatient OUD treatment therapy, especially in the setting of a global pandemic. This does a further disservice to a marginalized patient population already challenged by the limited number of physicians waivered to prescribe MAT with buprenorphine to begin with. 

The natural follow-up question remains: If MAT saves lives, why is it difficult to obtain certification to prescribe?

Medications
There are 3 current FDA approved medications for OUD addiction treatment: methadone, buprenorphine, and naltrexone. Buprenorphine (BUP) is a long-acting mu-opioid partial agonist used in managing opioid withdrawal, in long-term replacement therapy for OUD, and in chronic pain control. BUP can also be prescribed as a combination formula buprenorphine/naloxone under the brand name Suboxone. Naloxone is inert and only becomes active if the oral Suboxone form is crushed and attempted to use for abuse purposes. When deciding to initiate BUP acutely in the emergency department (ED) for opioid withdrawal a Clinical Opiate Withdrawal Score (COWS) should be calculated.⁶A diagnosis of OUD, as defined by the Diagnostic and Statistical Manual, Fifth Edition (DSM-V) as well as a COWS score of at least 8 are needed to consider BUP initiation. As a partial agonist, BUP may precipitate withdrawal in a patient dependent on full opioid agonists. Thus, you want the patient to be in withdrawal already. Methadone is a long-acting full mu agonist, dangerous in overdose in certain populations, and requires high engagement and patients to present daily to the clinic. Methadone also causes QTC prolongation. Naltrexone in the depot form had the brand name Vivitrol and is an opioid antagonist. It is already available for alcohol withdrawal. Most ED patients experiencing acute opioid withdrawal will have their symptoms adequately controlled with a sublingual dose of 8-16 mg BUP.⁷ Controlling patient withdrawal symptoms in the ED is critical to initiating long-term OUD recovery by increasing the patient’s comfort and willingness to be consulted about ongoing treatment options.

Be Kind
Motivational interviewing in the form of nonjudgmental communication and open patient education are key to determining the patient’s last opioid usage to avoid precipitation of acute withdrawal. Some patients will not be ready to enter treatment. Communicate that the emergency department will always be a safe place for them to return and that they can obtain resources when they are ready.

However, psychiatrists are one of the least accessible specialists in rural areas of the United States. ⁹ SAMHSA reports that drug-related deaths are 45 percent higher in rural areas than in urban areas, and rural US residents are twice as likely to die from opioid overdose as their urban counterparts.¹⁰ Clearly, there is room for improving access to this much needed care in these vulnerable areas.

Future Legislation
Twenty years have passed without modification to the X Waiver bill. However, the COVID-19 pandemic may offer an opportunity to reevaluate OUD care and training. In March 2020, the Drug Enforcement Administration waived a requirement that patients seeking BUP treatment have an in-person consultation with a waivered provider to start treatment. ¹¹Temporarily, the use of telemedicine can be used in lieu of in-person evaluation. Additionally, all stable patients currently in MAT Programs have been granted a temporary allowance of up to a 28-day take-home dose allowing patients to receive treatment and minimize unnecessary exposure to COVID-19.¹² These minor changes are significant in that they represent an opportunity for the appraisal and the modification of MAT restrictions and legislation, especially in the context of a national emergency and global pandemic.

Paradigm Shift
One historical comparison would be the CPR training movement. Traditionally, CPR was taught requiring mouth-to-mouth resuscitation in a cardiac arrest response. Further evaluation of this teaching revealed significant hesitance of lay bystanders to initiate cardiac arrest response for fear of mouth-to-mouth infection and disease transmission. Organizations like "National 2 Step CPR" are actively working towards removing this barrier to lifesaving care by advocating for "hands only" (Compression Only) CPR, which improves time to initiation and delivery of CPR by eliminating excess stresses on the cardiac arrest bystander, improving bystander performance and confidence in providing lifesaving care.

Now, imagine if we removed the barriers between medical professionals and their access to lifesaving care in the form of MAT. Other countries such as France have already modified regulations and may serve as a paradigm for change; following expansion of buprenorphine prescribing access in 1995, the country saw a 79% decrease in opioid-related mortality over the succeeding 3 years.¹³ United States emergency physicians should engage in the conversation to reduce barriers to MAT prescription and to increase ED-initiated buprenorphine. A 2015 randomized clinical trial published in JAMA found that ED-initiated buprenorphine treatment in the United States, compared with brief intervention and referral, was found to significantly increase engagement in formal addiction treatment and reduce self-reported illicit opioid use.¹

A 2020 JAMA study from Yale School of Medicine assessing readiness to prescribe MAT among EM attendings, residents, and advanced practice providers found that only 3.5% (9 of 258) were waivered, and 21% (56 of 258) felt ready to prescribe buprenorphine. Barriers to prescription included lack of training, lack of experience in treating opioid use disorder, as well as concerns about ability to link to ongoing care.¹⁴ Establishing a MAT curriculum for medical students and allowing current emergency medicine residents to successfully complete the 8-hour X-Waiver training during protected learning time could be the first steps in removing barriers to providing this lifesaving care. The COVID-19 pandemic has been characterized by fear, uncertainty, and has ultimately changed each of our lives. These effects are magnified for patients experiencing OUD. Social isolation can worsen comorbid anxiety and depression and may increase the risk of unwitnessed overdoses leading to more preventable deaths. We have the duty to recognize that this pandemic may also be the igniting force we need to mobilize essential improvements in medical education and training regarding OUD treatment.

Free Training
ACEP and Providers Clinical Support System (PCSS) have partnered to provide free virtual 8-hour training sessions required for X-waiver application. For more information and to sign up, visit https://www.acep.org/education/ed-x-waiver-training-corps/.

References

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2. Berk J. To Help Providers Fight The Opioid Epidemic, “X The X Waiver”. In. Vol 2020: Health Affairs 2019.
3. Jones CM, McCance-Katz EF. Characteristics and prescribing practices of clinicians recently waivered to prescribe buprenorphine for the treatment of opioid use disorder. Addiction. 2019;114(3):471-482.
4. Peterson C, Xu L, Mikosz CA, Florence C, Mack KA. US hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011-2015. J Subst Abuse Treat. 2018;92:35-39.
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8. Knopf A. The “Three-Day Rule” Needs To Be Extended to Allow Longer Treatment With Methadone or Buprenorphine. Clinco Communications, Inc. . https://atforum.com/2019/01/three-day-rule-allow-longer-treatment/. Published 2019. Accessed 07/13/2020, 2020.
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11. Schenk SK. Coronavirus is forcing us to confront addiction treatment paradoxes. MEDPAGE TODAY. https://www.kevinmd.com/blog/2020/04/coronavirus-is-forcing-us-to-confront-addiction-treatment-paradoxes.html. Published 2020. Updated 04/07/2020. Accessed 07/13/2020, 2020.
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