Training the Front Line: Substance Use Disorder Education for EM Residents

A grant from the Substance Abuse and Mental Health Services Administration has helped ACEP, ABEM, CORD, and EMRA develop a curriculum for emergency medicine residency programs. Learn how to help recognize and manage substance use disorders presenting in the ED.

Case Vignette
Daniel had overdosed, again. Someone must have noticed him passed out on the street and called 911 because, before he knew it, an ambulance crew had picked him up and dropped him off at the emergency department. He reminded me of dozens of other patients that I have taken care of over the last seven years in Boston—first as a medical student, then as a resident training in emergency medicine during the height of the nation’s opioid epidemic. He was a mid-30’s, white male who had grown up in an economically depressed part of the north shore of Massachusetts. From his first exposure to opioids at age 14 to his eventual progression to IV heroin and cocaine use, Daniel’s* medical history outlined the story of a life upended by addiction: untreated hepatitis C, multiple ED presentations for opioid overdoses, hospital admissions for complicated skin abscesses from which he often left against medical advice, and one ICU admission after getting intubated in the ED for excessive agitation while intoxicated with a bad combination of opioids and cocaine.

On this particular evening, Daniel had overdosed on heroin. By the time he had arrived to the ED, he had become increasingly somnolent with pinpoint pupils and a respiratory rate that was dipping into the danger zone. The nurse placed an IV and I gave him a tiny dose of IV naloxone (0.04 mg, one-tenth of the standard dose)—just enough to restore his respiratory drive, but not enough to send him into florid withdrawal.

Substance Use Disorders in the ED
The prevalence of substance use disorders (SUDs) among the ED patient population is on the rise.^1–3 The emergency department has become a critical point of access to the health care system for patients with SUD, representing nearly half of all ED visits in the U.S.⁴ And yet, the rates of treatment remain low. The National Survey on Drug Use and Health data from 2016 revealed that of the 19.9 million American adults who needed treatment for a substance use disorder, only 10.8% received addiction treatment within the past 12 months.⁵ Why are so many people left untreated? Lack of knowledge about evidence-based treatment modalities, the pervasive stigma surrounding addiction, and lack of a feeling of self-efficacy on the part of clinicians to intervene may all contribute to the missed opportunities to save lives.⁶

Some would argue that the emergency department is actually the optimal setting to perform screening and intervention for SUD. For example, EDs often serve the primary health care needs for patients with opioid use disorder (OUD), provide overdose reversal, attention to injuries related to substance use, and entry points into OUD treatment.⁷ When patients present with an acute problem to the ED, physicians may be able to leverage their motivation to change and initiate buprenorphine, distribute naloxone, counsel patients, and refer them to outpatient treatment and follow-up.⁸ Because of the unique role that emergency physicians are able to play in reducing overdose deaths and increasing linkage to addiction treatment, it is essential that SUD education be taught in every EM residency in the nation.

Development of the EM Curriculum
The Substance Abuse and Mental Health Services Administration (SAMHSA) has awarded the American College of Emergency Physicians (ACEP) a $220,000 grant to develop and disseminate SUD curriculum to EM residency programs around the country. With this grant funding, ACEP has partnered with the American Board of Emergency Medicine (ABEM), Council of Residency Directors in Emergency Medicine (CORD), and EMRA to carry out a two-year project, called “Training the Front Line”. The goals of this project are to teach residents about SUD disease processes and evidence-based treatment options, reduce stigma, and empower emergency physicians to actively engage patients in treatment. In the first phase of the grant in the fall of 2019, ACEP convened a committee of experts in the field of SUD research to determine the design the curriculum. The subject matter experts included Drs. Kathryn Hawk, Alexis LaPietra, Ryan McCormack, and Reuben Strayer. I had the privilege of serving as the EMRA representative to the committee and helped to shape a curriculum that would be practical and focused on the needs of EM residents.

Together, we created a series of short, 20-minute teaching modules organized by topic: Introduction to Opioids, Treatment and Management of Opioid Use Disorder, Alcohol and Benzodiazepines, Cannabis and Vaping, Stimulants, and Special Populations such as adolescents and pregnant patients. In the second phase of the project, twelve residency programs served as the pilot sites for the rollout of this curriculum from January to June 2020. Faculty at those residency programs delivered the modules to their residents, and residents provided feedback to ACEP about the quality of the curriculum. In the third phase, resident feedback will be used to revise the curriculum. By the end of 2020, the revised curriculum will be made available to all EM residencies in the U.S. As the final output of this grant, the 2021 In-Training Exam (ITE) will be updated to include examination questions based on this SUD curriculum.

By creating a standardized SUD curriculum that is specific to EM residents, we hope to equip emergency physicians with the tools they need to provide their patients with high-quality and evidence-based SUD screening, assessment, and treatment.

Evidence-based Interventions
What kind of evidence-based interventions are we talking about? In a randomized control trial by Yale University in 2015, patients who presented to the ED with opioid withdrawal were randomized to one of three treatment arms:

1. Referral to outpatient treatment
2. Referral and brief counseling intervention
3. Referral, counseling, and initiation of buprenorphine from the ED

The results were impressive: being given a buprenorphine “starter pack” from the ED increased a patient’s 30-day retention in treatment to 78%, nearly double the rate of the group who received brief counseling and referral alone (45%), as well as compared to the group who received referral alone (37%).⁹

In a study published in the Annals of Emergency Medicine in January 2020, Weiner, et al, determined that patients treated in the ED for overdose had a one-year mortality rate of over 5%.⁸ They found that a large number of patients discharged from the ED after an opioid overdose died in the first month. Approximately 20% of patients who died did so in the first month, and approximately 20% of those died in the first two days following discharge from the ED. With the median age at time of death of 39 years, the loss of life from those preventable overdose deaths was astounding. On the other hand, if patients are provided with medication for opioid use disorder (MOUD)—specifically buprenorphine or methadone maintenance treatment—one death can be prevented for every 40 patients treated, which would reduce the annual mortality from 5% to 2%.^8,10

By training emergency medicine residents in evidence-based practices such as reduced opioid prescribing to prevent development of OUD, use of alternatives to opioids for acute pain management, harm reduction techniques such as distribution of naloxone kits , and ED initiation of MOUD, we can significantly increase the likelihood that patients will engage with health services and achieve long-term improvements in health outcomes.¹¹

Case Resolution
So, what happened to Daniel that night in the ED? After giving him the small dose of naloxone, his breathing normalized and he did not go into withdrawal. I kept an eye on him while he slept through the rest of the night connected to end-tidal CO₂ monitoring and made sure that he didn’t need further doses of opioid reversal. By the morning, when he had sobered, one of our ED social workers talked to him about treatment options. Ultimately, he wasn’t ready to start buprenorphine or other MOUD treatment that day, but I left my shift knowing that I had treated him with respect and understanding.

One day he may be ready to come back for help. I hope that when that day comes, the next emergency physician to care for him will be empowered by resources such as this SUD curriculum to counsel and guide him towards effective treatment options. That indeed should be our standard.

Funding for this initiative was made possible (in part) by grant no. 1H79FG000021-01 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

References

1. Opioid Hospital Use Map - HCUP Fast Stats. Accessed June 4, 2020. https://www.hcup-us.ahrq.gov/faststats/OpioidUseMap?setting=ED
2. Weiss AJ, Barrett ML, Steiner A. Patient Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014. :19.
3. Trends in Emergency Department Visits, 2006-2014. :20.
4. The DAWN Report: Highlights of the 2010 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Accessed June 4, 2020. https://www.samhsa.gov/data/sites/default/files/DAWN096/DAWN096/SR096EDHighlights2010.htm
5. Park-Lee E, Lipari RN, Hedden SL, Kroutil LA, Porter JD. Receipt of Services for Substance Use and Mental Health Issues Among Adults: Results from the 2016 National Survey on Drug Use and Health. In: CBHSQ Data Review. Substance Abuse and Mental Health Services Administration (US); 2012. Accessed June 4, 2020. http://www.ncbi.nlm.nih.gov/books/NBK481724/
6. Schoenfeld EM, Westafer LM, Soares WE. Missed Opportunities to Save Lives—Treatments for Opioid Use Disorder After Overdose. JAMA Netw Open. 2020;3(5):e206369. doi:10.1001/jamanetworkopen.2020.6369
7. Martin A, Mitchell A, Wakeman S, White B, Raja A. Emergency Department Treatment of Opioid Addiction: An Opportunity to Lead. Acad Emerg Med. 2018;25(5):601-604. doi:10.1111/acem.13367
8. Weiner SG, Baker O, Bernson D, Schuur JD. One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose. Annals of Emergency Medicine. 2020;75(1):13-17. doi:10.1016/j.annemergmed.2019.04.020
9. 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. doi:10.1001/jama.2015.3474
10. Larochelle MR, Bernson D, Land T, et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Ann Intern Med. 2018;169(3):137. doi:10.7326/M17-3107
11. National Academies of Sciences E, Division H and M, Policy B on HS, et al. Evidence on Strategies for Addressing the Opioid Epidemic. National Academies Press (US); 2017. Accessed June 4, 2020. http://www.ncbi.nlm.nih.gov/books/NBK458653/