PAIN AND ADDICTION COMMITTEE
We are jacks of all trades, and if we can learn the basics (and more) of diverse specialties… we can learn this one addiction medicine intervention too.”
But why, you may ask, should I prescribe buprenorphine from the ED? First, it’s often where we find the patients who need it most.11 The patients with the most severe and unstable forms of their disease are those we see in emergency departments. Second, we see improved outcomes when treatment is started in the ED, when compared to delaying to outpatient follow up for initiation.12,13 ED buprenorphine prescribing has been shown to increase linkage to outpatient treatment and retention rates.14 While some may worry ED buprenorphine prescribing would lead to an increase in ED utilization, the opposite was shown to be true: those who get buprenorphine prescriptions from the ED have decreased emergency department utilization.15 Third, medications like buprenorphine are considered standard of care for opioid use disorder, and as such, should be provided whenever indicated, as is done for all other medical conditions. Patients with OUD can and do achieve remission, but only if they have access to treatment.
ED presentations are a type of golden hour for patients with OUD—a critical window of opportunity for initiation of evidence-based treatment. Patients presenting to the ED for opioid overdose in particular have high post-discharge mortality rates, with a significant number of deaths occurring in the first two days after discharge.16 If treatment is not started in the ED, there is a very real possibility the patient may have a fatal overdose before ever getting to an outpatient buprenorphine provider. We, as emergency physicians, have always been the ones to adapt, innovate, and rise to the occasion for our patients. You may be the only doctor your patient is able to see. You have the incredible ability to immediately and substantially reduce that patient’s risk of mortality by prescribing buprenorphine when needed. Statistically speaking, it may be the most life-saving intervention you perform during that shift. Emergency physicians are among the best-equipped doctors to intervene in the opioid crisis. Our specialty is one that is relatively quick to implement change in response to new and compelling guidelines, policies, and evidence. We are jacks of all trades, and if we can learn the basics (and more) of diverse specialties including cardiology, critical care, pediatrics, anesthesiology, radiology, palliative care, and OB/GYN, we can learn this one addiction medicine intervention too. Buprenorphine prescribing is within your scope of practice, and it is simpler than floating a pacer or determining the etiology of your patient’s nonspecific dizziness. Without past restrictions on buprenorphine prescribing, we all now have the power to make a difference in so many lives, and for society at large. I hope that with this change, ED buprenorphine prescribing will continue to become more commonplace. I am optimistic that, like me, you will view the removal of the X-waiver
as a long awaited and exciting opportunity for our specialty to be part of the solution to the opioid epidemic. May you be empowered to use buprenorphine as just one additional tool you have to save lives. After all, it’s what you already do best. For information and educational materials on treating opioid use disorder in the ED: AAEM’s white paper: Management of Opioid Use Disorder in the Emergency Department: A White Paper Prepared for the American Academy of Emergency Medicine SAMHSA: TIP 63: Medications for Opioid Use Disorder NIDA: Initiating Buprenorphine Treatment in the Emergency Department
For outpatient addiction medicine resources in your area: SAMHSA: Buprenorphine Practitioner Locator and Opioid Treatment Program Directory https://www.samhsa.gov/medications-substance-use-disorders/find-treatment References 1. Centers for Disease Control and Prevention. Drug Overdose. June 2, 2022. 2. Joint Economic Committee. The Economic Toll of the Opioid Crisis Reached Nearly $1.5 Trillion in 2020. 2022. 3. Evans E, Li L, Min J, et al. Mortality among individuals accessing pharmacological treatment for opioid dependence in California, 2006-10. Addiction 2015;110(6):996- 1005. (In eng). DOI: 10.1111/add.12863. 4. Dupouy J, Palmaro A, Fatséas M, et al. Mortality Associated With Time in and Out of Buprenorphine Treatment in French Office-Based General Practice: A 7-Year Cohort Study. Ann Fam Med 2017;15(4):355-358. (In eng). DOI: 10.1370/afm.2098. 5. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. Bmj 2017;357:j1550. (In eng). DOI: 10.1136/bmj.j1550. 6. The American Society of Addiction Medicine. Advancing Access to Addiction Medications. 7. Bukten A, Skurtveit S, Gossop M, et al. Engagement with opioid maintenance treatment and reductions in crime: a longitudinal national cohort study. Addiction 2012;107(2):393-9. (In eng). DOI: 10.1111/j.13600443.2011.03637.x. 8. Soyka M, Träder A, Klotsche J, et al. Criminal behavior in opioiddependent patients before and during maintenance therapy: 6-year follow-up of a nationally representative cohort sample. J Forensic Sci 2012;57(6):1524-30. (In eng). DOI: 10.1111/j.1556- 4029.2012.02234.x. 9. Poorman E. The Number Needed to Prescribe - What Would It Take to Expand Access to Buprenorphine? N Engl J Med 2021;384(19):17831784. (In eng). DOI: 10.1056/NEJMp2101298. 10. SAMHSA. Removal of DATA Waiver (X-Waiver) Requirement. 03/29/2023 (https://www.samhsa.gov/medications-substance-use-disorders/removaldata-waiver- requirement). Countinued on page 37 >> COMMON SENSE MAY/JUNE 2023
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