Editor’s note: This commentary is by Emily LeVan, who is a dual certified family and emergency nurse practitioner with over 10 years of practice in the emergency department setting who lives in central Vermont.
Racing pulse … covered in sweat … shaking like a leaf … goosebumps on arms … vomit on clothes … pacing in exam room … all those symptoms don’t even include the cravings, the intense cravings.
In a state that has led the nation in medication assisted treatment (MAT) for individuals struggling with opioid use disorder (OUD), starting buprenorphine (brand name Suboxone) in the emergency department when patients need it most is a vital and thus far underutilized part of stamping out the opioid epidemic in Vermont.
Buprenorphine is a safe, effective and life-saving medication used to treat OUD. It is a partial opioid agonist which means it does not produce a euphoria or “high” and is viewed by many as safer than its less strictly regulated opioid counterparts like oxycodone. It suppresses opioid withdrawal symptoms, reduces opioid cravings, and blocks the effects of other opioids.
Vermont has 14 hospitals and fewer than half offer rapid access to buprenorphine initiation through the emergency department. As an emergency department nurse practitioner with over 10 years of experience, I work in one of these hospitals and am a buprenorphine prescriber. I treat patients with OUD regularly, and, when appropriate, initiate buprenorphine treatment, connect patients with a peer counselor who is in recovery, and set them up with outpatient access to a buprenorphine prescriber.
Emergency departments across the country are well equipped to manage patients who present acutely with conditions related to OUD. A dose of Narcan to revive an unconscious patient who has overdosed, draining injection site abscesses or getting antibiotics and IV fluids into a patient who is septic from dirty needles from IV drug use are all interventions that are commonplace in today’s ED setting.
Many emergency departments, however, are not poised to treat the underlying problem, the disease itself. We dole out prescriptions to treat withdrawal symptoms, such as anxiety, nausea, and vomiting, neglecting the elephant in the room. Imagine a patient with bacterial pneumonia given a medicine for cough, rather than curative antibiotics. Sounds ridiculous, right? Then why do the majority of our emergency departments “treat” OUD in this way?
The reasons are numerous and multi-faceted. Many providers receive limited education about OUD and buprenorphine in their training. Onerous federal prescribing regulations limit the number of buprenorphine prescribers and the number of patients that can be treated by each provider. There is a social stigma; some providers view OUD as a moral failure rather than a disease. Treating this population can be frustrating, replete with treatment failure and relapse. The intense cravings associated with this disease can cause patients to behave in challenging, disingenuous and even manipulative ways.
Opioid related overdose deaths have risen steadily since the year 2000 plateauing in 2017 with a total of 72,000 opioid related deaths. Morbidity rates due to OUD follow a similar trajectory. Even more striking is that our health care system’s ability to treat this condition has not followed suit as the gap between disease prevalence and treatment capacity is close to 1 million.
Access to buprenorphine treatment equals harm reduction, saving lives and reducing health care costs. Buprenorphine when bundled together with behavioral therapy as part of medication assisted treatment may to help narrow this chasm between OUD and treatment capacity. Patients receiving buprenorphine and MAT have a 38% decrease in overdose deaths after one year of MAT. But patients lack access to this potentially life-saving medication.
Buprenorphine initiation in the emergency department setting is a way to improve access to treatment of OUD at a time when the need is greatest. Our state can continue to be a model for progressive treatment of OUD. We need public support to remove onerous prescribing regulations, such as the mandated special DEA X waiver. We need state and federal legislators to propose funding to enable EDs to develop MAT programs and forge the requisite interdisciplinary, community partnerships to ensure comprehensive, coordinated care. We need to educate policymakers, health care providers and the public about OUD, stressing that it is a disease, not a moral failure or a demonstration of lack of willpower.
