Suboxone Treatment Can Begin in the Emergency Room

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On a recent Saturday, a patient was brought into The Hospital of Central Connecticut Emergency Department overdosing on opioids; doctors diagnosed him with Opioid Use Disorder and asked if he wanted to start recovery.

When he agreed, they gave him a dose of Suboxone, a medication that eases what can be painful withdrawal symptoms and stops cravings for the drug. The man was then sent home. He returned to the emergency department for a second dose on Sunday and a third dose Monday. On Tuesday, he walked into Hartford HealthCare’s Medication Assisted Therapy Close to Home (MATCH) Program at Rushford in Meriden to work on his sobriety in an outpatient setting.

“This is what we consider a successful transition,” said Dr. J. Craig Allen, medical director at Rushford and co-chair of the HHC Opioid Management Council, which recently identified a need for providers to administer Suboxone in system emergency departments across the state.

The move, he said, was prompted by a state Medical Examiner’s Office report that there were more than 1,000 opioid-related overdose deaths in Connecticut in 2017.

“We saw this as a huge opportunity,” Dr. Allen said. “Research supports identification and intervention as a path to decreasing opioid overdose deaths. Screening for misuse and providing harm reduction education, naloxone prescriptions (the opioid overdose reversal medication) and referrals for medication-assisted treatment are considered ‘best practice’ to beat this crisis and improve public health.”

He added, “Optimal treatment is starting buprenorphine medication such as Suboxone as soon as possible with patients in the emergency department. This shows improved engagement and patients are more likely to remain in outpatient treatment 30 and even 60 days after discharge.”

MidState Medical Center was the first HHC emergency department (ED) to initiate Suboxone treatment on site. Dr. Jeffrey Finklestein, vice president of medical affairs for MidState and HOCC, says it was a change in thinking for ED providers that opened the door for the change.

“We were not serving this population well,” he said. “Based on the stigma of substance abuse, we felt it wasn’t the job of the ED to give outpatient medication. But, with all the news on the opioid crisis, we realized we could do something fairly easy and save lives.

“It was like an awakening.”

At Windham Hospital, Emergency Department Medical Director Dr. Mark Dziedzic said, “Being able to initiate Suboxone in the emergency department allows us to take advantage of a crucial moment in that patient’s path of drug abuse. When a patient comes to us seeking detox and is in active withdrawal, we can treat their symptoms completely with Suboxone. In the past, we only gave symptomatic treatment which is not very effective.

“Patients in active withdrawal are uncomfortable and could be more likely to use again even if they want to quit. By initiating Suboxone, we can bridge them for the time it will take for them to get to the medication-assisted treatment program as opposed to having them suffer.”

In order to start Suboxone in the ED, there has to be an outpatient clinic the patient can go to receive therapy and continue their prescription. Without the medication, which is called opioid replacement therapy, the patient will experience withdrawal symptoms and cravings leading to a high risk of relapse. In the past, the lack of outpatient programs has been a barrier to inpatient or ED induction of Suboxone. However, at HHC, the Behavioral Health Network (BHN) has developed 11 (soon to be 12) locations (Avon, Backus Hospital, Charlotte Hungerford Hospital, Cheshire, Dayville, Glastonbury, Groton, The Hospital of Central Connecticut, Mansfield, Meriden and Middletown).

“Our goal is to create a seamless system to help people with opioid use disorder receive first-line, evidence-based care regardless what Hartford HealthCare ‘door’ they enter. The emergency departments are our initial focus given the large number of high-risk patients, but soon we’ll be treating opioid use disorder in all our acute care hospital settings and primary care clinics,” Dr. Allen explained.

A three-day, broadly focused quality improvement project called a “Kaizen” was held last summer, bringing all BHN programs offering medication-assisted treatment for opioid use disorder into alignment. The workgroup established five areas or “pillars” they felt were essential for substance use disorder treatment. All programs working toward meeting these goals will be considered  Medication Assisted Treatment Close to Home (MATCH) clinics. The goals are:

  • Foster shared understanding and education. All staff, clients and involved family members receive standardized education on substance use disorder and its treatment.
  • Create a single point of contact for all MATCH programs. Regardless of a person’s location, one phone call will connect them to the closest MATCH clinic or other community treatment resource.
  • Establish same-day access to clinicians and Suboxone prescribers.
  • Create financial transparency so there is a clear understanding of insurance coverage and the client’s financial responsibility.
  • Expand recovery capital by placing a priority on engaging the family and community support services in the treatment and recovery process.

“The expansion of our medication provider network now allows us to treat more people with first-line, evidence-based, FDA-approved medications because we can safely transition them to outpatient MATCH settings,” Dr. Allen said.

With the support of two recent grants and a philanthropic gift, Dr. Allen cites upcoming enhancements that include telehealth access, seven-day programming and innovative technologic supports that allow for 24-hour recovery coach access and monitoring.

“I believe that Rushford and the BHN will provide the model for high-quality substance use disorder care for other healthcare systems in Connecticut and across the country,” he said.

Dr. Dziedzic said offering Suboxone in the emergency department should help increase the number of people seeking recovery.

“It gives them instant access during a moment where they are seriously considering getting help,” he explained. “These moments can be fleeting and the longer the patients have to wait, they might lose their resolve.”

The patient successfully transitioned from Suboxone in the HOCC ED to Rushford for outpatient services is a perfect example, Dr. Finklestein said, of helping patients.

“Sometimes it’s really hard to know the right thing to do but once you know it, it’s hard not to do the right thing,” he said. “A life was saved. You don’t get much better than that.”

For more information on the MATCH program at HHC, go to hartfordhealthcare.org/match.

 


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