Charlotte Goldfine, MD
University of Massachusetts Toxicology Fellow
Opioid use disorder has been increasingly on the rise, reaching epidemic proportions. There was an estimated 72,000 drug overdose deaths in 2017, an increase of 9.5% in the past year, which is largely attributed to the rise in the use of synthetic opioids.1 The CDC reported a 111% increase in Emergency Department (ED) visits for non-medical use of opioid medications from 2004-2008.2 The large number of patients presenting to the ED with opioid use disorder provides a unique setting and opportunity to provide resources and adjuncts to help prevent future morbidity and mortality associated with opioid use disorder.
Treatment of opioid use disorder can be very challenging with many barriers to successful treatment. Medication assisted therapy (MAT) is one such option which has been shown to improve outcomes and can successfully treat opioid use disorder.3 There are three different medication classes included in MAT. Opioid agonist therapy, which includes methadone; buprenorphine (both alone and in combination with naloxone) which is a partial opioid agonist; and naltrexone which is an opioid antagonist. One study in Baltimore of patients who overdosed on heroin showed a decrease in fatal overdoses of 50% after treatment with methadone and buprenorphine.4
One of the challenges to treating opioid use disorder with MAT is access to programs and physicians who can prescribe these medications.5 A study by D’Onofrio et al found that ED-initiated buprenorphine therapy resulted in decreased opioid use at 2 months and were more likely to be engaged in treatment compared to patients who were either referred for treatment or given a 15 minutes Brief Negotiation Interview.6 Thus, if Emergency Departments are able to both prescribe MAT and help patients access follow-up with either primary care physicians or treatment programs, it may help reduce mortality and morbidity associated with opioid use disorder and ultimately decrease non-medical opioid use.
On July 31, 2018, the Massachusetts state government adopted a new bill. This bill was signed into legislation by the governor on August 9, 2018. This legislation requires that all Emergency Departments have the capability to initiate MAT. It will also expand availability for MAT for prisoners, provide availability for behavioral health counsellors, and allow partial filling of opioid prescriptions without penalty of additional copays.7 The overall goal is to expand access to care, treatment, and prevention for substance use disorders.
In conjunction with this new legislation, the Substance Abuse and Mental Health Services Administration (SAMHSA) has provided several states, including Massachusetts, with grants with the objective to decrease opioid use and abuse by increasing accessibility to treatment services and ensuring that those treatments are both comprehensive and evidence-based. This funding will allow more clinics to be started, which will ultimately provide places for emergency department patients to be referred for further treatment.8
In order to meet compliance with the new legislation, Emergency Departments in Massachusetts have several steps to take. The first is training and licensing physicians to be able to prescribe outpatient MAT. Currently, a special waiver or DEA license is not required for in-hospital prescribing of MAT. However, in order to prescribe and dispense MAT for outpatient use, providers need to take a training course and apply for a provisional DEA license. The most common of these that ED providers are able to obtain is a buprenorphine waiver. The training is an 8-hour, one-time course.
The next step is ensuring that patient’s prescribed MAT will have a follow-up for continued treatment either through a primary care physician or treatment facility. While some facilities are already in existence, the potential increase in the amount of patient’s prescribed MAT may require increased treatment availability. The state grant through SAMHSA is a potential source of funding that can be used to increase the number of treatment facilities available in order to streamline referrals and help increase treatment success.
While legislation is likely not the final answer to solving the opioid epidemic, it is bringing both awareness and funding to a very important issue. As the effects of the bill take place, it will be important to continue to evaluate how it is impacting treatment for patients with opioid use disorder. It will also provide the opportunity to evaluate other ways we can continue to help this population.
1. Ahmad FB, Rossen LM, Spencer MR, Warner M, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2018.
2. Centers for Disease Control, Prevention. Emergency department visits involving nonmedical use of selected prescription drugs - United States, 2004–2008. MMWR Morb Mortal Wkly Rep. 2010;59(23):705–9.
3. National Consensus Development Panel On Effective Medical Treatment Of Opiate Addiction. “Effective Medical Treatment of Opiate Addiction.” JAMA: The Journal of the American Medical Association, vol. 280, no. 22, Sept. 1998, pp. 1936–1943., doi:10.1001/jama.280.22.1936.
4. Schwartz RP, Gryczynski J, O'Grady KE, et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. Am J Public Health 2013;103:917-922
5. Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted therapies — tackling the opioid-overdose epidemic. New England Journal of Medicine, 370(22), 2063–2066. doi:10.1056/NEJMp1402780
6. D’Onofrio G, Chawarski MC, O’Connor PG, et al. Emergency department–initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention. J Gen Intern Med. 2017;32(6):660-666.
7. An Act for prevention and access to appropriate care and treatment of addiction. MA-HR. 4742. 190th General Court. (2017-2018).
8. “State Grant Programs.” Veterans and Military Families | SAMHSA - Substance Abuse and Mental Health Services Administration, 5 Apr. 2016, www.samhsa.gov/programs-campaigns/medication-assisted-treatment/training-materials-resources/state-grant-programs.