A study found that addicted patients who were given buprenorphine in the emergency room were twice as likely to be in treatment a month later as those who were simply handed an informational pamphlet with phone numbers.
OAKLAND, Calif. — Every year, thousands of people addicted to opioids show up at hospital emergency rooms in withdrawal so agonizing it leaves them moaning and writhing on the floor. Usually, they’re given medicines that help with vomiting or diarrhea and sent on their way, maybe with a few numbers to call about treatment.
When Rhonda Hauswirth arrived at the Highland Hospital ER here, retching and shaking violently after a day and a half without heroin, something very different happened. She was offered a dose of buprenorphine on the spot. One of three medications approved in the United States to treat opioid addiction, it works by easing withdrawal symptoms and cravings. The tablet dissolved under her tongue while she slumped in a plastic chair.
Soon, the shakes stopped. “I could focus a little more. I could see straight,” said Hauswirth, 40. “I’d never heard of anyone going to an emergency room to do that.”
Highland is among a small group of institutions that have started initiating opioid addiction treatment in the ER. Their aim is to plug a gaping hole in a medical system that consistently fails to provide treatment on demand, or any evidence-based treatment at all, even as more than 2 million Americans suffer from opioid addiction. According to the latest estimates, overdoses involving opioids killed nearly 50,000 people last year.
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By providing buprenorphine around the clock to people in crisis — people who may never otherwise seek medical care — these ERs are doing their best to ensure a rare opportunity isn’t lost.
“With a single ER visit we can provide 24 to 48 hours of withdrawal suppression, as well as suppression of cravings,” said Dr. Andrew Herring, an emergency medicine specialist at Highland who runs the buprenorphine program. “It can be this revelatory moment for people — even in the depth of crisis, in the middle of the night. It shows them there’s a pathway back to feeling normal.”
It usually takes many more steps to get someone started on addiction medicine — if they can find it at all, or have the wherewithal to try. Locating a doctor who prescribes buprenorphine and takes insurance can be impossible in large swaths of the country, and the wait for an initial appointment can stretch for weeks, during which people can easily relapse and overdose.
A 2015 study out of Yale-New Haven Hospital found that addicted patients who were given buprenorphine in the emergency room were twice as likely to be in treatment a month later as those who were simply handed an informational pamphlet with phone numbers.
After Herring read the Yale study, he persuaded the California Health Care Foundation to give a small grant to Highland and seven other hospitals in Northern California last year, in both urban and rural areas, to experiment with dispensing buprenorphine in their ERs. Now the state is spending nearly $700,000 more to expand the concept statewide as part of a broader, $78 million effort to set up a so-called hub-and-spoke system meant to provide more access to buprenorphine and two other addiction medications, methadone and naltrexone.
Under that system, an emergency room would serve as a portal, starting people on buprenorphine and referring them to a large-scale addiction treatment clinic (the hub), to get adjusted to the medication, and to a primary care practice (the spoke) for ongoing care. Herring is serving as the principal investigator for the project, known as ED Bridge. The $78 million is most of California’s share of an initial $1 billion in federal grants that Congress approved for states to spend on addiction treatment and prevention under the 21st Century Cures Act, enacted in 2016.
“At first it seemed so alien and far-fetched,” Herring said, noting that doctors are often nervous about buprenorphine, which is more commonly known by the brand name Suboxone. They need training and a special license from the federal Drug Enforcement Administration to prescribe it for addiction (it’s also used to treat pain), although ER doctors don’t need the license to provide doses of the medication to patients in withdrawal.
But lately, Dr. Gail D’Onofrio, the lead author of the Yale study, has been fielding calls every week from ER doctors interested in her hospital’s model.
Since the study was published, a few dozen hospital emergency departments, including in Boston, New York, Philadelphia, Brunswick, Maine, Camden, New Jersey, and Syracuse, New York, have also started offering buprenorphine.
“I think we’re at the stage now where emergency docs are saying, ‘I’ve got to do something,’” D’Onofrio said. “They’re beyond thinking they can just be a revolving door.”
While the care provided in emergency rooms is particularly expensive, supporters of programs like ED Bridge say ERs are the best place for stabilizing any dangerously out-of-control condition, including addiction.
“We don’t think twice about someone having a heart attack, getting stabilized in the emergency department, and then getting ongoing care from the cardiologist,” said Dr. Kelly Pfeifer, director of high-value care at the California Health Care Foundation.
Highland has provided buprenorphine to roughly equal numbers of blacks and whites, with Latinos, Asians and other ethnic groups filling out the rest. Many of those patients are homeless and most are on Medicaid, the government health insurance program for the poor that, crucially for Herring’s program, California expanded under the Affordable Care Act. Buprenorphine can cost more than $500 a month.
Since February 2017, Highland’s ER has offered buprenorphine to more than 375 emergency-room patients. Two-thirds of them accepted it, along with an initial appointment for ongoing treatment at the hospital’s addiction clinic.
Dozens have continued taking buprenorphine, a weak opioid that activates the same receptors in the brain that other opioids do, but doesn’t cause a high if taken as prescribed. Even if they reject the idea of starting treatment, those who try buprenorphine in the ER may be more likely to do so in the future, Herring said.
At Highland, patients who get an initial dose of buprenorphine also usually get a prescription for Suboxone, which comes in strips that dissolve in the mouth and is harder to abuse, to last until they can get to an addiction clinic that Herring runs on Thursdays. There, he assesses their progress and often adjusts their dose on a weekly or biweekly basis until they can find a more permanent provider.
Herring has reached out aggressively to detox centers, where people often spend a few days withdrawing from heroin, and residential treatment programs. Although many such programs haven’t allowed residents to be on buprenorphine or methadone, California has started requiring them to.
Although Highland’s ER treats a fair number of opioid overdose victims — about 150 last year — they aren’t usually candidates for starting buprenorphine on the spot, Herring said. Many have just been revived with naloxone, an injectable drug that reverses overdoses, and there isn’t enough data yet about the safety of giving them buprenorphine so soon afterward.
“Figuring out how to do that safely and effectively has to be one of our greatest priorities,” Herring said.