Buprenorphine was a fantastic drug in the emergency department. Patients would come to our ED feeling awful from opiate withdrawal, and we made them feel so much better. We can recall so many patients coming in vomiting, anxious, sweaty, dehydrated, and looking awful — and with one or two shots of buprenorphine, we made them feel well enough to take on the task of beating opiate addiction. A clinic in our community could see these patients in a day or so and start the process of treating their opiate addiction with oral Suboxone (buprenorphine and naloxone). The system worked. We ED docs loved it, and our patients benefitted immensely. Our experience was confirmed by a 2015 study on buprenorphine/naloxone in the emergency department at Yale University, which demonstrated — in a randomized controlled trial — that patients treated with buprenorphine in the emergency department were significantly more likely to be engaged in addiction treatment, significantly less likely to use illicit opioids, and significantly less likely to need inpatient addiction treatment.
Then the insurance companies ruined everything.
One of our local insurance companies that mainly covers low-income patients changed contracts for addiction treatment. We discovered that patients going to this new addiction treatment clinic had to wait several weeks to see a provider who could prescribe buprenorphine. We did not want to treat patients differently based on their insurance: giving one patient buprenorphine and not giving it to another. So, we took buprenorphine out of our ED. We could treat their withdrawal, but we couldn’t get them into a clinic where they could receive Suboxone to treat their addiction.
So now, we have an “opiate withdrawal pathway.” Clonidine, atenolol, trazodone, ondansetron, and a short tramadol taper work to mask their symptoms and provide a gentler way off opiates. And then we’re stuck with a medical community where under 50 percent of our opiate-addicted patients can get on Suboxone in a timely fashion. Our once successful system is now broken, and we are struggling to create a new one that works.
We met a young man recently at a town hall meeting on prescription drug misuse in our community. A young bull rider, he had injured his ribs at a rodeo and ended up on hydrocodone. Hydrocodone led to oxycodone, which led to heroin — an addiction that lasted six years. He spoke of wanting to get off opiates but also of feeling so awful when he was in withdrawal that he would use heroin just to make the withdrawal stop. Getting high just didn’t matter anymore: He was just trying to escape withdrawal. Ultimately, with the help of our old system of administering buprenorphine in the ED, he was able to get on Suboxone and ultimately tapered off opiates. He was proud to report six years of sobriety to the town hall crowd.
Buprenorphine is an extremely valuable tool in the ED, with oral forms such as Suboxone being invaluable in the management of opiate addiction. To help more young men and women such as the bull rider in our county, we are working to re-build our medical community to make our system work again. Our efforts include creating grand rounds with free CME for our medical staff and community providers on how physicians can use buprenorphine in their daily practice for the treatment of pain, and the benefits — both to patients and providers — of obtaining the certification necessary to prescribe buprenorphine for addiction.
With increased interest in prescribing buprenorphine, we will be hosting free training days for physicians in our community to obtain this certification. This way we can increase the number of physicians who can prescribe Suboxone to treat opiate addiction and dependence. And finally, in the short term, while trying to train more physicians to use buprenorphine, we are working to set up ways for our emergency department patients to receive addiction therapy via telemedicine. In time, we’ll bring back the “good old days” where we could treat all of our patients in the emergency department for opiate addiction and dependence with what we believe is best for them.
Reb J. Close and Casey Grover are emergency physicians.
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