Emergency departments have become the front line in the battle against the epidemic of opioid use disorder, in part because they are the place individuals are brought after overdosing or during withdrawal. In addition, individuals with addiction are often marginalized from traditional sources of primary care, and so often default to using what is available to them: emergency departments.
Our nation’s emergency departments have seen a nearly 100% increase since 2005 in visits by patients seeking help related to opioid addiction. The rates of hospitalizations related to opioid addiction rose 64% over the same period.
Fortunately, there is an effective treatment for opioid addiction that emergency doctors can begin. Called medication for opioid use disorder (MOUD), it uses buprenorphine to reduce cravings for opioids. This treatment increases the likelihood that a patient will enter a recovery program and stick with it, yet the vast majority of patients with opioid addiction are discharged from emergency departments with inadequate or no treatment at all. A recent survey found that only 7% of U.S. emergency departments currently have protocols to prescribe buprenorphine for emergency department patients looking for treatment for their opioid addiction.
The problem here is one of human behavior — we’re talking about doctors’ behavior here.
One of the barriers to prescribing medication for opioid use disorder is that physicians aren’t allowed to prescribe buprenorphine unless they complete an eight-hour training course and get a special license (called a waiver) from the federal Drug Enforcement Administration. One of us (A.M.) created the Get Waivered program to help emergency physicians at Massachusetts General Hospital get this certification.
Yet one study found that only 47% of all physicians who obtained this DEA waiver ever prescribed buprenorphine to patients. You might wonder: Why would someone who went through an eight-hour training course to prescribe an effective medication not follow through and prescribe it?
One reason is that there can be a long time lag — some studies suggest 17 years — between the discovery of new evidence-based practices and their incorporation into everyday medical practice. That’s way too long when the opioid epidemic is taking 130 lives per day.
Behavioral science — the study of how people make decisions and take action in the real world — can help shorten this gap. Behavioral science has successfully changed physician behavior to increase prescribing generic drugs and reduce prescribing unnecessary antibiotics. It has also been used to help people reduce or stop smoking and get vaccinated against the flu.
Since the fall of 2018, we have been using behavioral science to treat opioid addiction by increasing the use of medication for opioid use disorder in the Massachusetts General Hospital emergency department by partnering with ideas42, a behavioral science innovation firm.
The first step was to make sure that emergency doctors know who needs addiction treatment. The emergency department is hectic, and its physicians are busy. To make this lifesaving issue salient amid everything else, we created a best-practice advisory alert in the electronic health record — it’s essentially a flag in the notes section of a patient’s record that alerts providers to his or her possible history of opioid dependence and lack of current treatment. The alert also encourages the physician to consider offering the patient medication for opioid use disorder in the emergency department if he or she is in withdrawal, or otherwise refer the patient to a bridge clinic for ongoing treatment.
Next, we wanted to make it easier for doctors, physician assistants, and nurse practitioners to have conversations about medication for opioid use disorder with patients they thought might need it by making sure the information they needed was at hand. We created a “badge backer” that hangs vertically behind a provider’s hospital ID badge. It contains a guide for talking with a patient about addiction and evaluating withdrawal, a QR code for an online calculator to evaluate withdrawal, a flowchart for treating opioid use disorder, and a public commitment that says “I treat opioid use disorder” on the front of the badge.
Because we wanted this initiative to stay top-of-mind over many months, we designed and sent monthly emails to the emergency department providers each month from January through June of 2019. These emails served as a recurring reminder of the department’s initiative to treat opioid use disorder. Each one provided feedback on departmental progress, highlighted a patient success story, and gave a shout-out to providers who followed the protocol.
We also designed an intervention targeting patients and put it where many would see it: in restroom stalls. These posters show a patient speaking with a clinic provider about addiction, emphasizing its treatability, and comparing seeking recovery to treating diabetes. It includes a map to a nearby clinic, an invitation to ask the emergency care team for information on treatment for opioid addiction, and a testimonial quote from a patient in recovery. The goal was to make it easier for a patient to ask for assistance if the provider did not proactively mention MOUD.
The medical field has already used behavioral economics to address part of the opioid problem: the overprescription of painkillers. In a recent study, for example, Dr. Jason Doctor and his colleagues at the USC Sol Price School of Public Policy found that emergency physicians who received a letter from the medical examiner informing them that one of their patients had suffered a fatal opioid overdose reduced the amount of opioids they prescribed by almost 10% over the next three months. Another study, from the University of Pennsylvania, used a new default option — the option that will be selected if no action is taken — in electronic health records to decrease the number of opioid pills that physicians prescribe. The new default set the prescription of opioids to 10 tablets instead of requiring the physician to manually enter a number.
While efforts to reduce the risk of unnecessary exposure to opioid prescriptions are certainly a part of the solution, this is akin to closing the barn door after the horse has left for the millions of people already living with opioid addiction. Incorporating behavioral insights into emergency department procedures can help people who are currently struggling with addiction get connected to treatment.
There is no single solution to overcoming the opioid epidemic, but making it easier for physicians to get patients started on buprenorphine through behaviorally informed interventions can go a long way in tipping the scales. As long as it remains harder for patients to get help than it is to use illicit opioids, we will not stop this crisis.
Alister Martin, M.D., is an emergency physician and faculty member at the Center for Social Justice and Health Equity at Massachusetts General Hospital and Harvard Medical School. Ted Robertson is a managing director at ideas42.
The people who are dying are drug addicts using street drugs. Countless Chronically I’ll Patients are being Tortured by forced Reductions, undisclosed experimental reconfigurations of their “Opiate” Medications, as well as the Undisclosed Fact that drug manufactures can cut the Active ingredient by up to 45 percent ! Not just “Opioids”, once effective sleep medication, Anxiety, ADHD, and others are Fraudulent. People unfortunate Enough to exist on dissed-ability are Committing Suicide the likes of which had never been seen in history. Good Doctors are/have left the field And Are Committing Suicide. Obama directed Billions to the DEA and the best they can do is go after patients and their doctors. The Government, CDC, DEA have No business in Medicine. Get your facts straight: The Majority of our Medications are Non Standardized !!! I’ve Returned Over 40, and still, Not One Is Authentic.
Amen Joy,,u nailed it…but ,”they” and the likes of those who wrote this article don’t want to know the truth,or hear it,or publish it,,One of my comments has been already censored,,Corrupt regimes have no use to truth,What America is doing to their chronic or pre-existing medically ill is genocide and make no mistake,,they know it,,They want us dead,,in their arrogant,prejudicial ,inhumane minds,,they see us a ,”addict’s,,or in the great wizards psychotic mind of kolodnys made up terms,”complex opiates use disorder,” for taking lawful medicines as prescribed by our doctors for medical conditions,that to them,is a addict now a days,,Its ,”To kill a mockingbird,” in the 21st century.,,The prejudice is soo great,,not a single lawyer will help us for now,,,If the United States followed the treaties they signed w/the U.N.. and the International Narcotic boards,our medicines would be separate from drugs,.Our doctors could not be arrested for prescribing a lawful medicine and the government would not be allowed to practice medicine.Which is why America quit the United Nations Human Rights council,3 years ago,for they knew they would have to follow the treaties,,if they didn’t quit.This genocide has shown me,that hatred,prejudice,arrogance,torture,and 1 man that used ever evil tool of prejudice to fuel this genocide,just like hitler did,,can get away w/it..it truly is,,”To kill A Mockiongbird ,” in 2019,,,and ONLY AMERICA,, is doing it,,all other countries are following the U.N treaties,,thats 165 other countries btw,,amaryw
Great article.
Thee only thing this article promotes is a justification for e.r,, doctors to willfully torture the medically ill in physical pain…Psychiatry is thee only field of study that u need no physical fact to justify a new ,”disorder,” thus $$$ in a shrinks pocket and torture forced onto the medically ill..Tell me why,,,NO OTHER COUNTRY,, is doing what America is doing to their medically ill in physical [pain from a medical condition??maryw
What the …?
Does this column address only addicts using illegal drugs, or does it include CPP’s who need legally Rx’d opioids to survive due to neverending horrific pain?
Why is this critical distinction so often ignored by those who should know better?
Consider the following quote from the above article:
“To make this lifesaving issue salient amid everything else, we created a best-practice advisory alert in the electronic health record — it’s essentially a flag in the notes section of a patient’s record that alerts providers to his or her possible history of opioid dependence and lack of current treatment.”
The quote uses the word “dependence”, unlike the rest of the article that uses the word “addiction”. HUGE problem. Any CPP on opioids would be in big trouble encountering the authors.
So, again, what is the authors’ intent? This article needs to be rewritten, and if the authors are targeting CPP’s who take opioids to survive living with horrific pain, then, shame on them.
Doctors must keep up with medical developments, get their yearly required “Continuing Education” credits for maintaining AMA membership status. Very logically, certainly for ER doctors, would be education and prescription status for treating opioid disorders with buprenorphine. If this is not happening, then the AMA needs to step up to the plate !
The distinction between those with medical issues that are physically painful is not being made for a few reasons,.,,,Many are soooo arrogant/full of themselves they actually think they have the right to decide who forcible suffers in physical pain from a medical condition.Notice how 1 shrink named Andrew Kolodny came up w/all these ,new definitions to make money for suboxone,,go read the mans reviews,,their terrible,,U have got insurance companies who don’t want to pay for pain management.I use to see my pain doc,1nce a year,250 bucks,,I guess thats too much $$$,,idiots!!!But u have nurses,doctors etc,,who honestly think they have the right to decide for all of mankind,,only in America btw,,who should forcible suffer in physical pain and who should not..As 1 European judge stated,,America’s idea of a ,”humane,” does NOT,,DOES NOT,, line up w/the rest of the civilized nations,,,unquote,,,and he’s right,165 other countries honor the U.N treaty against tortureing the health care setting by not tortureing the medically ill in pain from their medical condition.,Out of 167 countries belonging to the U.N,,2,,only 2,,America and 1/2 of Canada,,is willfully practicing torture in the healthcare setting by using words like opiate use disorder,denial of effecitive medicine to effectively lessen physical pain..America has made it a crime/disorders to have a NORMNAL human behavior to want physical pain lessen,,,whilest shrinks,ie,the-rapist,,fill up their pocket books.U label anyone opiates use disorder,,they will never see a opiate for paincare for surgery,cancer,doctors error,,,ever again in their life time,,u sentence a human to death,,,if u label them opiate use disorder,,and a life time of FORCED PHYSICAL PAIN FROM ANY MEDICAL CONDITION,,IE,,,TORTURE,,,maryw
Why do you say addiction what about dependency. Some people really need this medication and have been using it for many years responsible and you put them in your catch all net i think you are killing people with your do go over attitude!
Why is buprenorphine o e of the most abused medications out there? Seems to me much like the oxycontin tin debacle of the early 2000’s