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.