Treating Addiction in the Emergency Department...The Missing Link

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drusso

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http://medicine.yale.edu/news/article.aspx?id=9200

“Effectively linking ED-initiated buprenorphine treatment to ongoing treatment in primary care represents an exciting new model for engaging patients who are dependent on opioids into state-of-the-art care.”

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I saw this. Lol. Seems like a really bad idea
 
just a few years ago, an ER physician from a big name medical center recommended that ED docs prescribe "a few days" of Opana for discharge from ED.

i dont get it. asking ED docs to prescribe a medication to essentially help with addiction when you have no established relationship with said patient, no real long term doctor-patient relationship, no method for follow up or monitoring, seems potentially disastrous.
 
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There are now three documented failures of SBIRT on the books. Anyone who thinks behavioral change can be coaxed in a brief encounter is out of their mind.
 
There are now three documented failures of SBIRT on the books. Anyone who thinks behavioral change can be coaxed in a brief encounter is out of their mind.
It's called an intervention. It only works if a person decides they've hit rock bottom, which is the exception as opposed to the rule. But you're right, trying to ensure that in a single encounter has a very low success rate.
 
This would only work in a closed system like Kaiser where there can be tight integration between the ED and
the PCP/addictionologist.

In my area the PCPs who obtained the DATA 2000 waiver are all full - or claiming to be - and not taking new
patients.
 
This would only work in a closed system like Kaiser where there can be tight integration between the ED and
the PCP/addictionologist.

In my area the PCPs who obtained the DATA 2000 waiver are all full - or claiming to be - and not taking new
patients.

But, "Seventy-eight percent of patients in the buprenorphine group (89 of 114 [95% CI, 70%-85%]) vs 37% in the referral group (38 of 102 [95% CI, 28%-47%]) and 45% in the brief intervention group (50 of 111 [95% CI, 36%-54%]) were engaged in addiction treatment on the 30th day after randomization (P < .001). The buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days (95% CI, 5.1-5.7) to 0.9 days (95% CI, 0.5-1.3) vs a reduction from 5.4 days (95% CI, 5.1-5.7) to 2.3 days (95% CI, 1.7-3.0) in the referral group and from 5.6 days (95% CI, 5.3-5.9) to 2.4 days (95% CI, 1.8-3.0) in the brief intervention group (P < .001 for both time and intervention effects; P = .02 for the interaction effect)."

When the meta-analyticians aggregate these findings the effect size will be significant. Here is how it works: research changes policy, policy changes payment, payment changes practice...

Absent content expertise and LOCAL intelligence, EBM is GIGO...
 
so the solution to the opioid addiction problem is for the ER to give out opioids to addicted people.

something about that seems off kilter.

let me postulate. a hypothetical group, lets name it Opana group, is given (obviously) oxymorphone upon discharge. i would guess that the number of days of illicit opioid use per week would drop from 5.4 days to 0.0 days, and if patient were told that they would be able to ask for Opana at the addiction treatment center, there would be 100% compliance - of those still alive.


my issue - it is not in the ER scope of practice to treat chronic opioid addiction. it is in the primary care scope of practice to initiate treatment in opioid addiction, however.
 
so the solution to the opioid addiction problem is for the ER to give out opioids to addicted people.

something about that seems off kilter.

let me postulate. a hypothetical group, lets name it Opana group, is given (obviously) oxymorphone upon discharge. i would guess that the number of days of illicit opioid use per week would drop from 5.4 days to 0.0 days, and if patient were told that they would be able to ask for Opana at the addiction treatment center, there would be 100% compliance - of those still alive.


my issue - it is not in the ER scope of practice to treat chronic opioid addiction. it is in the primary care scope of practice to initiate treatment in opioid addiction, however.
Emergency physicians treat addiction all the time. The heroin addict that ODs and needs resuscitation, the alcoholic that needs DT and seizure treatment, the opiate addict that comes to the ED in withdrawal, looking for a fix, lying about his condition to hopefully score something to abate the withdrawal that needs clonidine, anti diarrheal and detox referral. But if you mean suboxone and methadone for addiction, prescribed out of the ED, then I agree: bad idea, and possibly a DEA violation unless they have an X DEA # and appropriate additional training.

I do understand the desire to go down this road however, by EM researchers. The ED has taken the most undeserved friendly fire as a result of this opiate abuse epidemic. You all discharge your addicts, and in the ED they end up, at 3 am on Christmas, and some poor sucker in the ER has to find some way to deal with it, exhausted, overwhelmed and between codes, traumas and MIs.
 
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your example exemplifies the problem. ER docs do not treat addiction itself. they treat withdrawal symptoms, or overdose symptoms, not the addiction itself.

cognitive therapy? nope.
behavioral therapy? nope.
counselling/psychotherapy? nope.
substance abuse monitoring? nope.
peer support? nope.
non-opioid long term pharmaceutical therapy? nope.
vocational training/support? nope.

do ER docs treat the following?
Short Definition of Addiction:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
 
your example exemplifies the problem. ER docs do not treat addiction itself. they treat withdrawal symptoms, or overdose symptoms, not the addiction itself.

cognitive therapy? nope.
behavioral therapy? nope.
counselling/psychotherapy? nope.
substance abuse monitoring? nope.
peer support? nope.
non-opioid long term pharmaceutical therapy? nope.
vocational training/support? nope.

do ER docs treat the following?
No, but here's a quick story.

I had a patient come back to the ED and give thanks for saving their life, and you know how rare that is in the ED. I had no recollection of them. I figured they must have come in for an MI, trauma or that I had intubated them. But, no. They said, that I had talked to them "like a human being," and "like no other doctor ever had," and at their rock bottom moment of addiction (it happened to be severe alcohol addiction). They went to AA as recommended and were clean and sober for a prolonged period and considered their life saved, and specifically felt the credit belonged to me and my words, but more so the way I said them. (I'd say they deserve the credit, but that's a different discussion). It doesn't happen every day, or even every year, but it can happen and has happened to me more than once including a few "pain" patients I refused to prescribe opiates to, had discussions with, and referred for addiction treatment. My point is that you can make a difference, if you continue to care, and allow a small portion of yourself to remain un-cynical. It's corny, but true, and that's coming from someone that tends to lean more cynical. Whether you consider that "treating addiction" or not, I don't know, but the patient in question would insist it was a life saved from addiction, nonetheless.
 
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:claps:
but your story doesnt further your contention that ER docs treat addiction itself. a fortunate chance encounter lead the patient to reexamine his life, and do the hard work into becoming clean. Congrats, cool that you helped.
 
Here is somebody who continues to care:
 
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There are now three documented failures of SBIRT on the books. Anyone who thinks behavioral change can be coaxed in a brief encounter is out of their mind.

http://www.medscape.com/viewarticle/844075

"This is an "innovative" approach, Jeffrey Samet, MD, MPH, of the Boston University School of Medicine Clinical Addiction Research and Education Unit and the Boston Medical Center, told Medscape Medical News.

"Anytime we can engage patients to begin to address their addiction to opioids is super. The ED is a place where people who don't want to come in for medical care come in for medical care because something is pushing the issue, and we know one of the biggest problems in getting people addiction treatment is having them show up," Dr Samet added. Seeing an opioid-dependent patient in the ED provides a "reachable moment for people who are very hard to reach," he said.

"This study compared three "very reasonable strategies," Dr Samet noted. He admitted he was "surprised" by the cautionary tone of the study's conclusion. "If I was the head of an emergency department and saw this study and the high quality of the scientific methods, I would have it as part of the menu of options," he said."
 
Here is somebody who continues to care:


Am J Public Health. 2015 Apr 23:e1-e7. [Epub ahead of print]
Disparity in Naloxone Administration by Emergency Medical Service Providers and the Burden of Drug Overdose in US Rural Communities.
Faul M1, Dailey MW, Sugerman DE, Sasser SM, Levy B, Paulozzi LJ.
Author information

Abstract
OBJECTIVES:
We determined the factors that affect naloxone (Narcan) administration in drug overdoses, including the certification level of emergency medical technicians (EMTs).

METHODS:
In 2012, 42 states contributed all or a portion of their ambulatory data to the National Emergency Medical Services Information System. We used a logistic regression model to measure the association between naloxone administration and emergency medical services certification level, age, gender, geographic location, and patient primary symptom.

RESULTS:
The odds of naloxone administration were much higher among EMT-intermediates than among EMT-basics (adjusted odds ratio [AOR] = 5.4; 95% confidence interval [CI] = 4.5, 6.5). Naloxone use was higher in suburban areas than in urban areas (AOR = 1.41; 95% CI = 1.3, 1.5), followed by rural areas (AOR = 1.23; 95% CI = 1.1, 1.3). Although the odds of naloxone administration were 23% higher in rural areas than in urban areas, the opioid drug overdose rate is 45% higher in rural communities.

CONCLUSIONS:
Naloxone is less often administered by EMT-basics, who are more common in rural areas. In most states, the scope-of-practice model prohibits naloxone administration by basic EMTs. Reducing this barrier could help prevent drug overdose death. (Am J Public Health. Published online ahead of print April 23, 2015: e1-e7. doi:10.2105/AJPH.2014.302520).
 
As an ER doc, the POS drug seekers have NO interest - ZERO - in quitting. I had one patient over the weekend to whom I said I'd write for some Tramadol ER. She said, "Why don't you just give me 20 of what I always get? I've never taken that. I don't know what will happen." I said that there was a time when she'd never had Tramadol, and she didn't know what would happen. I told her that she was lucky she was getting anything, and, for bargaining, I should just discharge her. She said, "I'm not bargaining" (less than 1 minute after saying "Just give me 20").

She goes to the two pharmacies right next door to the hospital. One pharmacist calls and says that the Rx is not covered - and she's complaining about this! Hand, gift horse, bite, etc.

But wait - there's more! Even though I told her that I would not write for anything else, she came back - immediately. Signed in, and told the nurse that she just needed "a two minute conversation". He told her that, no, it would be MUCH longer than that, and that nothing would change. Moreover, I had to see another patient ahead of her.

Because of this, she left again.

She probably came back the next day. I work tomorrow, and I'll check then.

I, for one, want NO part in buprenorphine. ZERO, nada, do not want.
 
I, for one, want NO part in buprenorphine. ZERO, nada, do not want.

Well, your experience might be the Truth. But, unfortunately the Truth does not equal the Data...Here is how it works: research changes policy, policy changes payment, payment changes practice...Once the Data is "hard-wired into the mission," it becomes "the Truth" vis-a-vis policy and payment structure. You'll have to ask permission from your employer to deviate from the practice standard...

There are too many "wise, grey-haired" doctors running around who believe that their Truth trumps the Data. Please, just get back in line. Your Press-Ganey score depends upon it.
 
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As an ER doc, the POS drug seekers have NO interest - ZERO - in quitting. I had one patient over the weekend to whom I said I'd write for some Tramadol ER. She said, "Why don't you just give me 20 of what I always get? I've never taken that. I don't know what will happen." I said that there was a time when she'd never had Tramadol, and she didn't know what would happen. I told her that she was lucky she was getting anything, and, for bargaining, I should just discharge her. She said, "I'm not bargaining" (less than 1 minute after saying "Just give me 20").

She goes to the two pharmacies right next door to the hospital. One pharmacist calls and says that the Rx is not covered - and she's complaining about this! Hand, gift horse, bite, etc.

But wait - there's more! Even though I told her that I would not write for anything else, she came back - immediately. Signed in, and told the nurse that she just needed "a two minute conversation". He told her that, no, it would be MUCH longer than that, and that nothing would change. Moreover, I had to see another patient ahead of her.

Because of this, she left again.

She probably came back the next day. I work tomorrow, and I'll check then.

I, for one, want NO part in buprenorphine. ZERO, nada, do not want.

I think you and I are hard wired for prevention rather than treatment✌
 
Well, your experience might be the Truth. But, unfortunately the Truth does not equal the Data...Here is how it works: research changes policy, policy changes payment, payment changes practice...Once the Data is "hard-wired into the mission," it becomes "the Truth" vis-a-vis policy and payment structure. You'll have to ask permission from your employer to deviate from the practice standard...

There are too many "wise, grey-haired" doctors running around who believe that their Truth trumps the Data. Please, just get back in line. Your Press-Ganey score depends upon it.
Lol. Unfortunately, not far from the truth.
 
first, we all have seen multiple threads how research can be tainted.

second, you yourself rail about how it is horrible how government based systems and hospital programs are destroying a doctor's ability to practice of his own clinical decision making.

Yet you are now making the exact same argument, that research - self limited and a study of tenuous quality * - will determine policy and trump a doctor's decision making ability. is this what you want?



*not a blinded study, no placebo group or placebo controls, follow up only 30 days. in JAMA, a journal that i associate with some degree of scepticism.
The reduction on use of illicit drugs is self-reported and there was no difference in the rates of negative urine tests opioid use. how much do you trust an addict to say how much they are using?
inpatient rate of addiction services use higher for those who got did not get buprenorphine. the study is making the assumption that inpatient addiction use is bad, and outpatient is good/better. is that the proper assessment?
 
Richard Saitz is a smart & ethical guy. It would be interesting to hear his views.
 
first, we all have seen multiple threads how research can be tainted.

second, you yourself rail about how it is horrible how government based systems and hospital programs are destroying a doctor's ability to practice of his own clinical decision making.

Yet you are now making the exact same argument, that research - self limited and a study of tenuous quality * - will determine policy and trump a doctor's decision making ability. is this what you want?



*not a blinded study, no placebo group or placebo controls, follow up only 30 days. in JAMA, a journal that i associate with some degree of scepticism.
The reduction on use of illicit drugs is self-reported and there was no difference in the rates of negative urine tests opioid use. how much do you trust an addict to say how much they are using?
inpatient rate of addiction services use higher for those who got did not get buprenorphine. the study is making the assumption that inpatient addiction use is bad, and outpatient is good/better. is that the proper assessment?

I'm just having fun with the lengths that people will go to torture logic and "Data" in order to make it to make it fit their ideological agendas...let's get back to the issue at hand: When should provocation discography be performed in the Emergency Department?
 
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http://www.forbes.com/sites/cjarlot...-to-prescribe-opioids-to-discharged-patients/

Emergency Physicians Are Not Likely To Prescribe Opioids To Discharged Patients

CJ Arlotta
CONTRIBUTOR

While some people visit primary care physicians when they’re in pain, others head to the emergency room. With emergency physicians wanting to provide pain relief to their patients, prescribing opioids to discharged patients may seem like the best option to some — but many physicians are refusing to jump the gun too soon.

Published in the Annals of Emergency Medicine, a journal for the American College of Emergency Physicians, a new report, titled “Opioid Prescribing in a Cross Section of US Emergency Departments,” found that only 17% of patients discharged from the emergency department were given prescriptions for opioid pain relievers. The study also concluded that almost all of these prescriptions were immediate-release formulations and an overwhelming majority of them were small pill counts.

Dr. Lewis Nelson, one of the paper’s authors, warned of the adverse effects of prescribing emergency department patients with extended-release painkillers. “Long-acting and extended-release opioids are very dangerous,” he said in an interview. “They are associated with a great risk of overdose and death, as well as addiction and abuse. They are only appropriate for patients already using large amounts of short-acting, immediate-release formulations.”

After studying the files of 3,284 discharged patients from 19 different emergency departments, researchers learned that the most common opioid painkillers prescribed were oxycodone (52.3%), hydrocodone (40.9%) and codeine (4.8%). A little more than 70% of these patients also received an opioid in the emergency department, where the most common painkiller prescribed was oxycodone (49.2%).

“Based to some extent on the nature of the injury or illness, the expectations of the patient, and the ability to provide follow-up care, a physician use his or her clinical judgment to determine which and how much of pain medicine is optimal,” Nelson said. “There are no clear rules, but most clinicians should fall within a scope of decision-making.”

Emergency medicine physicians prescribed opioids for several types of pain. The report found that the most common diagnosis among study participants was musculoskeletal back pain — abdominal pain followed, and then extremity fractures and sprains.
 
Dr. Lewis Nelson, one of the paper’s authors, warned of the adverse effects of prescribing emergency department patients with extended-release painkillers. “Long-acting and extended-release opioids are verydangerous,” he said in an interview. “They are associated with a great risk of overdose and death, as well as addiction and abuse. They are only appropriate for patients already using large amounts of short-acting,immediate-release formulations.”


And this guy is an idiot. Never speak about what you don't know for a journal. All i gots todo is get on 8 or 10 loratabs and he will give me the big O. Opanarosanadana.
 
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