Fighting the Opioid Epidemic

From the Emergency Department, University of Colorado Hospital

​It’s commonly thought that addiction is due to a personal flaw or moral failure: if the person experiencing addiction would only try harder he could overcome his cravings and become an upstanding member of society.

Yet the medical consensus​ is that addiction is a disease like any other, and can affect anyone. Although initially a person may misuse substances from their own free will, opioids change the way the brain works​ in ways that make it incredibly hard to quit. Plus, many people become dependent on opioids after taking a legitimate prescription. 

The main barrier to recovery is, of course, managing withdrawal symptoms. Unfortunately, for many who reach out for support the cravings can be so intense they feel they have no choice but to misuse substances again to ease their symptoms.

A new way forward

To help break this cycle, the emergency department at University of Colorado Hospital has begun a new pilot project to treat patients presenting with Opioid Use Disorder, using the medication buperenorphine. This medication drastically reduces the cravings associated with opioid withdrawal and has been shown to lead to better patient outcomes when used in conjunction with counseling.

Before the pilot started in June 2018, emergency department providers didn’t have a way to help patients presenting with an underlying addiction. “They could give patients phone numbers and resources but it was up to the patient to set up an appointment with someone who could prescribe buperenorphine,” said Roberta Capp, MD, MHS​, medical director for care transitions and clinical program development in the emergency department at University of Colorado Hospital. (Pictured above, top row, l-r: Jason Hoppe, DO, Kennon Heard, MD, Matthew Zuckerman, MD; bottom row: Angela Khoshnoud, Shannon Nash, Roberta Capp, MD)

“The evidence shows that when we start a patient on medication the moment they ask for help, they are much more likely to be successful,” she said.

The UCH program, funded by a grant from the Office of Behavioral Health, allows nurses and providers to screen patients while in the emergency department and offer those who are identified with Opioid Use Disorder the chance to begin treatment during their visit. The program is a harm reduction model, based on a study from Yale University that indicated that patients who receive treatment in the emergency department to manage withdrawal symptoms and cravings are more likely to reduce long-term use and engage in ongoing treatment for their addiction. 

Identifying eligible patients

“Social workers do a lot of the heavy lifting when it comes to our screening questionnaire,” Dr. Capp said. “They determine the complexity of a patient’s situation. Once we start their initial treatment in the ED and release them, someone who has an underlying mental health condition or is experiencing homelessness may be directed to a community mental health center with resources beyond buperenorphine prescribing, whereas someone with no underlying comorbidities may be referred to a primary care provider who specializes in buperenorphine treatment.”

So far, patients who are diagnosed with opioid use disorder have been open to beginning treatment. Angela Khoshnoud is the social work manager for the Emergency Department at UCH. She explains that it’s important to start treatment in the emergency department as that is where patients are most vulnerable.

“Typically patients with Opioid Use Disorder present to the emergency department in a crisis of some sort, and we’re finding they are more receptive to beginning treatment while in this heightened and vulnerable state,” she said. “If a person with Opioid Use Disorder leaves the ED with just a piece of paper with resources, by the time they can get to a traditional treatment clinic, if at all, they’re already experiencing withdrawal and will often use again to stop the intolerable symptoms. We’re breaking down these barriers to care by helping them manage their symptoms while connecting them to external clinics that can continue their treatment long-term.”

Changing a culture

With the stigma of addiction so high, Khoshnoud, Dr. Capp, Dr. Matthew Zuckerman​, Dr. Kennon Heard​ and Jason Hoppe, DO​, associate professor of emergency medicine at UCH, have been working hard to change attitudes. A shift in perspective was critical, since patients undergoing buperenorphine treatment may take up a bed for 6–12 hours while providers attend to emergencies around them.

“It’s not easy to disseminate information to our entire staff,” Dr. Hoppe said. “We’ve delivered education through our department pathway but we’ve also been making ourselves present to push the project forward from our core team.” 

This is important for Dr. Hoppe and his team as he believes the emergency department is a vital safety net for vulnerable patients.

“Emergency medicine overall is taking on a lot of public health causes, and is often the only place patients receive care with things like suicide screening, HIV screening and domestic violence,” he said. “We’re making good progress reducing opioid addiction. All the patients I’ve enrolled so far have been in disbelief that someone is trying to help them.” 

Dr. Capp agrees, explaining that all her efforts are worthwhile when she speaks with patients who have opioid use disorders.

“I recently met a man in his twenties who was in the ED with his pregnant wife and small child,” she said. “After we went through the induction, he held my hand and thanked me for saving his life. Moments like that speak to how desperate people are to get help and they just don’t know how to find it.

“We believe everyone who is asking for help should be given help,” she said. “We’re still only at the beginning of the program and we’re open to the fact that there will be adjustments. But what we’re facing right now is an epidemic, and we can save lives by intervening right here in the emergency department.”