E6: MAT in the Emergency Department

E6: ED MAT

Dr. Emerman and Laura Beal (APRN-CNP Emergency Medicine)

This is OnePath with Metrohealth, your toolkit for helping to combat the opioid epidemic as a member of the medical community with empathy, mindfulness, and a big-picture perspective. I’m Libbey Pelaia, educator within Metrohealth’s department of Opioid Safety. Thanks for joining us.

A large part of managing the opioid epidemic has, unfortunately, become the responsibility of those working in the emergency department. Having the proper tools and resources available in these high-pressure situations is integral to saving lives and helping folks begin their journey towards recovery.

When patients come into the ED displaying symptoms of an opioid overdose, withdrawal, or symptoms of substance use disorder, medication assisted treatment, or MAT, is often one of the primary options offered for managing their symptoms.

Dr. Charles Emerman, department chair of emergency medicine at metrohealth, has been involved in the development of the ED MAT program from the beginning, and says that Metrohealth has had an active ED MAT program for the past several years.

The essence of the program is many of our physicians have the special federal license that you require in order to prescribe medication assisted treatment for patients with opioid use disorder. And along with a lot of the resources that we have available to us, we identify patients who might benefit from that treatment, engage them in treatment and facilitate getting them into a longer term treatment after starting treatment in the emergency department.

At MetroHealth, caregivers employ a process that goes by the acronym SBIRT, standing for screening, brief, intervention, and referral to treatment.

So the basics of it is you engage patients, you talk to them about their social history, what sort of things they do, what sort of things they might need help with, which may be alcohol related or tobacco related, or in the case of what we're talking about here, opioid related. So it's fairly straightforward, which is you ask patients permission to talk to them about these things and you ask them open-ended questions and find out what they have to tell you.

So part of it is establishing that the patient has an opioid use disorder, and that means asking them questions about their medication use, whether it's prescribed or illicit. Finding out what their pattern has been, are they getting things off the street? Are they having issues related to illicit use, particularly have they had issues in the past with withdrawal or overdose, or is their use of opioids interfering with their lives? So those are the sort of general questions we'd ask them. And then we want to find out whether they're amenable to treatment. And if so, what type of treatment they might be interested in.

There are three medications approved by the FDA for the treatment of opioid use disorder: buprenorphine (including Suboxone which is a Buprenorphine/Naloxone Combination), Naltrexone (including extended release Naltrexone also known as Vivitrol), and Methadone-- a highly-regulated method of treatment that MetroHealth is currently unable to administer.

Suboxone is offered in tablet and sublingual film form and works as a partial agonist to opioid receptors in the brain.

Vivitrol is an intramuscular injection given to a patient once a month, an extended-release form of naltrexone, the only form of treatment to work as a full antagonist to opioid receptors-- a patient will not achieve the desired euphoric effect if opioids are used while on Vivitrol.

Both of these options are thought of as less-habit forming than Methadone, a medication that works as a full agonist to treat opioid use disorder, offered in pill, liquid, and wafer forms for daily use.

So those are the three options, and then you talk to people to find out what fits in with their lifestyle and what we can do to maintain them in treatment. Methadone is a good option for people that need a very structured sort of environment. To get methadone you have to go to the methadone treatment center pretty much every day. So you see the same people, they do their own testing. Some people benefit from that sort of structure.

The buprenorphine is a once a day pill. So for people who, for whatever reason, can't go down to the methadone treatment center, they live too far away, or they have a job, or there's some stigma to go into a methadone treatment center in some cases, so for people who don't want to have that exposure, buprenorphine is a good option for them.

And then the naltrexone is a once a month shots. So for patients who have difficulty to remember to take a pill every day, or that hasn't worked for them in the past, the naltrexone is a another good option for them. So those are our three basic options. There are some patients who can stop using opioids without any medication assisted treatment, but many of them can't do so. Those that do so without medication assisted treatment, tend to go through support group treatments, such as the opioid equivalent of AA, those work for some people not for many.

Along with having specially-trained and licensed physicians in the ED, there are also social workers, psychiatry faculty, case managers, and peer supporters working there.

We worked very closely with community agencies. We have a very good relationship with the city of Cleveland and they have their own resources, and we work with them on this.

Social workers have their own particular license, so they're very expert in initiating counseling and referral to treatment. They have their own licensure. So they have special expertise in that. Case managers in our system are experienced nurses and they have access to the resources of the organization, along with linkages to case managers from other organizations, insurance companies, social service agencies, and then the peer support group are not licensed people. They are people that have experience in substance abuse disorder and they've got a wide range of resources out in the community that they can refer patients to.

The peer support people have their own specific training, they're sort of down to earth people. They talked the ... I don't mean patients' language and they speak English or Spanish, but they understand street talk. And so they are able to really relate to the patients and empathize with them in a particular way. So they are very resourceful. They've got ... They have the ability to get patients admitted to sober living environments in a way that we don't always have access to.

-- we will speak a LOT more about peer supporters in coming episodes, but for now, know that Metro takes a diversified approach to providing an intensely supportive ED.

If we can engage somebody in treatment and keep them in treatment for several months, we will be successful. And really the key is ... And particularly for me in the emergency department, I need to get them stabilized and get them into treatment. There's ... And this is the reason why we initiate it in the emergency department. If you don't initiate treatment in the emergency department and you make referrals, you lose about half the patients before ... I don't mean lose in terms of dying, but you lose them to follow up. They just don't show up. Even if you make appointments for them, give them cab vouchers, here's when you need to go, be there next Tuesday at one o'clock, about half of patients don't show up, but if we start them on treatment, if we start them, then we're successful in about three quarters of the time to getting patients engaged in treatment.

And what we know for medication assisted treatment is that the longer you keep them engaged in treatment, the more successful you are. This is longterm treatment. The old notion from 15, 20 years ago about sending patients to detox, that doesn't work. You can send to detox and get them off of the medication for a very short period of time, but they go back to using again. The chemical changes that narcotics caused in the brain take a long time to reverse. And when you talk to patients about their recovery, what you'll find out is it is months to years before they start feeling normal. You have to get them over that period. You can get them over the acute withdrawal, but there's a prolonged withdrawal that lasts for months. If you don't provide them with medication assisted treatment, they will fail and go back to using. So that's what we try and do, is get them engaged in treatment, longterm counseling, longterm medication, assisted therapy. That's what will be successful.

Another key player in the world of ED MAT for opioid use disorder at MetroHealth is Laura Beal, APRN-CNP. She has a very important qualifier to enable her to prescribe MAT as a nurse, one that Dr. Emerman has to have as well.

I have an X waiver, which is what's required to prescribe MAT in the emergency department.

For physicians, I believe it's just an eight hour training, and then they get their X waiver. You have to get your own DEA license number, and then they give you the X license. For nurse practitioners and physician assistants, you have to do 24 hours. One is in person, eight hours in person, and the other 16 can be online. And then, you apply for your X waiver and you start prescribing.

Laura’s day to day work in the ED varies, but she says that on a normal day...

I'll come in, in the morning, I'll take a look at the emergency department, who's being seen, and I'll try to look and see if I see anything that looks suspicious for addiction signs or symptoms. Obviously an overdose, yes, you're going to go down and see if you can intervene. Other than that, you have to look for other signs and symptoms like cellulitis infections. That's from shooting up. That's something that if you see a patient who came in for that, that's a little suspicious. And then, you can look into their chart and see if you're right or not by their track record. How many times have they been in the ED? Maybe they've been there before as an overdose, and today they're just coming in with a wound. Sometimes it'll just say... You have to do a little detective work... It'll say flu like illness, and then if you look into their chart, you can see that they've been here before for suspicious things.

Laura says that checking a patient’s OARRS, or Ohio Automated Rx Reporting System record is key to being able to see the big picture of their prescription history.

The state pharmacy follows anything that's illicitly prescribed. They keep a record of it and you always have to check and see who's, if they're getting a lot of Percocet, a lot of opioids from people, or if it looks like they're doctor shopping, they're going to different prescribers and getting things. That's something that's a little suspicious as well.

Sometimes they'll come in and they'll say, "Well, I've been taking Suboxone. I got shut out of my program and I need a refill." So, that's a really good tool for us to use as well, because we can verify, "Okay, were you going to someone? Oh, okay, yeah, you were, and it was the same person. And how long have you been going?" Just like a fact checker. It's awesome.

The only thing we can't check on is methadone, because they give it out at the clinic, the actual methadone clinic. So, if someone comes in and wants a dose for their methadone because they missed the clinic, we don't have any way to verify it unless they have documentation with them.

When Laura’s not in the ED, she’s often in the Project DAWN van-- the mobile unit committed to project DAWN, AKA Deaths Avoided with Naloxone.

It's possible that a patient will come up to the van… and get a Project DAWN kit. And maybe they've heard that we're doing Suboxone in the ER and they don't want to go into the ER, so they'll talk to them and then they'll connect to us, and then we intervene that way as well.

We'll go over there, we'll talk to them, we'll assess them. See how long they've been using, what kind of drug they're using, if they're appropriate for medication assisted treatment, and then we'll get them hooked up with an addiction medicine provider. We'll actually get them an appointment and we'll write them a prescription for their first... Usually it's a week, that's as long as we can prescribe for... And then we'll keep in touch with them and see if they need help with anything. Anything else, like rides, we can get them rides. We have a Lyft account through one of the grants at the hospital. So, if that's an issue, you can get them a ride to be picked up and scheduled to drive them there and picked up and taken home. There's phone calls, sometimes opioid safety office we'll get phone calls and we might get an email from someone saying, "Hey, can you call this person? They're asking about help."

MetroHealth is doing the most to ensure that each staff member in the ED or in the mobile unit is prepared to give the most comprehensive level of care possible.

Even my team in the emergency department, all three of us, we got trained to schedule patients. So now, we can actually do the scheduling ourselves, which is, I mean, it's more hands on it seems and it's more coordinated care. The case managers are part of care coordination, so that's really what we're doing. We're doing everything we can for them. We're assessing them, we're doing their labs, ordering their labs, getting them appointments, giving them prescriptions and rides. I mean, that's the whole thing one person can actually do.

I guess I'm just glad to be a part of our team and I love what I'm doing. I rarely get days off and there are times… there’s nothing better than hearing one of the people you helped have success, hearing about them or having them thank you. I mean, that makes it all worth it. I mean, it can be very challenging and the emergency department is a very stressful place to begin with. I think, I'm glad that I'm doing what I'm doing, and no matter how hard it gets, it could take... I don't know, 25 frustrating days in a row... but if I hear that someone's doing well and I actually made a difference that makerrs all the frustration worth it. So, I'm glad to be a part of our team.

Next time on One Path…

We talk about the Enhanced Recovery After Surgery program at Metrohealth.
OnePath with Metrohealth is a production of Evergreen Podcasts, produced, written, and engineered by Hannah Rae Leach and mixed by Sean Rule-Hoffman. Special thanks to Mike Tobin, Karolyn Tibayan, Joan Papp, Joya Riffe, and the entire Department of Opioid Safety in making this show possible.