Despite an opioid crisis, most ERs don’t offer addiction treatment. California is changing that.
January 08, 2019 | German Lopez | Vox
This is what it looks like when we stop treating addiction as a moral failure.
When Michael Curci still used opioid painkillers and heroin, he didn’t see himself living beyond his mid-20s.
Image: German Lopez/Vox
“I didn’t even think I was going to make it,” Curci told me, while at the El Dorado County clinic where he receives treatment for opioid addiction. “I didn’t think I was going to have any type of future.”
Curci is now 28. The moment that helped him survive came in October 2017, when he went to an emergency room not due to an overdose or an injection-related infection but to seek treatment for addiction. Unlike most hospitals in the US, Marshall Medical Center, an hour’s drive east of Sacramento, provided him with real treatment — particularly, buprenorphine, a highly effective medication that treats opioid addiction by mitigating withdrawal and cravings for the drugs.
For Curci, the approach has worked — after years of drug use, parties, doctor-shopping to get painkiller prescriptions, and even prison time due to two robberies meant to help get money for more drugs. There have been setbacks and one brief relapse since Curci got into treatment, but “now I know I’m going to have a future,” he said. “Now I know that I can do these types of things. I can have a job. I can do whatever I want with my life.”
If Curci had gone to the emergency room at most other American hospitals, his story might have ended differently. Patients in ERs with other chronic conditions, like heart disease or diabetes, typically meet with a specialist quickly to start the long-term process of managing their condition. A patient with drug addiction, on the other hand, is often sent on his way with a pamphlet for treatment options, a few talking points, and not much else — even though the evidence suggests that this hands-off approach does little to reduce the serious risk of overdose and death.
Curci, though, encountered a still-unusual approach of treating addiction in the emergency room — one that California, Massachusetts, and other states are now expanding in earnest as the country deals with an opioid epidemic.
At the core of this work is a straightforward idea: treating addiction like any other medical condition, and building treatment for addiction into the rest of the health care system.
If done right, this idea could dramatically expand access to addiction treatment across the US. Instead of relying on expensive, infrequent, and siloed addiction treatment facilities, people with addiction could go to their doctor or local hospital to get help. They could pay for that treatment not out-of-pocket — as remains common — but with health insurance, making treatment much more affordable. The medication they use would be viewed not as a crutch — a common view of buprenorphine — but as akin to insulin, aspirin, or any other medication for chronic conditions. And as with other conditions (from diabetes to cancer to heart disease), relapse wouldn’t be treated as a moral failure, but a normal part of recovery.
The ER is one place where this broader approach can begin. Most emergency rooms across the country, though, do not offer this care. Much of that is caused by stigma toward drug use and addiction, which can make it difficult to persuade ER doctors to do something they historically haven’t done. But even if health care providers do want to offer addiction treatment, there are concerns: How do you do it? Will it be expensive? Where will patients go for continuing care after they leave the emergency department, especially in a country where treatment options are often inaccessible or nonexistent?
California and other states’ experiences, though, suggest an ER addiction treatment program isn’t only possible, but that it works. California is now gearing up to expand the idea, with the state’s Bridge Program and Public Health Institute gearing up to award more than $8 million to as many as 30 hospitals in the coming weeks. By making treatment more like other kinds of health care, the state is hoping to see more stories like Curci’s.
As America’s opioid epidemic continues, the approach is increasingly necessary. Drug overdoses were linked to a record 70,000 deaths in 2017, more than two-thirds of which involved opioids, and 2018 appears to have been about as bad. And beyond the overdose deaths, federal surveys have found that there are more than 2 million people addicted to opioids in the US — and experts say that is, if anything, an underestimate. Those are millions of people who could potentially benefit from treatment if it’s made more available.
Filling America’s addiction treatment gap
Most people in the US with drug addictions struggle to get treatment. A 2016 surgeon general report found that just 10 percent of people with a substance use disorder get specialty treatment, in large part due to a lack of access to care. Even when specialty treatment is available, federal data indicates that fewer than half of treatment facilities provide evidence-backed medications like buprenorphine or methadone.
These medications have been around for decades. Studies show that they reduce the all-cause mortality rate among opioid addiction patients by half or more and do a far better job of keeping people in treatment than non-medication approaches.
But misconceptions remain about buprenorphine and methadone, in large part because they are opioids themselves. Curci himself told me that he worried the medication was just “substituting one drug with another.” But the problem with addiction isn’t that someone is using drugs or even opioids. The problem is when drug use turns compulsive and harmful, leading to health problems, broken relationships, crime, and other negative consequences. So if buprenorphine or methadone helps someone stabilize his life, as was true in Curci’s case, then the medications really do treat the addiction even if they’re taken indefinitely.
But as the federal data indicates, these medications remain difficult to get in America.
In theory, health care providers can prescribe buprenorphine, but not many do. According to the White House opioid commission’s 2017 report, 47 percent of US counties — and 72 percent of the most rural counties — have no physicians who can prescribe buprenorphine. Only about 5 percent of the nation’s doctors are licensed to prescribe buprenorphine. And if a health care provider does want to get certified, the process can be time-consuming — requiring, under federal law, a special training course that’s eight hours for doctors and 24 hours for nurse practitioners and physician assistants.
Methadone is similarly inaccessible. It’s siloed off into special clinics, which face arduous federal, state, and local regulations, and are frequently forced to operate in low-income and minority neighborhoods due to not-in-my-backyard attitudes. Many places don’t have any methadone clinics at all — including El Dorado County, where Curci got help at Marshall.
Traditional addiction treatment clinics can also offer the medications, but, based on the federal data, the majority don’t. That’s a result of the kind of stigma Curci previously held: Despite the evidence of effectiveness, many traditional addiction treatment programs don’t see people as genuinely in recovery if they use buprenorphine or methadone.
The opioid epidemic, however, has led policymakers and people in addiction treatment to reevaluate the evidence and to try to dramatically expand access to addiction treatment. That’s now extended to ER-based solutions.
The idea is not that someone has to come into the ER through an overdose or injection-related infection to start getting into treatment. As Arianna Sampson, who helped set up the ER program at Marshall Medical Center, told me, the possibility of withdrawal — which is characterized by terrible flu-like symptoms, along with crippling anxiety — is enough of an emergency to start getting people into treatment. In short: If someone wants help, they can get it at the ER 24/7.
“We have an open door,” Sampson said.
Seeking help at the ER
One patient, whom I’ll call Claire, went to the the UC Davis Medical Center in Sacramento in withdrawal and wanted to start on buprenorphine for her opioid addiction. At 48, Claire had most recently been using opioids for five years, though she had struggled with drug use for much of her life.
The emergency department at the Marshall Medical Center in Placerville, California
Image: German Lopez/Vox
Claire carried around a large bag, which, among other items, held phones that she played games on to distract herself from the withdrawal pain that she was currently going through. Asked where she felt the pain, she responded, “Everywhere.” On a scale of 1 to 10, she rated her pain an 11.
Claire found out about the ER program through its substance use counselor, Tommie Trevino. But when she showed up, she was skeptical it would work. “I’m in withdrawal,” she said. “I’m scared it’s not going to be enough.”
The UC Davis ER staff checked her vital signs and asked her about her previous medical history, which included pancreatitis, hepatitis C, and a fractured back. They asked when she last used heroin, since buprenorphine requires at least partial withdrawal to work. Claire said she had last used at 8 pm, a bit over 14 hours before she showed up at the ER. That’s enough time for withdrawal.
In between doctor and nurse check-ins, Claire opened up to Trevino about struggling with addiction, an abusive husband, and better times before she fell down into heroin use once again. She complained about the withdrawal pain, which she said was causing her to hurt all over her body. She talked about her 5-year-old granddaughter. “She’s my life,” Claire said. She joked, “I don’t even like my kids anymore.”
A nurse gave Claire a first dose of buprenorphine, then, when it wasn’t enough (which is pretty typical), another dose. Within an hour, Claire was relaxed. Her heart rate calmed. When she first came in, Claire was restless and in pain, refusing food because she was nauseated from withdrawal. Now she could sleep. She said she was hungry and got a sandwich shortly before she left.
“That stuff works pretty fast,” Trevino said.
By the time Claire left, she had begun setting goals for her recovery and said she felt “great” and was “grateful” for the chance to get treatment.
There is growing evidence for the ER approach
Watching the ER visits, the most striking thing about them was how normal they were and how much the clinicians involved simply treated addiction like any other health problem. Patients had their vital signs taken. Doctors and nurses checked for other medical needs. Patients got other care as necessary. The discussion about addiction, too, seemed largely like any other doctor’s visit — with a back-and-forth about the patient’s problems and desires, and how that could be balanced out with what the health care provider considers best.
This is not how America has, by and large, confronted addiction in the past. Addiction has notoriously been characterized as a moral failure. The most common response I get to any addiction story argues that overdoses are just “Darwin’s theory in action.”
A growing body of scientific evidence, though, shows that this has never been the right way to approach addiction, and addiction should instead be treated much like the ER visits that I witnessed.
One big study, published in JAMA in 2015, randomized participants at Yale New Haven Hospital in Connecticut into a more typical ER approach for addiction that referred patients to treatment elsewhere, another approach that tried to more directly motivate patients to seek treatment, or buprenorphine treatment. A month in, the patients who got on buprenorphine treatment in the ER were around twice as likely to remain in addiction treatment compared to other participants, and reported less than half the days of illicit opioid use per week as the other groups.
A follow-up study published in Addiction in 2017 also concluded that buprenorphine treatment is cost-effective compared to other approaches.
One hitch to the initial study: While buprenorphine patients reported less illicit opioid use per week, all patients — regardless of approach — were about as likely to test positive for opioids in urine tests.
Gail D’Onofrio, lead researcher on the study, argued that this doesn’t mean that the buprenorphine treatment was less effective, because urine tests can pick up opioid use from days ago. So if someone has reduced their opioid use but is still using to a lesser degree — still a welcome, if imperfect, development — that wouldn’t show up with a urine test, but it would in the self-reports.
D’Onofrio did caution, though, that the study’s promising results don’t necessarily mean that the ER approach will work everywhere. Yale’s hospital, which is highly respected and connected to a lot of local treatment resources, may be able to do this kind of work better than most others. (Even the standard, referral-only approach that the study used was more extensive than what most ERs do.) The same might not be true in other parts of the country.
So research will likely need to validate the approach in other areas. Some of the people involved in California’s work — along with the National Institute on Drug Abuse, a federal agency — are working to produce those studies. But there’s good reason to think it’ll work, given the Yale study and the overall evidence behind buprenorphine.
Treatment is needed after the ER, too
The hardest part of getting addiction treatment in the emergency department may not be anything in the ER itself. Instead, leaders of ER programs in different states told me that the biggest hurdle may be ensuring that a patient has a place to get longer-term care after the ER starts that patient on addiction treatment.
At the UC Davis emergency room, Claire left with a buprenorphine prescription to tide her over, and staff set up an appointment with a county clinic for low-income patients like her that can usually see new patients within a week.
It was, Trevino told me, the typical process: A patient comes in with withdrawal, overdose, or an injection-related infection; gets started on medication treatment; and is set up with another health care provider for longer-term care.
A bit east, at Marshall Medical Center, it was the same process that Curci went through when he was referred to El Dorado Community Health Centers, where he’s still a regular patient. It’s what anyone would expect from the ER with any other medical condition.
But longer-term care is a thorny problem. Even if an ER starts people on addiction treatment, it’s possible, even likely, that there won’t be a treatment clinic around, or a clinic will have a waiting period of weeks or months. It’s the equivalent to having the ER stabilize someone with a heart attack and giving them some short-term medication, but there being no cardiologists or other specialists around for follow-up care.