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ER docs: Medical ‘paradigm shift’ makes opioid use disorder meds more accessible, saves lives

In the past, physicians needed to apply for a special permit called an X-waiver to prescribe buprenorphine. Last week, the Drug Enforcement Administration announced an end to the X-waiver program.

The disease-aware approach includes prescribing buprenorphine, or Suboxone, to patients that come to ERs experiencing symptoms of opioid withdrawal.
The disease-aware approach includes prescribing buprenorphine, or Suboxone, to patients that come to ERs experiencing symptoms of opioid withdrawal.
REUTERS/Brian Snyder

With opioid addiction continuing at crisis levels around Minnesota, some Twin Cities emergency room physicians are treating opioid use disorder as an illness rather than a moral failing.

The disease-aware approach includes prescribing buprenorphine, or Suboxone, to patients that come to ERs experiencing symptoms of opioid withdrawal. Those patients are later offered Suboxone refills at the hospital and connected to affiliated addiction medicine clinics.     

In the past, physicians needed to apply for a special permit called an X-waiver to prescribe buprenorphine. But last week, the U.S. Drug Enforcement Administration (DEA) announced that the X-waiver program had been eliminated as part of the 2023 Omnibus BillThis means that any physician with an active DEA license can prescribe the drug, potentially getting the life-saving medication to more people with opioid use disorder. 

Eliminating the X-waiver requirement represents a significant “paradigm shift,” said Dr. Jon Cole, an ER physician at Hennepin County Medical Center and medical director of the Minnesota Poison Control System: “Patients will have substantially greater access to treatment now, all over Minnesota, as long as their local physicians are willing to prescribe the medication.” 

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Last week, I spoke with Cole, and two other Minneapolis ER physicians — Dr. Nick Simpson, chief medical director of Hennepin Healthcare Emergency Medical Services, and Dr. Tim Kummer, medical director for Hennepin County Emergency Medicine Community Outreach.  The three shared their perspectives on the key role that ER docs can play in supporting patients through opioid addiction. This interview has been edited for length and clarity.

MinnPost: Recent discussions about the potential decriminalization of illicit substances lends itself to a larger discussion about adopting a less judgmental perspective around substance use disorder. Is the move toward easier access to Suboxone also a shift in that direction? 

Jon Cole: There is no patient population where words matter more than for patients with substance use disorder. How we speak about the disease is really important in terms of being humane toward patients and meeting them where they are at to help with their substance use disorder  in an evidence-based way that helps them succeed toward recovery.

Jon Cole
Jon Cole
How we refer to the condition is really important even up to how we refer to the therapies. Buprenorphine and methadone are the FDA-approved drugs we use to treat opioid use disorder. And even in the past few years, how we speak about the treatment we use for that has changed.  We’ve moved away from saying medication-assisted therapy, to either calling it “medication for addiction treatment” or medication for opioid use disorder.

This gets at the inherent bias of addiction being a moral failing or personal weakness that needs treatment outside of medication. There is very good evidence that this is a disease that can be effectively treated just with medication, that people can treat it with medicine, just like they would diabetes or hypertension. We’d never prescribe medication to treat someone’s diabetes and call it “medication-assisted diabetes treatment.” It’s just medication to treat their disease. 

It helps everybody involved to get in the mental mindset of, “I’m treating a disease. This is a medication that I’m using to treat this disease.” 

MP: What are the advantages of treating opioid use disorder with buprenorphine rather than with methadone? 

Tim Kummer
Tim Kummer
Tim Kummer: One of the challenges that our patients face is that they don’t necessarily want everyone in their lives to know that they are going through this. One of the things that Minneapolis has just gotten up and running that is really unique are these “Safe Station” programs, where they’ve got a few different fire stations where patients with opioid use disorder can go and get their medication checked, check in with a nurse or speak with a peer recovery specialist. 

One thing that is challenging with methadone is the methadone bag. Not always, but many times, it looks like a money bag from a bank with a lock, and inside of that is the methadone.  So it feels a little scarlet letter-y, whereas Suboxone is a normal medication that you slip in your pocket and people think it’s for your heart or whatever. It is easier to keep that more hidden from the people around you. 

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Nick Simpson
Nick Simpson
Nick Simpson: That paradigm shift of how we think about it is far-reaching, more than how it was before. When I started residency in 2011, we’d just make sure we could get people in withdrawal to survive so that they could be discharged. Now there are discussions about, “How can we get them into treatment? How can we offer other harm-reduction strategies for their friends and family?” There is a more holistic view of how we can care for patients and the community. 

MP: Tell me more about the patients you are treating for opioid use disorder.

TK: We have a full spectrum of patients who have opioid use disorder. We have everything from people who are brought in because they weren’t breathing and they got CPR on the street or they got Narcan and they woke up and were brought into the ER so we could observe them and keep them safe all the way to the other end of the spectrum. For instance, I was in triage last night and I had patients coming in to say, “I ran out of my Suboxone. I can’t get it filled again until Monday. I’m not in withdrawal. I know I’ll go into withdrawal. I’m hoping you can give me my script for a couple of days until I see my clinic.” In-between that we have patients coming in and saying, “I’m in really bad withdrawal. I want to get sober. Can you help me?” 

MP: How long have you been able to prescribe buprenorphine for patients in the ER? 

JC:  The X-waiver first became law in 2002, so theoretically we could’ve been doing it since then. I don’t think this was a particularly common practice in emergency medicine really at all until the twenty-teens.

In 2015, a study was published that showed that this practice was not only feasible but safe and effective. At 30 days post treatment, study participants that were treated with buprenorphine in the ER and given a prescription were nearly twice as likely to still be in treatment than those that weren’t. That study shifted the specialty of emergency medicine to say, “This is an effective thing that we can do for our patients that has meaningful outcomes in terms of keeping them in treatment.” Treatment is life-saving for those patients.  

The first physicians in our department who were X-waivered were in 2018. We started our program about three years after that paper was published. 

MP: Can you give me an example of what this approach has been able to do for people? 

TK:  One of the challenges of working in emergency medicine, especially in the last three years, is we accrue a lot of moral injury because we can’t do very much for patients.  One of the better moments for me, selfishly — and for patients — is when you have somebody who has decided, “I want to get sober,” and they’re in withdrawal and because at HCMC we can get them Suboxone right away and they can almost instantly start to feel significantly better. We know from the studies and from working with our colleagues in addiction medicine that we have a reasonable chance that if a person feels better they will go home with medications and they will enter a world that will do its darndest to help them to stay sober. When we don’t get a lot of wins that feels good. 

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MP: I bet it does. But you probably don’t get many patients back in the ER saying, “You helped me,” do you? 

JC: It turns out that’s not true. I do see patients coming back because they succeed in treatment and they bring a friend back who is still using and they say, “They helped me here. Please help my friend, too.” That word-of-mouth referral is one of the most rewarding things I’ve witnessed since we started doing this. 

We’ll get follow-up that people are doing well in treatment and they started with us in the ER. It’s hard for me to find the words to articulate what an incredible paradigm shift that is from when I was a resident from 2006 to 2009. It feels incredibly rewarding to help people feel better not only in the moment, but also help them take the first steps toward their recovery. It is the most rewarding part of my practice over the last three years. 

It took people in emergency medicine a while to see that the one-year mortality rate that they see in opioid withdrawal is as high or higher than the patients that they see in the ER with chest pain. These patients are at very high risk for death in the next year. That is why it is so important for us to connect them to evidence-based, effective therapies as soon as possible. 

MP: Do you get any pushback from hospital colleagues about offering these services to a group of people who may be coming back, bringing their friends, people who say things like, “We don’t want these addicts in our hospital?” 

TK: It’s a growing problem and I think this kind of work empowers us and our nursing colleagues and our medics and everyone that we work with in the system to believe that actually we can do something and the doing of something is empowering because this is not getting better. It is nice to be able to say, “I understand that maybe there is a concern that you don’t want anyone else coming to the ER because we’re super busy,” but they’re coming anyway, this is a tool to do something about it. 

NS: The other thing that we talk about internally is, “Let’s say we have another 100 people tomorrow that we can offer this therapy to. How can we get all of the people into our clinic?” That’s where the system is headed now: How can we accommodate more people in the clinic setting if we start to capture more people in the EMS and the ER setting?

MP: How common is it in other hospitals around the state that physicians are providing these services in the ER? 

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JC: Project Echo is a program through Hennepin Healthcare that provides addiction medicine training for all of Minnesota and focuses on rural care. My experience with that is throughout the state there is everything from literally no care whatsoever in the ER all the way up to bridge clinics in the ER where an addiction medicine provider will come down and see patients. We are in a fast-changing era where the standard of care is changing pretty rapidly. 

MP: Is there anything else you’d like to make sure you say on this topic? 

NS: To put all this stuff together, as a physician, the more barriers we see removed, the less scary this is for me. I’ve always known it existed but it’s always been this thing that you have to have a special license for. It was unsettling and it made me feel like there was an excessive risk involved. But as time goes on and I learn more and more about it and I see it used and I see the good that it can do, having those barriers come down creates a sense of normalcy, making it like every other medicine that we prescribe. 

JC: We want people who use drugs to know that the emergency department is a safe place to seek care and we want to help them with their disease.