Abstract
Recent evidence shows that emergency physicians (EP) can help patients obtain evidence-based treatment for Opioid Use Disorder by starting medication for addiction treatment (MAT) directly in the Emergency Department (ED). Many EDs struggle to provide options for maintenance treatment once patients are discharged from the ED. Health systems around the country are in need of a care delivery structure to link ED patients with OUD to care following initiation of buprenorphine. This paper reviews the three most common approaches to form effective partnerships between EDs and primary care/addiction medicine services: the Project Alcohol and Substance Abuse Services and Referral to Treatment (ASSERT) model, Bridge model, and ED-Bridge model.The ASSERT Model is characterized by peer educators or community workers in the ED directly referring patients suffering from OUD in the ED to local addiction treatment services. The Bridge model encourages prescribing physicians in an ED to screen patients for OUD, provide a short-term prescription for buprenorphine, and then refer the patient directly to an outpatient Bridge Clinic that is co-located in the same hospital but is a separate from the ED. This Bridge Clinic is staffed by addiction trained physicians and mid-level clinicians. The ED-Bridge model employs physicians trained in both emergency medicine and addiction medicine to serve within the ED as well as in the follow up addiction clinic.Distinct from the Bridge Clinic model above, EPs in the ED-Bridge model are both able to screen at-risk patients in the ED, often starting treatment, and to longitudinally follow patients in a regularly scheduled addiction clinic. This paper provides examples of these three models as well as implementation and logistical details to support a health system to better address OUD in their communities.
Highlights
There were more than 70,000 drug overdose deaths in the United States in 2017, 68% of which involved opioids, an increase of 12% from 2016.1,2 This rapid rise in opioid-related deaths has prompted swift action by the medical and public health communities to slow the epidemic and prevent further loss of life
Given the peer-centered approach, which leverages less highly skilled advocates rather than clinicians, the ASSERT model is a viable solution for departments which do not have the resources to support ED clinician waiver training or hospital systems that are not interested in investing in a functional Bridge Clinic
The drawbacks of this model, are that ED clinicians are not the central point of contact for patients with regard to their use disorder while they are in the ED
Summary
There were more than 70,000 drug overdose deaths in the United States in 2017, 68% of which involved opioids, an increase of 12% from 2016.1,2 This rapid rise in opioid-related deaths has prompted swift action by the medical and public health communities to slow the epidemic and prevent further loss of life. In a meta-analysis conducted by Mattick et al, buprenorphine was superior to placebo in retaining people in treatment in all of the 14 placebo-controlled comparisons.[2] This finding was further supported by D’Onofrio et al through a randomized clinical trial involving 329 opioid-dependent patients who were treated at an urban teaching hospital They found that among patients with OUD, ED-initiated buprenorphine treatment, when compared to brief intervention or referral only, significantly increased engagement in addiction treatment, reduced selfreported illicit opioid use, and decreased use of inpatient addiction treatment services.[11] Clark et al demonstrated a 50% lower risk of relapse than behavioral treatment without MOUD.[12] In a study of 33,923 Medicaid patients diagnosed with OUD, treatment with buprenorphine was found to be effective across a range of outcomes, including reducing all-cause mortality, improving physical and mental health, and decreasing illicit drug use. Education and Referral to Treatment (ASSERT) model is characterized by peer educators or community workers in the ED directly referring patients found to be suffering from OUD in the ED to local addiction treatment services
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