Yale-designed treatment for opioid use disorder in EDs gains widespread use
A Yale-designed treatment, in which emergency department doctors administer the drug buprenorphine to patients experiencing opioid use disorder, has been increasingly adopted in hospitals across the U.S., a new analysis finds.
Writing in the JAMA Network Open, a journal of the American Medical Association, Yale researchers report that the drug, which safely decreases withdrawal symptoms, was used for treatment during more than 441,000 emergency department (ED) visits from 2002 to 2017. Using data from ED visits nationally, they find that use of buprenorphine increased from 12.3 per 100,000 ED visits in 2002-2003 to 42.8 per 100,000 ED visits in 2016-2017 — a 300% increase.
Since discovering the effectiveness of the drug for the treatment of opioid use disorder in 2015, a Yale research team has advocated for a wider use of the medication in emergency rooms. Through an ongoing national outreach effort and funding from the National Institute on Drug Abuse Clinical Trials Network, the Yale physician-scientists have led the charge to educate and train frontline practitioners.
“This is an excellent example of how Yale science has changed medical practice nationally,” said Dr. David Fiellin, professor of medicine, emergency medicine, and public health, director of the Yale Program in Addiction Medicine, and one of the lead authors of the report.
Buprenorphine activates the brain’s opioid receptors and helps patients safely manage and treat opioid addiction. These treatments save lives, the researchers say.
“For individuals who come to an emergency department after an opioid overdose and receive buprenorphine, their one-year mortality rate falls by 40%,” said Fiellin. And, he added, patients treated with buprenorphine have been shown to have an improved social and family outcomes, better job performance, and lower rates of infections (including HIV).
The increased recognition of the benefits of buprenorphine comes at a critical time, the researchers said. According to the data, a growing number of patients with opioid use disorder are showing up in emergency departments. The COVID-19 pandemic has driven up overdose cases and limited access to addiction treatment programs, they said.
“The opioid epidemic has been exploding,” said Dr. Gail D’Onofrio, professor of emergency medicine, chair of the department of emergency medicine, and co-lead author. “We expect to see a 30% rise this year in opioid deaths. Most likely this is due to social isolation, lack of access to care, and the overwhelming feeling of despair during COVID.”
In 2015, in a landmark study, D’Onofrio and Fiellin found that patients admitted to EDs for opioid use disorder who were treated with buprenorphine were twice as likely to remain in addiction treatment one month later compared with those who were simply referred to treatment programs. Before that, this treatment wasn’t widely available at the nation’s EDs, Fiellin said.
Barriers to widespread use of buprenorphine included practitioners’ lack of education about the treatment and its benefits, lack of formal training, and confusion about required waivers needed to prescribe the drug. A study by D’Onofrio and Fiellin, published earlier this year in JAMA Network Open, found that just 21% of emergency department clinicians at four academic emergency departments indicated readiness to offer buprenorphine to patients in need due to these barriers.
The Yale physician-scientists have been working to improve those numbers. “There’s a multidisciplinary effort to train all health professional students in the requirements for a waiver to prescribe buprenorphine, including all medical students, nursing students, physician assistants and residents trained at Yale,” said D’Onofrio. These efforts are funded by the Substance Abuse and Mental Health Services Administration.
The Yale team, which includes Dr. Kathryn Hawk, assistant professor in emergency medicine and attending physician in the Yale New Haven Hospital Emergency Department, also worked directly with the American Academy of Addiction Psychiatry (AAAP) and the American College of Emergency Physicians to create a course related to administering buprenorphine by emergency physicians. AAAP is distributing the course nationally.
In addition to these education efforts, the Yale team is conducting a large trial comparing different formulations of the medication at approximately 30 emergency departments around the country and providing consultations to any emergency systems who want more guidance. All of them are improving adoption rates, D’Onofrio said.
“Yale demonstrated the benefit of this model years ago,” said Fiellin. “Since then, we have been actively involved in disseminating it nationally. This data indicates that we’ve been successful.”