"Once we save people, we have to talk seriously about next steps," says Scott Weiner, MD, FACEP, assistant professor at Harvard Medical School and director of the Brigham Comprehensive Opioid Response and Education Program at Brigham and Women's Hospital.
In 2016, about 64,000 people in the United States died from drug overdoses, at least half of which were opioid related. The fatalities will keep rising without more comprehensive interventions, suggests research presented during a tele-news conference from the American College of Emergency Physicians' (ACEP) annual meeting.
"The numbers…completely fail to communicate the levels of suffering that are going on in the individual patient," said Krista Brucker, MD, FACEP, an emergency physician at Indiana University School of Medicine in Indianapolis, IN, and author of a study aimed at determining what factors put individuals at risk.
"There are as many paths into addiction as there are out of it," Brucker said, noting that about half of a person's predisposition for a substance-use disorder is genetic.
The project found that a substantial portion of patients who come to the ED after surviving an overdose had high rates of other mental health diagnoses (55%) and exposure to early abuse or family dysfunction (60%).
"In order to truly reach overdose survivors, we need a much better understanding of who they are and the many challenges they face when they seek care," she said.
"Designing and implementing effective outreach and referral programs will require listening carefully to patients and taking into account the impact of untreated mental illness, exposure to childhood trauma, and many other medical and social determinants of health."
While an underlying behavioral health crisis continues in the United States, EDs are well positioned to meet patients where they are during the teachable moment of a crisis, Bruker added, noting that only a third of the patients treated at her safety net hospital have regular access to primary care.
A separate study presented at the ACEP meeting highlighted another factor putting patients at extraordinarily high risk for overdose: A previous overdose.
During the study led by Scott Weiner, MD, FACEP, assistant professor at Harvard Medical School and director of the Brigham Comprehensive Opioid Response and Education Program at Brigham and Women's Hospital in Boston, more than 12,000 individuals (i.e., about 400 a month) who had overdosed in Massachusetts were given the reversal drug naloxone by emergency medical services (EMS).
Despite the clinical effectiveness of the drug:
- 6.5% of patients died later the same day
- 9.3% of patients died within one year, about 40% of whom died outside the hospital
- Not counting patients who died the same day, more than half of the deaths occurred within a month of being saved with naloxone
"Naloxone is not a panacea," Weiner said.
It's still crucial that the antidote continue to become more ubiquitous, carried by EMS, police officers, and bystanders, he emphasized.
But it's not enough to bring rescued patients to "sober in the hallway" of the ED, give them a list of detox centers, and discharge them, he explained.
"Once we save people, we need to talk seriously about the next steps. There have been several innovative models throughout the country where they actually start buprenorphine or suboxone directly in the ED and get people to not suffer the withdrawal symptoms that often make them leave and start using again," Weiner said.
"But even that's not enough," he continued. "We need a follow-up system after that—a warm handoff. We need to be able to start them in the ED and say, 'Tomorrow, you can come to this clinic and we'll help you.'"
However, according to an online poll of 1,261 emergency physicians also presented during the meeting, more than half of respondents (57%) said that detox and rehabilitation facilities were rare or never accessible.
Debra Shute is the Senior Physicians Editor for HealthLeaders Media.