NY Times on 8/18/2018 by Abby Goodnough
OAKLAND, Calif. — Every year, thousands of people addicted to opioids show up at hospital emergency rooms in withdrawal so agonizing it leaves them moaning and writhing on the floor. Usually, they’re given medicines that help with vomiting or diarrhea and sent on their way, maybe with a few numbers to call about treatment.
When Rhonda Hauswirth arrived at the Highland Hospital E.R. here, retching and shaking violently after a day and a half without heroin, something very different happened. She was offered a dose of buprenorphine on the spot. One of three medications approved in the United States to treat opioid addiction, it works by easing withdrawal symptoms and cravings. The tablet dissolved under her tongue while she slumped in a plastic chair, her long red hair obscuring her ashen face.
Soon, the shakes stopped. “I could focus a little more. I could see straight,” said Ms. Hauswirth, 40. “I’d never heard of anyone going to an emergency room to do that.”
Highland, a clattering big-city hospital where security wands constantly beep as new patients get scanned for weapons, is among a small group of institutions that have started initiating opioid addiction treatment in the E.R. Their aim is to plug a gaping hole in a medical system that consistently fails to provide treatment on demand, or any evidence-based treatment at all, even as more than two million Americans suffer from opioid addiction. According to the latest estimates, overdoses involving opioids killed nearly 50,000 people last year.
By providing buprenorphine around the clock to people in crisis — people who may never otherwise seek medical care — these E.R.s are doing their best to ensure a rare opportunity isn’t lost.
“With a single E.R. visit we can provide 24 to 48 hours of withdrawal suppression, as well as suppression of cravings,” said Dr. Andrew Herring, an emergency medicine specialist at Highland who runs the buprenorphine program. “It can be this revelatory moment for people — even in the depth of crisis, in the middle of the night. It shows them there’s a pathway back to feeling normal.”
It usually takes many more steps to get someone started on addiction medicine — if they can find it at all, or have the wherewithal to try. Locating a doctor who prescribes buprenorphine and takes insurance can be impossible in large swaths of the country, and the wait for an initial appointment can stretch for weeks, during which people can easily relapse and overdose.
[Read about the national shortage of doctors who can prescribe buprenorphine.]
A 2015 study out of Yale-New Haven Hospital found that addicted patients who were given buprenorphine in the emergency room were twice as likely to be in treatment a month later as those who were simply handed an informational pamphlet with phone numbers.
After Dr. Herring read the Yale study, he persuaded the California Health Care Foundation to give a small grant to Highland and seven other hospitals in Northern California last year, in both urban and rural areas, to experiment with dispensing buprenorphine in their E.R.s. Now the state is spending nearly $700,000 more to expand the concept statewide as part of a broader, $78 million effort to set up a so-called hub-and-spoke system meant to provide more access to buprenorphine and two other addiction medications, methadone and naltrexone.
Under that system, an emergency room would serve as a portal, starting people on buprenorphine and referring them to a large-scale addiction treatment clinic (the hub), to get adjusted to the medication, and to a primary care practice (the spoke) for ongoing care. Dr. Herring is serving as the principal investigator for the project, known as E.D. Bridge. The $78 million is most of California’s share of an initial $1 billion in federal grants that Congress approved for states to spend on addiction treatment and prevention under the 21st Century Cures Act, enacted in 2016.
“At first it seemed so alien and far-fetched,” Dr. Herring said, noting that doctors are often nervous about buprenorphine, which is more commonly known by the brand name Suboxone. They need training and a special license from the federal Drug Enforcement Administration to prescribe it for addiction (it’s also used to treat pain), although E.R. doctors don’t need the license to provide doses of the medication to patients in withdrawal.
But lately, Dr. Gail D’Onofrio, the lead author of the Yale study, has been fielding calls every week from E.R. doctors interested in her hospital’s model.
Since the study was published, a few dozen hospital emergency departments, including in Boston, New York, Philadelphia, Brunswick, Me., Camden, N.J., and Syracuse, have also started offering buprenorphine.
“I think we’re at the stage now where emergency docs are saying, ‘I’ve got to do something,’ ” Dr. D’Onofrio said. “They’re beyond thinking they can just be a revolving door.”
As Dr. Herring’s shift began one Tuesday, a 30-year-old woman in a white baseball cap entered the E.R. She said she had been using heroin for the past three years, but had been taking opioids since a doctor prescribed her the painkiller Norco after a softball injury when she was 12. She had overdosed twice and had never stopped using for more than two months at a time. Most recently, she told the doctor, she had been snorting fentanyl from a dealer who gave it to her for free in exchange for meth provided by her friend.
She was talking fast about how she hadn’t been able to sleep for days. She had just moved into a sober-living house in Berkeley, about 20 minutes away, and withdrawal was kicking in. The manager of the house had sent her to Highland.
“My heart was just pounding,” the young woman, who asked to be identified only by her first name, Angelica, told Dr. Herring. “My stomach hurt from everything going straight through me. My body just won’t turn off.”
Dr. Herring nodded. “It’s called wired and tired,” he said. A nurse brought her a buprenorphine tablet as they went over her history, and Dr. Herring told her to come to his addiction clinic in two days for a follow-up visit and more medication.
While the care provided in emergency rooms is particularly expensive, supporters of programs like E.D. Bridge say E.R.s are the best place for stabilizing any dangerously out-of-control condition, including addiction.
We don’t think twice about someone having a heart attack, getting stabilized in the emergency department, and then getting ongoing care from the cardiologist,” said Dr. Kelly Pfeifer, director of high-value care at the California Health Care Foundation. “And the risk of death within a year after an overdose is greater than it is for a heart attack.”
She added that since E.R. visits like Angelica’s are usually brief and uncomplicated, they aren’t as expensive as many other types of E.R. care.
Here in Oakland, a city of 416,000, opioid addiction cuts across lines of race and ethnicity. Highland has provided buprenorphine to roughly equal numbers of blacks and whites, with Latinos, Asians and other ethnic groups filling out the rest. Many of those patients are homeless and most are on Medicaid, the government health insurance program for the poor that, crucially for Dr. Herring’s program, California expanded under the Affordable Care Act. Buprenorphine can cost more than $500 a month, putting it out of reach for many of the uninsured.
Since February 2017, Highland’s E.R. has offered buprenorphine to more than 375 emergency room patients. Two-thirds of them accepted it, along with an initial appointment for ongoing treatment at the hospital’s addiction clinic.
Many were in withdrawal. Some had infections from injecting opioids. Others were seeking help for an unrelated medical problem, like a broken arm, but disclosed that they were addicted to heroin or opioid painkillers.
Dozens have continued taking buprenorphine, a weak opioid that activates the same receptors in the brain that other opioids do, but doesn’t cause a high if taken as prescribed. Even if they reject the idea of starting treatment, those who try buprenorphine in the E.R. may be more likely to do so in the future, Dr. Herring said.
“You’ve given them a chance to test-drive it,” he said. “They’ll still remember in a month, in a year.”
At Highland, patients who get an initial dose of buprenorphine also usually get a prescription for Suboxone, which comes in strips that dissolve in the mouth and is harder to abuse, to last until they can get to an addiction clinic that Dr. Herring runs on Thursdays. There, he assesses their progress and often adjusts their dose on a weekly or biweekly basis until they can find a more permanent provider.
Dr. Herring has reached out aggressively to detox centers, where people often spend a few days withdrawing from heroin, and residential treatment programs. Although many such programs haven’t allowed residents to be on buprenorphine or methadone, California has started requiring them to.
Signs posted throughout the E.R.’s waiting area — “Need Help With Pain Pills or Heroin? We want to help you get off opioids” — have helped spread the word. That’s how a man named Abai found his way to Dr. Herring; his sister had come to the E.R. with a respiratory infection, seen the signs and told him about the program.
Abai, who is 35 and asked that his middle name be used to protect his privacy, had been released from federal prison six weeks earlier, and was trying hard not to return to heroin and other drugs that he had used incessantly before his 18-month sentence. He had been buying buprenorphine off the street, but now he had a job offer and wanted a more stable source of treatment.
“It keeps me away from doing any hard drugs and that’s really critical for me,” he said. “Being on federal probation, they have zero tolerance.”
About an hour later, after Dr. Herring briefly met with him, a nurse called Abai’s name and put a buprenorphine tablet under his tongue. He left after promising to come to Dr. Herring’s clinic the next morning.
An urban public teaching hospital like Highland, with lots of mission-driven doctors and a commitment to serving the poor, can do this — particularly in the Bay Area, where attitudes about addiction are among the most progressive in the country. But can every hospital? Given the choice, would they?
“You do hit sort of a culture clash,” said Arianna Sampson, a physician assistant at Marshall Medical Center in Placerville, Calif., about two hours northeast of Oakland in rural El Dorado County. Ms. Sampson worked with Dr. Herring to start an E.D. Bridge program there last year, and her emergency room has provided initial doses of buprenorphine to 41 patients since last August. But Ms. Sampson has had to work to overcome stigma about buprenorphine — that it’s just one opioid replacing another — in the community, she said.
The Placerville program refers patients to a local community health center that prescribes buprenorphine, where many have become regular patients.
Although Highland’s E.R. treats a fair number of opioid overdose victims — about 150 last year- — they aren’t usually candidates for starting buprenorphine on the spot, Dr. Herring said. Many have just been revived with naloxone, an injectable drug that reverses overdoses, and there isn’t enough data yet about the safety of giving them buprenorphine so soon afterward.
“Figuring out how to do that safely and effectively has to be one of our greatest priorities,” Dr. Herring said.
The efforts to help don’t always work. One afternoon in May, a homeless woman named Jessica came to the Highland E.R. with a festering abscess on her arm, the result of a heroin injection gone bad. She was thin, with a whispery voice. Waiting for help, she asked a nurse what month it was.
The staff had flagged her as a patient for Dr. Herring, and he learned she had been using for seven years. Because she had injected heroin just before coming to the E.R., she was not a candidate for an immediate dose of buprenorphine; people have to be in at least mild withdrawal to start taking it, otherwise it can throw them into full-fledged withdrawal. Christian Hailozian, the E.D. Bridge program coordinator, sat down next to her with a checklist of questions.
“So you live just by yourself, in your car?” he asked. “No friends or family with you?”
“Do you have a phone number I can reach you at? You don’t have a phone?”
“O.K. ma’am, we’re going to let the doctors treat your arm right now,” he went on. “But we’d really like you to come back tomorrow. O.K.? It would be really good to try and reduce the amount of heroin you’re doing and try to start on these meds. You’re going to have to put yourself in a little bit of withdrawal.”
Jessica was preoccupied with her swollen arm, staring past Mr. Hailozian. After her abscess was drained, she left in a hurry, scuffing across the floor in pink slippers.
That day was a long one for Dr. Herring, who met with Abai and Jessica in between a steady flow of emergencies, including a harrowing one involving a toddler who had stopped breathing. He worked until midnight.
The next morning, he arrived at the hospital early and hustled to the basement office where he holds his weekly clinic for patients who started buprenorphine in the E.R. Angelica and Abai were already waiting, as were a young homeless couple carrying all their belongings. Ms. Hauswirth was there, too, with a friend from her detox center, Christa Blackwell.
Ms. Hauswirth wasn’t feeling well. She had never let herself experience withdrawal before, scrambling to find heroin or pills before it kicked in. Although she was now taking 16 milligrams of buprenorphine daily, a healthy dose, she was still feeling sick by the end of each day.
“It’s a war within my body,” she told Dr. Herring.
He added a nighttime dose of eight milligrams to her regimen; she had used very heavily for several years and needed more help than some.
Ms. Blackwell, 42, was livelier, telling Dr. Herring that she was doing well on 16 milligrams of buprenorphine daily.
But Dr. Herring had a warning for her: “People can feel like they’re cured. So just keep taking it, like a vitamin.”
“You’ve torched everything, and the medication is letting it grow back, and it’s going to be beautiful,” he added. “But it’s going to take some time.”