Newsletters

POSTED: June 18th, 2018
POSTED IN: EM Pulse - The Official Newsletter of MOCEP, May/June 2018,

We’d like to thank everyone that completed the survey MOCEP sent out earlier this year. The response rate was great and will really help focus the Board over the next year. As a reminder, three of the 6 questions discussed addiction. The other questions related to free standing EDs, and as legislation regarding them didn’t go anywhere, we think we can wait to see what occurs during the next legislative session. Here are the questions pertaining to addiction and the membership’s response.

1. Should MOCEP support needle exchange programs? Yes-70%
2. Should MOCEP support ED physicians providing MAT in the ED? Yes-67%
3. Should MOCEP serve as a resource to those interested in beginning MAT in the EDs? Yes-77%

Legislation for needle exchange programs passed the Missouri House last year but stalled in the Senate. Some states have had programs for nearly 30 years. The best data we have indicates that programs decrease the rates of HIV and hepatitis C without increasing drug use. The CDC, WHO, and National Academy of Science have all conducted studies and reached similar results. Some data also indicates the exchange programs decrease needle sticks and transmission to first responders, as well. As part of a harm reduction strategy, this is why momentum for these programs continues to grow, whether MOCEP chooses to support them or not.

Regarding MAT initiation in the ED, we still believe that it should be up to local EDs and providers to implement this if they feel comfortable doing so. We are not supporting a mandate or saying that this should be the current standard of care. However, it does appear that under the right circumstances this can be successfully implemented in EDs that choose to do so. If set up correctly, the programs shouldn’t add more work to the provider in the ED. This idea also addresses an important issue as the 1 month mortality rate after an overdose is incredibly high.

Currently, MOCEP is in discussion with the Missouri Hospital Association to assist those providers and facilities that are interested and choose to do this. Should your ED be interested in this, we’d like MOCEP to be able to support you in providing this service. If this is not something that your ED is prepared to do, we respect and understand that decision but would still like to offer the College’s support in treating this population in any way that we can.

Of course, support for these issues was not unanimous and some of the membership has very legitimate concerns and questions including at what point are we going beyond the scope of our profession. For now, we’d like to at least take a moment to try to address some of these concerns, present the other side of why we’re asking our membership about them, and open a dialogue.

The idea of initiating MAT in the ED is not to serve as a replacement for an addiction treatment center and take all the patients they don’t want. In fact, it is the opposite; we want to give them more patients, particularly patients that have struggled to access care in the past. To be successful, the ED has to have facilities that interested patients can reliably access in a timely fashion. If not, just starting them on medication is probably not helpful.

The idea would be to start patients on the medication and have them follow up within a few days, somewhat analogous to following up with your primary care doctor after being seen in the ED for anything else. The hope is that by starting medication and controlling withdrawal and cravings, this will be the incentive for patients to follow up and get more at the treatment facility. For many patients, fear of withdrawal and cravings becomes the main motivation of continued drug use. Hopefully by treating this when they are receptive, they will be more likely to make good decisions such as going to rehab. The point is not for them to return to the ED for more medication.

While in the past timely follow up may have been unrealistic, many treatment centers can and do receive federal and state money for taking these patients. Now you may think, won’t this just make the ED busier? While this can’t be definitively ruled out, EDs that have implemented these programs have not been overrun by patients trying to get suboxone. Additionally, there are multiple easy to use protocols that can be used in the ED. Actually getting the x-waiver (the license needed to prescribe suboxone), well, that is unfortunately still rather burdensome.

Another potential problem would be the patient that keeps presenting to get medicine either for personal use or to sell. Maybe the only nice thing about the electronic health record is that this should be pretty easy to catch and prevent. What is also nice is that, at least anecdotally, most of these patients follow up with the treatment center so diversion risk appears minimal, and likely less than with the other opioids we already prescribe. And once again if the patient is not following up or there are concerns about diversion, then referral without medication is likely the best option. Once again, this is just some of the thought process behind implementing these programs in the ED. Whether your hospital can or should do this is best left for your group to decide.