Beyond the 'revolving door': At Highland Hospital, the ED is a gateway to addiction treatment

It's not an uncommon scenario: A person presents at an ED in withdrawal, they're given medicine to manage their symptoms and sent on their way—but one California hospital takes a unique approach that emphasizes immediate treatment for substance misuse, Abby Goodnough reports for the New York Times.

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 A 'Bridge' to treatment

Oakland, California-based Highland Hospital's ED Bridge program prioritizes substance misuse treatment over symptom management. Through the program, patients who come to Highland's ED with withdrawal symptoms are started on buprenorphine—one of three medications that's FDA-approved to treat opioid addition—and are referred to a larger-scale treatment clinic within the hospital, followed by a primary care practice for continued care, Goodnough reports.

Patients at Highland typically receive a prescription for Suboxone—a brand of buprenorphine that comes in the form of dissolvable strips—to last them until they're able to get to Herring's treatment clinic.

Andrew Herring, an emergency medicine specialist at Highland, proposed the program after reading a 2015 study from Yale-New Haven Hospital that found patients given buprenorphine—a medication that satisfies opioid cravings without causing a high—in the ED were twice as likely to be in treatment a month later than those who were given an informational pamphlet and phone numbers to call about treatment, Goodnough writes.

According to Herring, the ED can offer an entry point to long-term recovery. "With a single [ED] visit we can provide 24 to 48 hours of withdrawal suppression, as well as suppression of cravings," he said. "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."

Kelly Pfeifer—director of high-value care at the California Health Care Foundation, which provided grant funding to set up the program—said EDs are the best setting to stabilize any dangerous condition, including opioid withdrawal. "We don't think twice about someone having a heart attack, getting stabilized in the [ED], and then getting ongoing care from the cardiologist," she said. "And the risk of death within a year after an overdose is greater than it is for a heart attack."

In addition, ED visits to treat withdrawal are typically short, simple, and not as expensive as many other forms of ED care, Pfeifer said.

The programs success spurs

Since February 2017, Highland has offered 375 ED patients treatment with buprenorphine, and two-thirds have accepted it along with a follow-up appointment at the hospital's clinic, Goodnough reports.

The ED Bridge program is not in place at seven other Northern California hospitals, and according to Goodnough, a number of EDs elsewhere in the country have also begun offering buprenorphine.

The program's success also spurred California to invest almost $700,000 to expand the ED Bridge program as part of a larger $78 million program aimed at expanding access to buprenorphine as well as other forms of medication-assisted treatment, such as methadone and naltrexone.

Gail D'Onofrio, the lead author of the Yale study, said she believes "we're at the stage now where emergency docs are saying, 'I've got to do something.'" She added, "They're beyond thinking they can just be a revolving door" (Goodnough, New York Times, 8/18).

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