Changing culture and improving care for patients with opioid dependence

To combat the opioid crisis that continues to claim lives in the U.S., more health systems are developing holistic programs to address opioid use disorder within the four walls of their hospitals.

One method increasingly used in the acute care setting is medication assisted treatment (MAT). During a March 9 webinar, hosted by Becker's Hospital Review and sponsored by Vituity, three industry experts discussed how health systems could develop and implement MAT programs in their emergency departments (EDs).

The panelists were:

  • Gregg Miller, MD, Chief Medical Officer, Vituity
  • Dylan Carney, MD, MPH, Director of Medication Assisted Treatment Program, Vituity
  • Candace Fong, PharmD, system Vice President of Medication Safety, CommonSpirit Health (Chicago)

Why health systems should combat the opioid epidemic through the ED

In 2017, there were more than 72,000 drug overdose deaths in the U.S., and 68 percent of those involved opioids, according to CDC data from the most recent year available. 

In addition, the rate that opioid overdose patients visit the ED has increased in recent years. Between July 2016 and September 2017, ED visits for suspected opioid overdoses increased by 30 percent, according to the CDC.

"The ED is a great doorway into the system, and [it] is the only portal open 24 hours a day, 7 days a week, 365 days per year," Dr. Miller said.

However, many health systems are not well equipped to help patients with opioid use disorder in the ED, explained Dr. Miller.

Opioid use disorder patients who enter the ED don't always receive care to properly treat the underlying disease, explained Dr. Miller. In fact, many patients simply receive telephone numbers of local treatment clinics, which is not an effective strategy to help treat opioid use disorder, he added.

"There is a much better way to manage this epidemic in the ED, in a way that gives hope to both patients as well as overwhelmed, burdened staff," Dr. Miller said.

A better way to manage the opioid crisis in the ED 

Many hospitals across the country are implementing MAT programs within their EDs to better manage the opioid crisis in their communities. By combining medications like buprenorphine with counseling and referral to treatment, these programs provide comprehensive, cost-effective, and evidence-based care to patients with opioid use disorders, Dr. Carney explained. 

Throughout the last few years, MAT programs have moved from the outpatient arena into EDs because of their efficacy, according to Dr. Carney.

A 2015 study published in JAMA analyzed patient outcomes in three different groups: one group received a referral to a treatment program, another group received a referral and counseling in the ED, and the third group received their first dose of buprenorphine in addition to referral and counseling.

The study found that the group that initiated treatment in the ED was nearly twice as likely as the other groups to still be receiving treatment at the 30-day mark. “Those patients were also less likely to use opioids after ED discharge,” Dr. Carney said.

Due to its efficacy, more health systems are adding or expanding MAT programs for opioid use disorder. 

Key steps to initiating a MAT program

There are three key steps hospitals need to take to ensure they implement a successful medication-assisted treatment program for opioid use disorder,according to Dr. Carney.

1. Ensure buprenorphine is on the hospital formulary. “Hospitals need toensure that this drug, used to treat opioid withdrawal symptoms, is on their formulary so providers can prescribe it, and it is readily available,” according to Dr. Carney.

2. Connect with local outpatient treatment clinics. "Build a solid handoff process to prioritize ED and hospital discharges and early follow up," Dr. Carney said. In rural areas where there might not be a local outpatient treatment clinic, providers should partner with telehealth companies that can provide patients with the services they need.

3. Provide education and training to clinicians. Educate the physicians, nurses, and pharmacy to ensure that they are all on board with the new process.

How Dignity Health implemented its MAT program 

Dignity Health, now part of Chicago-based CommonSpirit Health, has about 1.8 million ED visits per year to its hospitals, and on average, 697 of those are opioid overdose visits, Dr. Fong explained. Opioid overdose visits account for about $4.4 million in annual costs to the organization, excluding intensive care unit stays, Dr. Fong said.

As a result, Dignity Health saw an opportunity to help better address opioid use disorder by launching a MAT program in its EDs. The system began the program in early 2019 when a grant fund was made available in California. Eleven of the system's 24 California hospitals have the program grant-funded. An additional 7 hospitals implemented non-grant funded programs MAT programs in 2019 as well. 

"It became an opportunity for us to really make an impact with opioid use disorder and have our hospitals be active participants in this," Dr. Fong said.

Dr. Fong, who has helped implement this program at Dignity Health in collaboration with Vituity, shared recommendations for establishing a MAT program that can be used as tips for health systems looking to implement similar programs. 

1. Drive buy-in.Clinicians are the ones that will be driving the change on the frontlines, Dr. Fong explained. As a result, it is essential that a health system spends time helping those clinicians understand the program, so they support it. At Dignity Health, the system had physician champions to help generate buy-in among clinicians. In addition, it is important that senior leadership understands the benefits the program brings to the organization, Dr. Fong added.

2. Develop a standardized approach. Dignity Health realized quickly it would need a standard approach to establish the program and ensure success at its 11 hospitals participating in the grant-funded program. "With 11 different hospitals that have 11 different personalities and cultures, we realized we needed a standard approach," Dr. Fong said.  The health system developed a comprehensive toolkit that laid out the requirements for the grant program as well as standard procedures to start a MAT program. In addition, Dignity Health created a standard order set for its hospitals.

3. Use a substance use navigator. Dignity Health used a substance use navigator as the key liaison between the health system and the patient for the grant-funded hospitals. Before a dose of the medication was administered, the patient would be seen by this substance use navigator. Across the 11 hospitals in the program, patient acceptance of the substance use navigator grew throughout 2019. In December, 44 percent patients that came to the ED for an overdose were seen by the substance use navigator and were administered buprenorphine. 

4. Get the right people in pharmacy involved. Dr. Fong also tapped the right people in pharmacy to get buprenorphine on the health system's formulary. Dignity Health has a system pharmacy and therapeutics committee that helps determine which medications get placed on the facility formulary.

5. Ensure proper education not only for staff but for patients. Dr. Fong emphasized the importance of educating staff members on the process, but also ensuring patients understand the process and why a MAT program can work for them. 

To learn more about the benefits of incorporating a MAT program in the ED, read this article by Vituity's Dylan Carney here

About Vituity

As a physician-led and -owned, multispecialty partnership, Vituity has driven positive change in the business and practice of healthcare for nearly 50 years. Our clinicians provide compassionate, integrated acute care across the country, serving over 6.4 million patients annually.

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