Despite an opioid crisis, most emergency rooms do not offer drug treatment. California is changing that. • Good Assurance

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SACRAMENTO, Calif. – When Michael Curci was still using opioid painkillers and heroin, he did not see himself living beyond his mid-twenties.

"I did not even think I was going to get there," Curci told me, while he was at the El Dorado County Clinic where he was being treated for an addiction. opioids. "I did not think I was going to have a future."

Curci is now 28 years old. The moment that helped him survive came in October 2017, when he went to an emergency room not because of an overdose or an overdose. an infection related to an injection, but to be treated for dependence. Marshall Medical Center, located an hour's drive east of Sacramento, provides real treatment, unlike most American hospitals. buprenorphine, a highly effective drug that treats opioid addiction by reducing weaning and cravings.

For Curci, the approach worked – after years of drug use, parties, solicitation from a doctor to obtain painkiller prescriptions and even imprisonment for two robberies qualified to get money for more drugs. There have been setbacks and a brief relapse since Curci's treatment started, but "now I know I'm going to have a future," he said. "Now, I know I can do this stuff. I can have a job. I can do what I want in my life. "

Michael Curci said his life was resuming after getting help for opioid addiction in an emergency room at the Marshall Medical Center in Placerville, California.

Michael Curci said his life was resuming after getting help for opioid addiction in an emergency room at the Marshall Medical Center in Placerville, California. German Lopez / Vox

If Curci had gone to the emergency rooms of most American hospitals, his story could have ended differently. Emergency patients suffering from other chronic diseases, such as heart disease or diabetes, usually meet a specialist quickly to begin the long-term process of managing their disease. On the other hand, an addict patient often receives a pamphlet containing treatment options, a few talking points and little else – even though the evidence suggests that this non-interventionist approach does little to reduce the serious risk of overdose and death.

Curci, however, has encountered an unusual approach to addiction treatment in the emergency room – an approach that California, Massachusetts and other states are developing more and more seriously as the country opioid epidemic.

At the heart of this work is a simple idea: treating addiction like any other medical condition and integrating addiction treatment with the rest of the health care system.

If done right, this idea could significantly expand access to drug treatment in the United States. Instead of relying on expensive, infrequent and compartmentalized drug treatment centers, addicts could visit their doctor or the local hospital for help. They could pay for this treatment not out of pocket – as is common – but with health insurance, making the treatment much more affordable. The medication that they use would not be considered a crutch – a common view of buprenorphine – but appears to be insulin, aspirin or any other medication for the treatment of chronic diseases. And as with other diseases (from diabetes to cancer to heart disease), a relapse would not be treated as a moral failure, but as a normal part of recovery.

Emergencies are a place where this broader approach can begin. However, most of the country's emergency rooms do not offer this care. Much of this is caused by stigma towards drug use and addiction, that can make it difficult to persuade emergency physicians to do something they have never done. But even if health care providers want to offer treatment for addiction, there are concerns: how do you do it? Will it be expensive? Where will patients go for treatment once they have left emergency, especially in a country where treatment options are often inaccessible or nonexistent?

The experience of California and other states, however, suggests that an addiction treatment program in an emergency room is not only possible, but that it works. California is now preparing to develop the idea, with the state's Bridge Program and the Institute of Public Health going to allocate more than $ 8 million to no fewer than 30 hospitals in the coming weeks. By making treatment more like other types of health care, the state hopes to see more stories like Curci's.

As the opioid epidemic continues in America, this approach is increasingly needed. Drug overdoses were tied to a record 70,000 deaths in 2017of which more than two-thirds were opioids, and 2018 appears to have been about as bad. And beyond overdose deaths, federal polls have discovered that there are more than 2 million people opioid-dependent in the United States – and experts say that is at least an underestimate. These are millions of people who could potentially benefit from treatment if it were made more accessible.

Bridging the addiction treatment gap in America

In the United States, most addicts struggle to get treatment. A general surgeon 2016 report found that only 10% of people with a substance use disorder were taking specialized treatment, largely because of a lack of access to care. Even when specialized treatment is available, federal data indicates that less than half of treatment facilities provide evidence-based medications such as buprenorphine or methadone.

These drugs have been around for decades. Studies show that they reduce the all-cause mortality rate in opioid-addicted patients by: half or more and do a much better job of keep people in treatment than non-drug approaches.

But misconceptions about buprenorphine and methadone persist, largely because they are opioids themselves. Curci himself even told me that he feared that the drug would only be "substituting one drug for another". But the problem of addiction is not that someone consumes drugs or even opioids. The problem is that drug use becomes compulsive and harmful, leading to health problems, broken relationships, crime and other negative consequences. So if buprenorphine or methadone helps a person stabilize his life, as was the case in Curci, the drugs really treat the addiction, even if it is taken indefinitely.

But as indicated by federal data, these drugs remain difficult to obtain in America.

In theory, health care providers can prescribe buprenorphine, but few do. According to the White House Commission on Opioids 2017 report47% of US counties – and 72% of rural counties – have no doctor who can prescribe buprenorphine. Only about 5 percent Country doctors are allowed to prescribe buprenorphine. And if a health care provider wants certification, the process can be very time-consuming – require special training under federal law eight hours for doctors and 24 hours for nurse practitioners and medical assistants.

Methadone is also inaccessible. He is confined to special clinics subject to very strict federal, state and local regulations, and often have to work in low income neighborhoods and minority neighborhoods because of attitudes that are not in my backyard. Many places do not have methadone clinics, including El Dorado County, where Curci got help in Marshall.

Traditional drug treatment clinics may also offer drugs, but most federal data do not do so, according to federal data. This is the result of the stigma that prevailed before, according to Curci: despite evidence of its effectiveness, many traditional programs of treatment of drug addiction to not see people who are really recovering if they use buprenorphine or methadone.

The opioid epidemic, however, has prompted decision-makers and people on addiction treatment to reevaluate evidence and attempt to dramatically expand access to drug treatment. It is now extended to emergency-based solutions.

The idea is not that someone is starting to go to the emergency department after an overdose or injection-related infection to start a treatment. As Arianna Sampson, who helped set up the emergency program at Marshall Medical Center, said the possibility of weaning, characterized by terrible flu-like symptoms, accompanied Disabling anxiety is enough for patients to get treatment. . In short: if someone needs help, he can have it in the emergency room 24/7.

"We have an open door," said Sampson.

Ask for emergency help

A patient, whom I will call Claire, withdrew from UC Davis Medical Center in Sacramento and wanted to start taking buprenorphine for her opioid addiction. At age 48, Claire had been using opioids for five years, although she had battled drugs for most of her life.

The emergency department at the Marshall Medical Center in Placerville, California, where patients with opioid addiction are being treated on the spot.

The emergency department at the Marshall Medical Center in Placerville, California, where patients with opioid addiction are being treated on the spot. German Lopez / Vox

Claire was carrying a large bag that contained, among other things, phones she was playing on to distract herself from the pain of withdrawal she was currently going through. When asked where she felt the pain, she replied "Anywhere." On a scale of 1 to 10, she rated her pain as 11.

Claire discovered the emergency program through her addiction counselor, Tommie Trevino. But when she arrived, she was skeptical that it would work. "I'm back," she says. "I'm afraid it's not enough."

Staff at UC Davis ER examined her vital signs and asked her about her medical history, including pancreatitis, hepatitis C and a broken back. They asked when she had last used heroin because buprenorphine requires at least partial withdrawal at work. Claire said that she had used the last time at 8 pm, just over 14 hours before she arrived at the emergency room. That's enough time for the withdrawal.

Between the visits to the doctor and the nurse, Claire spoke to Trevino about her addiction problem, an abusive husband and better times before falling back into heroin use. She complained of the pain of withdrawal which, according to her, hurt her entire body. She talked about her 5 year old granddaughter. "She is my life," said Claire. She joked, "I do not even love my kids anymore."

A nurse gave Claire a first dose of buprenorphine, then, when that was not enough (which is rather typical), another dose. In an hour, Claire was relaxed. His heartbeat has calmed down. When she arrived for the first time, Claire was restless and in pain, refusing to eat because she was sick of her weaning. Now she could sleep. She said that she was hungry and that she took a sandwich shortly before her departure.

"This thing works pretty fast," said Trevino.

By the time Claire left, she had started setting goals for her recovery and said that she felt "good" and was "grateful" for the opportunity to seek treatment. .

There is more and more evidence for the ER approach

When looking at emergency room visits, the most striking aspect about them was their normal state and the fact that the clinicians involved were simply treating addiction like any other health problem. The vital signs of the patients were taken. Doctors and nurses checked for other medical needs. The patients received other care if necessary. The discussion of addiction also largely resembled any other visit to the doctor – with a back and forth on the patient's problems and desires and how it could be balanced with what the provider considers the best.

This is not the way America has, in the main, confronted dependency in the past. The addiction was notoriously described as moral failure. The most common response I have to a history of addiction is that overdoses are just "Darwin's theory in action."

There is growing scientific evidence, however, that this has never been the right way to deal with addictions and that this dependence should instead be treated in the same way as the emergency department visits I attended.

A big study, Posted in JAMA In 2015, randomized participants from Yale New Haven Hospital in Connecticut took a more traditional approach to addiction emergencies, which referred patients to other facilities, another approach to inciting more directly patients to seek treatment, or treatment with buprenorphine. One month later, buprenorphine-treated patients in the emergency department were approximately twice as likely to remain in addiction treatment as the other participants and reported less than half of the days of illicit opioid use per week compared to other groups.

A Follow-up study Posted in Addiction in 2017 also concluded that buprenorphine treatment is cost effective compared to other approaches.

A snag in the initial study: While buprenorphine patients reported less illicit opioid use per week, all patients – regardless of approach – were about as likely to be opioid positive in the first week of life. urine tests.

Gail D'Onofrio, the study's lead researcher, said this did not mean that buprenorphine treatment was less effective because urine tests could detect the use of opioids in previous days. So if a person has reduced their opioid use, but still uses it to a lesser extent – it's a welcome development, even if it's not perfect – it's not going to happen with a urine test but that would end up in the self-assessments.

D'Onofrio warned, however, that the promising results of the study did not necessarily mean that the emergency method would work everywhere. Yale Hospital, highly respected and connected to many local treatment resources, may be able to do this type of work better than most others. (Even the standardized, referenced approach used by the study was more comprehensive than that used by most emergency rooms.) This may not be the case in other parts of the country.

The research will probably have to validate the approach in other areas. Some people involved in the work of California – with the National Institute on Drug Abuse, a federal agency – are working to conduct these studies. But that's a good reason to think that it will work, given Yale's study and the general evidence behind buprenorphine.

Treatment is also needed after emergencies

Perhaps the most difficult part of dealing with addiction in the emergency department is nothing in the emergency department itself. Instead, emergency care program managers in different states have said that the biggest hurdle could be to guarantee a patient a place to receive long-term care after treatment begins. patient in addiction.

In the emergency room of UC Davis, Claire left with a buprenorphine prescription and the staff made an appointment with a county clinic for low-income patients like this, who can usually see new patients in a week.

Trevino said that it was the typical process: a patient arrives with a withdrawal, an overdose or an infection related to an injection; embarks on the drug treatment; and is set up with another health care provider for long-term care.

A little to the east, at Marshall Medical Center, it's the same process that Curci followed when he was referred to El Dorado Community Health Centers, where he is still a regular patient. This is what everyone would expect from emergencies, regardless of their state of health.

But long-term care is a thorny issue. Even if an emergency department starts treatment for addiction, it is possible, or even likely, that there is no treatment center in the vicinity or that there is a waiting period of several weeks or month. It is as if the emergencies stabilize someone with a heart attack and give them short-term medication, but there is no cardiologist or other specialist for follow-up care.

Dr. Neil Flynn talks with a patient about his opioid addiction at the Transitions Clinic in Sacramento, California. German Lopez / Vox

This is one of the most common concerns raised by health care providers specializing in addiction care about the supply of substance abuse treatment, said Sarah Wakeman, MD drug addiction specialist and medical director of the Massachusetts General Hospital Substance Toxic Use Disorder Initiative. As Massachusetts, one of the states hardest hit by the opioid crisis, has adopted legislation For more emergencies to be treated for opioid dependence, much of its effort has gone into creating a source for follow-up care. But the process of deploying this legislation and associated programs has not been easy.

"It was difficult to convince emergency medicine doctors to obtain a waiver for buprenorphine without knowing what would happen after the emergency department," she said.

To overcome this barrier, it was necessary to link existing addiction treatment providers, who needed to coordinate to work more effectively and to accommodate more patients. But in some cases, the existing pool of providers was not enough, so new clinics or providers had to be created from the ground up.

In California, the same concerns were raised. Much of the work in Sacramento has been focused on simply looking for more treatment providers and addiction treatment clinics to track patients, said Aimee Moulin, who helped place the emergency program at UC Davis Medical Center.

Transitions Clinic, one of the clinics with which the emergency department has partnered with Sacramento, has an incredible story: its founder, Neil Flynn, was at the forefront of HIV / AIDS at the height of this epidemic in the 1980s and 1990s. While he saw some of his HIV – positive patients become addicted to opioid analgesics and that the opioid crisis worsened, he moved to the front of the group. another outbreak, obtained authorization to prescribe buprenorphine and started to treat addiction.

When I asked what treatment buprenorphine had given them, the patients, after meeting with Transitions, all said the same thing: "It changed my life." They explained to me how they worked. could now look after their family, keep a job and get a job. return to other interests. A patient was very happy to have been hired for a singing job at a major video game company.

But all that cost the patients a lot: $ 200 a month. Transitions does not accept insurance.

The $ 200 a month was used to pay as many appointments as needed. When I was there, Flynn often asked someone to come for a free follow up a week later. But there was still $ 200 a month, completely dependent.

According to Flynn, if he was getting insurance, there was a good chance that his clinic – which was barely reaching the threshold of profitability, pointed out to lose money, because health insurance did not pay much, and he had new expenses, such as hiring staff for billing and working with insurance companies. This is a common problem of drug treatment, for which insurance reimbursement rates are often low.

But $ 200 a month is a lot to ask for, especially for people with opioid addiction who may not have been able to keep a job because of their illness. The good news is that insurance will pay for buprenorphine itself when a patient picks it up at the pharmacy, but that does not cover other costs.

Moulin and Trevino recognized the problems associated with transitions. But they noted that the transitions had a big advantage: it could take patients in a few days. The other partner with whom UC Davis worked, a county clinic, actually accepted insurance, especially Medi-Cal (the Californian equivalent of Medicaid), but she could usually see patients only after a delay. waiting for a week. Claire, who is unemployed and works at Medi-Cal, had to go to the county clinic.

It is difficult to find partners, particularly in rural areas, but even in some resource-rich areas, such as Sacramento: options may be so scarce that the advantages and disadvantages must be circumvented, with providers remaining in the hope that someone or something – like For example, an injection of federal government funds will help finally solve the underlying problems that lead to an insufficient number of drug treatment providers.

Wakeman argued for another solution: obtain more traditional health professionals licensed to prescribe buprenorphine. Under the federal law, doctors, nurse practitioners and medical assistants can obtain a waiver to prescribe buprenorphine. But this requires special training, which means that health care providers must commit to doing so. If they do, however, they could dramatically expand access to opioid addiction care.

Integrating addiction treatment into health care

A simple idea is at the heart of all emergency work: treating addiction like any other illness and introducing treatment for addiction in the rest of the health care system.

Dr. Laura Kehoe gives a presentation at Mass General Hospital in Boston on November 20, 2018. Kehoe teaches a dispensing certification course allowing doctors to prescribe buprenorphine for opioid addiction. Jonathan Wiggs / The Boston Globe via Getty Images

When I asked Moulin how she was considering her role in the California emergency program, she replied, "Basically, I'm only an emergency doctor." That's how it's done. She would have liked others to see this work: dealing with addiction is just a part of the job of working in health care.

Mill and others have said that the main obstacles to this task are a mixture of stigma, misconceptions about addiction and institutional inertia.

Modern understanding of addiction emphasizes treating addiction as a disease, with social and environmental contributors. Even among physicians, it is still very common that people perceive addiction not as a disease, but as a moral failure. Some health care providers also wonder why they should be interested in drug addiction, since they were not usually obliged to do so in the past. Education overcomes these two prejudices, but they are persistent problems.

Other providers are concerned that addiction treatment will flood patients and addicts in their offices and clinics. But this, says D'Onofrio de Yale, misunderstands the reality: "They are already in your emergency department, because they are there with withdrawal problems or other complications. … In fact, you have a good chance of reducing your emergency department visits once you have received treatment. "

Another problem mentioned by Moulin is the widespread belief that opioid dependence is intractable. A lot of news covers the alarming statistics on opioid addiction, but not the solutions, which suggests that the situation is dark and insoluble. Emergency physicians also often see addicted patients return after multiple overdoses; over time, this makes them puzzled as to whether these people are actually doing better.

But treating addiction also requires recognizing that setbacks can occur and are even common. After Curci's first visit to the emergency room for treatment, he enrolled in a 90-day residential program. Once out he found a job, a car and his own place to live – things he could never keep before. But a few months later, Curci said, he ruined everything by leaving his former girlfriend, who was consuming heroin, in his life. This led to a relapse.

Relapse is common to all kinds of chronic diseases, from cancer recurred after remission to an episode of sudden depression after years of calm mind. Relapses with other illnesses can even be caused by the patient's actions – such as the patient who continues to eat too many hamburgers despite having heart disease, or the person who is taking insulin and has diabetes. Yet, health care providers would not let patients suffer simply because they were wrong.

"We do not say," Ok. You did not take your insulin well, so I will not prescribe it. I will let you die here, "said D'Onofrio.

To address these misconceptions, emergency managers focus on successes. "Once we have a patient that works well, I will go back to the nurses and say, 'It's really great that so-and-so has come in and we've followed them on treatment, and they're still there,'" says Moulin. . It gives doctors and nurses "the feeling of making a difference," said Moulin.

Sometimes convincing staff that the treatment works is as simple as getting it treated on its own. Sampson, of the Marshall Medical Center, spoke to me about a patient who went into misery, withdrawing from opioids. Au bout de 30 minutes d’administration de buprénorphine, le patient était visiblement mieux – il avait l’air «humain», pour reprendre les termes de Sampson. Il a ensuite été inscrit au traitement.

Une salle d'urgence au Marshall Medical Center de Placerville, en Californie.

Une salle d'urgence au Marshall Medical Center de Placerville, en Californie. German Lopez / Vox

Arianna Sampson a participé au lancement du programme de traitement de la dépendance aux opioïdes dans les salles d’urgence du Marshall Medical Center.

Arianna Sampson a contribué au lancement du programme de traitement de la dépendance aux opioïdes dans les urgences au Marshall Medical Center. German Lopez / Vox

Finalement, l’infirmière qui travaillait avec Sampson à l’époque, sceptique au sujet du traitement à la buprénorphine, lui a dit: «Nous avons sauvé la vie de cette personne. C'était remarquable. "

Les décideurs pourraient faire plus pour soutenir le traitement de la toxicomanie

S'il y a eu une plainte universelle parmi les personnes à qui j'ai parlé, c'est que les différents niveaux de gouvernement ne font pas assez pour soutenir le traitement de la toxicomanie basé sur les urgences. Dans certains cas, les gouvernements font même obstacle.

Dans les salles d’urgence, les réglementations relatives à la prescription de buprénorphine sont une préoccupation constante. Il existe une règle spéciale qui permet aux prestataires de services d’urgence d’administrer de la buprénorphine pendant une période allant jusqu’à 72 heures – sans la prescrire -, notamment pour traiter le sevrage. Toutefois, si un patient a besoin d'une ordonnance à plus long terme avant de se présenter à un rendez-vous de suivi, il doit être en mesure de lui prescrire de la buprénorphine – et de surmonter tous les obstacles liés à une certification adéquate.

Les prestataires à qui j'ai parlé ont reconnu la nécessité de certaines réglementations relatives à la buprénorphine, car c’est un opioïde qui peut être utilisé. détourné pour abus. Mais les exigences de formation ajoutent un obstacle supplémentaire – un obstacle qui n'existe pas pour les médicaments pour d'autres affections médicales – qui peut empêcher les prestataires de traitement de la dépendance. Et la réglementation stricte peut même être auto-destructrice, car research suggère que la principale raison pour laquelle les gens se tournent vers des moyens illicites pour obtenir de la buprénorphine est un manque d'accès légal au traitement pour le traitement de la toxicomanie.

Le problème plus général, cependant, est le manque de soutien du gouvernement pour le traitement de la toxicomanie en général. Au cours des dernières années, le gouvernement fédéral a approuvé un nouveau financement right here and The en réponse à l'épidémie d'opioïdes qui va au traitement de la toxicomanie. Une partie de cet argent a profité au programme des urgences en Californie.

Mais le financement est loin des dizaines de milliards que les experts estimate est nécessaire pour faire face à la crise des opioïdes. De plus, les nouveaux programmes de financement sont généralement des subventions limitées, qui expireront dans quelques années et ne financeront les programmes sur le terrain que pour un ou deux ans à la fois.

Imaginez comment cela fonctionne pour le programme des urgences: vous n’obtiendrez peut-être pas assez de fonds pour commencer tout le programme, en particulier pour soutenir non seulement le côté des urgences, mais également les prestataires et les cliniques qui organiseront les rendez-vous de suivi. Ensuite, le financement sera limité à un ou deux ans. Donc, vous démarrez ce programme qui supposera probablement des coûts pour les années à venir, mais le financement limité n’est garanti que pour un ou deux ans.

C'est pourquoi les experts m'ont toujours dit que les niveaux de financement doivent non seulement être beaucoup plus élevés, mais également maintenus à long terme. Wakeman, Flynn et d’autres ont invoqué comme modèle le Ryan White Care Act, adopté en réponse à l’épidémie de VIH / sida; cette loi a mis en place un programme fédéral permanent qui oriente les fonds pour que presque tout le monde puisse avoir accès au traitement contre le VIH / SIDA. Il y a aussi des changements avec les programmes d'assurance santé, tels que ceux de Virginie pris avec Medicaid, qui permettrait aux assureurs de payer non seulement le traitement de la toxicomanie, mais également à des tarifs qui couvrent réellement les coûts de traitement.

Les lacunes considérables constatées dans les rapports fédéraux, allant du chirurgien général à la commission des opioïdes de la Maison-Blanche, ne commencent à réellement se résorber que lorsque ces mesures auront été prises.

Cela s’étend à d’autres types de traitement de la toxicomanie et d’autres types de traitement, au-delà des médicaments, aussi. À la salle des urgences de UC Davis, j’ai vu de nombreux cas impliquant des drogues autres que des opioïdes – en particulier l’alcool, bound aux États-Unis plus de décès chaque année que toutes les surdoses de drogue combinées. De meilleurs soins sont également nécessaires dans ces autres domaines.

«Nous nous efforçons de ne pas créer un système de gestion d’un seul médicament», m’a dit Kelly Pfeifer, directrice de l’équipe des soins de grande valeur à la California Health Care Foundation. "Nous essayons d'utiliser l'argent et l'attention consacrés à l'épidémie d'opioïdes pour soutenir nos efforts visant à mettre en place une solide structure de traitement de la toxicomanie intégrée à notre système de soins de santé afin que toute personne toxicomane puisse obtenir les soins dont elle a besoin."

C'est du moins l'espoir, même si c'est loin de ce que font les États-Unis aujourd'hui.

"Tout ce dont nous parlons est ce que nous faisons pour chaque autre problème de santé", a déclaré Wakeman. "Il s'agit vraiment simplement d'introduire le traitement de la toxicomanie dans le courant médical."

La bonne nouvelle est que si ce travail est fait, nous risquons de voir moins d’histoires sur tous les décès dus à une surdose chaque année et de voir davantage d’histoires telles que celle de Michael Curci.

De retour aux centres de santé communautaires du comté d’El Dorado, Curci a réaffirmé à quel point il était reconnaissant pour le programme des urgences de la Californie – l’espoir que cela lui donnait, après avoir eu l’impression de ne pas avoir grand-chose à attendre. Il réfléchit à renouer le contact avec sa famille et ses amis, à travailler, à trouver sa propre place, une voiture et la possibilité d'aller à l'université.

"Je sais que je vais bien faire les choses", a déclaré Curci. «Parce que je vais faire tout ce qui est en mon pouvoir pour que tout soit clair. Je ne veux plus être cette personne.


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