More than a year after a comprehensive law was passed to address the state’s opioid epidemic, few patients appear to be taking advantage of a key provision designed to help them connect with addiction treatment after an overdose, according to a Globe survey of emergency room doctors.
As originally proposed by Governor Charlie Baker, the law would have required those taken to the emergency room after an overdose to be held involuntarily for up to 72 hours to receive treatment.
But the final version approved by the Legislature excised that requirement, dictating instead that hospitals must simply offer substance abuse treatment to these patients after a voluntary assessment.
The evaluation, a series of questions, takes roughly 10 minutes to complete and is typically administered by a mental or behavioral health clinician.
But hospitals across the state report that a large majority of eligible patients — anywhere from 50 to 90 percent — decline the evaluation, according to a dozen emergency medicine doctors contacted by the Globe. The result: Patients are often discharged no closer to receiving treatment than they were before their overdose.
Hospitals that responded to the Globe’s survey were Boston Medical Center, Massachusetts General, UMass Memorial, Berkshire Medical Center, South Shore, Emerson, Everett, Sturdy Memorial in Attleboro, Lowell General, Lawrence General, St. Vincent in Worcester, and Mercy Medical in Springfield.
Emergency departments are viewed as a key place to connect with overdose patients, with the number of opioid-related visits in the state increasing 71 percent over five years. For patients who have just suffered an overdose, having a meaningful conversation with a doctor can be a pivotal moment, according to Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness.
“When patients overdose, they’re often hitting rock bottom,” he said. “This is an opportunity for many patients to turn their life around and begin recovery.”
The assessment requirement was initially described by lawmakers as a mandatory evaluation, but as written, the bill requires hospitals only to offer patients the chance to be assessed. After the evaluation is completed, the clinician is supposed to connect patients to the appropriate resources for treatment, such as outpatient counseling or detoxification.
But legislation mandating evaluations rarely works, Alexander said, without appropriate implementation from physicians.
“The devil is in the details,” Alexander said. “There’s no question that all too many patients are discharged without any meaningful effort to diagnose them, and meaningful engagement.”
Emergency medicine doctors interviewed by the Globe expressed frustration at their limitations in connecting patients to treatment.
“You can try . . . but patients who are addicted to opiates are in denial a lot,” said Dr. Nathan MacDonald, chief of emergency medicine at Lowell General Hospital. “Even after an overdose, they feel like they’re still in control and it’s just a bad break and won’t happen again. They’re not in a place where they are receptive.”
When patients decline to undergo the evaluation, doctors at Lowell General talk with them about the services available and give them a list of resources they can call for treatment. But those measures can have a limited reach.
“Sometimes we find the papers crumpled up in the wastebasket,” MacDonald said.
Hospitals have not been required to collect or submit data to the state on how many evaluations they complete, and some hospitals do not track that information, so it’s impossible to know exactly how often they are being performed or how many people gain access to treatment as a result.
In response to an inquiry about whether the governor is satisfied with the results of the requirement, a Baker spokeswoman highlighted the administration’s increased spending on substance abuse treatment. But his office also emphasized that the requirement was the result of a compromise and that Baker had originally pushed for more aggressive tactics. Critics of that proposal said treating patients against their will would be ineffective and strip them of their rights.
“While some objected to the administration’s original proposal, which mirrors civil commitment laws for individuals with mental illness, the administration will continue to pursue all strategies to combat the opioid epidemic,” Lizzy Guyton, Baker’s communications director, said in a statement.
Dr. George Kondylis, chief of emergency medicine at Lawrence General Hospital, said pushing care onto an unwilling patient is unethical. He and several other doctors said they were deeply uncomfortable with the idea of forcing a patient to undergo treatment and chafed at Baker’s proposal for involuntary commitments.
“We’re here to help people; we’re not here to take someone’s rights away. The challenge with saying you’re going to hold someone against their will is, if it creates a risk, people aren’t going to come to the hospital because they know they’re going to be held,” Kondylis said. “I’d love to think there’s a better way than what we do right now.”
The Massachusetts hospital that has posted some of the highest rates of success — more than two-thirds of patients accept the evaluation and are later connected to treatment — is South Shore Hospital in Weymouth.
Doctors there bring a clinician and peer recovery coach into the room before they even ask if the patient would consider accepting an evaluation. Peer recovery coaches are trained staff who themselves have overcome opioid addiction and are on-call 24/7. After the patient is medically stable, the physician — together with the clinician and peer recovery coach — asks patients if they would mind having a more detailed conversation about addiction, and if they would consent to an evaluation.
Jason Tracy, the chief of emergency medicine, attributes the success to the hospital’s aggressive approach.
“I think in years past there was a feeling that a patient needed to want treatment before any efforts to engage them needed to occur,” Tracy said. “We have come to understand that our only way out of this epidemic is to really increase the intensity in which we try to get patients to engage.”
And at Mercy Medical Center in Springfield, clinicians follow up with overdose patients 24 hours after they are discharged. While only 15 percent of patients accept the evaluation in the emergency department, 25 percent arrange treatment services during a follow-up, according to Dr. Robert Roose, the hospital’s vice president of behavioral health.
Those practices — using peer recovery coaches and following up with discharged patients — are routinely used in Rhode Island, where last year, Governor Gina Raimondo signed a package of bills requiring comprehensive discharge planning for patients with addiction.
In the year since the bills were passed, the state has reported that 52 percent of patients receive counseling or treatment after entering an emergency department for an overdose, setting a standard that experts say Massachusetts could model.
According to Dr. Traci Green, a member of Rhode Island’s Overdose Prevention and Addiction Task Force, a peer recovery coach is on call 24 hours a day at all hospitals and is required to maintain contact with patients for 90 days after they are discharged from the hospital. Some hospitals in the state are part of a pilot project that would involve recovery coaches as soon as overdose patients enter the emergency department.
Mass. General was one of the first hospitals in the nation to embed recovery coaches on care teams. That initiative, as well as the hospital’s Bridge Clinic, which provides short-term medical care for discharged patients not yet connected to outpatient care, has been extremely successful, according to Dr. Ali Raja, vice chairman of emergency medicine.
Dr. Gail D’Onofrio, chairwoman of the emergency medical department at Yale Medical School and a leading specialist in addiction medicine, said the key to helping the most “reluctant and hesitant” patients is to maintain an aggressive approach.
“It’s missing the boat to ask people if they want to be evaluated. That’s ridiculous,” D’Onofrio said. “That’s like me asking someone who comes in with dangerously high blood pressure, ‘How do you feel about me trying to treat you?’ You just do it.”Catie Edmondson can be reached at firstname.lastname@example.org. Follow her on Twitter @CatieEdmondson.