Emergency rooms once offered little for drug users. That’s starting to change
Sixth in an occasional series about breaking the grip of opioid addiction. Read the other stories here.
The woman came to Dr. Alister Martin three years ago, pleading for help. She was in the throes of opioid addiction, he in the first year of residency at the Massachusetts General Hospital emergency department. “I don’t want this life,” she told him.
But when Martin asked his supervisor what he should do, the attending physician said to send her home. A world-famous Harvard-affiliated medical center, the biggest hospital in Massachusetts, offered nothing to this patient.
That was hardly unusual, then or now. For decades, programs for people with addiction have developed largely outside the medical system.
But the young Mass. General doctor was appalled. Martin had chosen to specialize in emergency medicine because ER doctors are the people who help anyone, anytime. “We’re in the middle of an opioid crisis,” he recalled thinking, “and we’re kicking people out of the emergency room.”
What Martin did in the ensuing years would help move Mass. General to the vanguard of a new approach to addiction: Instead of sending addicted people on their way, the hospital can start treatment right in the emergency department.
And now a new state law is requiring all hospitals to do the same, a mandate that calls on hospitals to meet the challenge of a crisis claiming four or five lives each day in Massachusetts.
“The pace of this is very accelerated because we’re in crisis mode,” said Dr. Scott G. Weiner, president of the Massachusetts College of Emergency Physicians and a doctor at Brigham and Women’s Hospital. “Before, we had no resources to offer, or little resources. We might give them a list of phone numbers. Now we have services for this population.”
This population — people suffering from addiction — shows up on hospital doorsteps for a variety of reasons: Overdoses. Withdrawal pains. Severe infections from injecting drugs. And once in a while, as with Martin’s patient, a simple wish to get better.
Summoning energy, ingenuity
After discharging his patient, Martin did not want to let that happen again. His boss, emergency department vice chairman Ali S. Raja, also had plans to improve the response to addiction and decided to deploy Martin’s energy and ingenuity.
“To have him drive it was so much more effective than having me tell people and force them to do it,” Raja said.
At the time, Mass. General already had a Bridge Clinic poised to immediately start patients on medication to treat addiction and work with them until they find care closer to home. But the word was not getting out to ER doctors.
Martin asked Dr. Sarah E. Wakeman, who leads the hospital’s addiction initiatives, how he and his fellow residents could raise awareness. She urged them to reach higher: Why not get all the emergency doctors certified to prescribe a medication to treat addiction?
That would require abandoning the traditional notion that addiction treatment means a bed in a detox or rehab facility. Instead, the Bridge Clinic philosophy holds that it’s much more urgent to get people started on medication, usually a drug called buprenorphine (often referred to by a trade name, Suboxone), which can stop their compulsion to take drugs, prevent them from overdosing, and clear a path to repairing their lives.
But most emergency doctors didn’t consider managing addiction to be part of their job. They got little training about the disorder in school — and at work they saw only its saddest manifestations. Those who get better, after all, don’t come back to the ER. “A lot of folks didn’t know this was a disease you could treat,” Martin said.
Adding to the obstacles, the federal government requires doctors to take an eight-hour course before they can get a certification, or “waiver,” permitting them to prescribe buprenorphine, which is an opioid. Even today, only about 6 percent of the nation’s physicians have obtained such waivers.
Lessons on driving change
Martin resolved to get the ER doctors to want to possess a waiver. He applied the lessons he had learned a couple of years earlier, when he had interrupted medical school to earn a master’s in public policy from Harvard’s Kennedy School of Government. There he had studied how to influence behavior to bring about policy change.
Martin and his team called the campaign “Get Waivered,” complete with posters, publicity, and a gold pin to designate and honor those who completed the training. They made it easy to sign up, with a website that distilled the process to four steps. An anonymous donor provided money so that doctors could take the course while at work, instead of sacrificing their scarce free time.
They declared December 2017 “Get Waivered Month.”
The department chairman, Dr. David F. M. Brown, and other influential physicians took the course first and told their colleagues about its value. Soon the skeptics were signing up and then the one-time opponents.
Bridge Clinic medical director Dr. Laura G. Kehoe, who teaches the course, tailored it to emergency room staff, incorporating a powerful addition: a talk by someone in recovery from opioid addiction.
Dr. Andrew S. Liteplo, a Mass. General emergency doctor, said he found Kehoe’s course eye-opening.
“They brought the patient in and you’re like, ‘Wow, he is totally put together and it looks like his addiction has been completely curtailed and managed,’ ” he said. “It’s made me realize how much of a medical disease it is.”
By last April, 38 of the 42 Mass. General emergency physicians had obtained buprenorphine waivers. Martin said that many of them still proudly wear their “Get Waivered” pin affixed to their white coats.
One patient’s story
Word of the program spread outside the hospital, and in the fall a 31-year-old man named Louis heard about it from relatives. Caught in an intensifying addiction to heroin and pills, he decided to pay a visit to the Mass. General emergency room.
“I was blown away by how helpful they were, how much time they were willing to spend on me individually,” he recalled.
A physician assistant gave Louis a supply of buprenorphine and instructions on how to use it, as well as an appointment at the Bridge Clinic the next day. Louis went home and waited, as instructed, until he started to feel withdrawal symptoms later that evening. Then he took his first dose, which he said made him feel “like I was getting back to a normal place.”
Louis, who withheld his last name to protect his privacy, continues to take buprenorphine once a day and visit the Bridge Clinic regularly. Now, he said, he can wake up and head to work without having to plot a way to alleviate his drug cravings. “It is nice to just be able to have your day go normal,” he said.
The Mass. General experience has provided some guideposts for hospitals elsewhere in the state as they strive to meet the requirements of the state law passed this year. The mandate, believed to be unique in the nation, requires hospital emergency departments to have the capacity to provide buprenorphine or methadone and then connect patients directly with ongoing care.
But while it’s challenging to get doctors to obtain waivers, connecting people to care after discharge may prove to be the hardest part, especially for smaller and rural hospitals. Addiction obviously doesn’t get cured with a dose or two of medication, and emergency doctors by definition do not provide ongoing care.
“At 2 a.m. you can have everything ready in the emergency room, but it’s not valuable if you don’t have the operational connection to the next dose,” said Hilary Jacobs, president of Lahey Behavioral Health Services in Danvers.
Bridging the gap in treatment
That’s where the Bridge Clinic comes in, seeing patients soon after they appear in the emergency room and continuing their treatment until they transition to another provider. The Brigham opened a five-day-a-week Bridge Clinic in April, and Beth Israel Deaconess Medical Center opened one in October. Boston Medical Center has had a similar clinic since 2016.
Emergency physicians at the three hospitals are getting their waivers to prescribe buprenorphine, and Boston Medical Center is having its primary care doctors and obstetrician-gynecologists take the course as well.
But outside Boston, hospitals may not have the wherewithal to open a Bridge Clinic or the need to get all physicians waivers, Weiner said. Some may designate on-call prescribers who can start the medication and perhaps add addiction treatment to an existing in-house service, such as psychiatry, to pick up the ball the next day.
Others may forge relationships with providers in the community, who will need to be able to accept new patients on a moment’s notice.
But will patients keep their appointments, especially in communities where they might have to travel miles?
Mass. General has no data on what percentage of those referred did show up at the Bridge Clinic, although it is studying the question. The hospital is also examining another question: Are emergency room doctors following the new protocol for opioid-addicted patients? Despite all the enthusiasm generated by “Get Waivered,” the number of patients entering treatment after an emergency department referral is averaging under a dozen a month, fewer than expected.
No one knows why, and that sent Alister Martin back to his Kennedy School connections. He linked the hospital with Ideas42, a consulting firm that applies behavioral science to solve social problems. With a grant from the Laura and John Arnold Foundation, Ideas42 is looking for answers for Mass. General.
As for Martin, he’s now in his final year of residency. He doesn’t know what happened to the woman he’d had to turn away three years ago. But he harbors a fantasy that someday she’ll come back — and with relief and pride, he’ll finally offer the help she needs.