From your extensive experience in emergency medicine for over 30 years, how did you see addiction interfacing in emergency medicine?
How I see addiction interfacing with emergency medicine is that in the emergency department, we see many patients with complications of their addiction. There are some obvious direct complications like overdose or withdrawal. There are illnesses that occur because of use or how you use it, such as infectious diseases and abscesses that are more common in IV drug use. Interestingly, I have seen some complications of inhalation. I had a patient who was smoking crack out a crack pipe, and a piece of the pipe broke off and went down into her lungs. People who use drugs have a higher incidence of all types of physical trauma.
People who have addictions also interface with the emergency department for reasons that have nothing to do with their addiction. They’re just as likely to get the flu, to get pneumonia, to have other events, such as heart attacks, as the general population. We see people with addictions every day, and it’s important to recognize it.
Emergency medicine is often the first entry point that patients will have into the healthcare system. If they don’t have a primary care doctor, whenever they have an illness and think they need to see a doctor, they go to the emergency department. This may be the first opportunity to open the door to recovery. You can address SUDs right away if you can recognize it and screen for it. If the patient has a good experience in the emergency department, they’re more likely to come back if they desire treatment, and they’re more likely to continue seeking healthcare in other venues. But if they have a bad experience in the emergency department, they’re less likely even to want to go into the healthcare system at all.
There are a lot of stigmas in emergency personnel for people who use drugs. But once they move to treat the patient with addiction just like you would any other patient, the interactions improve. All the things you worry about with people with addiction — that they’re disruptive, they’re going to not do what you recommend, etc., all of that goes away. The patients who have good interactions in the emergency room and feel they are being treated well leave happy. I think once you get past that stigma problem, all of the things you were worried about will go away.
What led you to move into addiction medicine over the past 5 years?
It started a long time ago. I practiced through the 1990s and early 2000s when the medical community was increasingly using opioids for pain. We were being pressured to use opioids for pain at times when I didn’t think it was necessarily appropriate. I never believed that they weren’t addictive. I had a family member who developed an addiction after having orthopedic surgery with prescribed opioid pain medicines. This was back in the 1970s, and I could foresee the opioid problem emerging. I remember in the mid-1990s talking to one of my colleagues in the emergency department, and we were talking about this move to increase the use of opioids. We both said that if we do this, we’re going to have a whole generation of people addicted to opiates. And that’s exactly what happened. I started seeing the effects of the addiction in my patients: more overdoses, more withdrawal, more infectious disease, and I started seeing the effects on families when parents would bring their family members in and how desperate they were and how difficult it was to get people into treatment. I started to see how overdose affected large families and family members directly.
What really influenced me was that just after I had moved to Maine, I had a friend, a coworker, who died of an overdose. I knew she had developed an addiction; I was the last healthcare provider to see her alive. After she died, I called my friends and I said, “When’s her funeral? I want to come down.” And they said, “Oh, there’s not going to be a funeral.” There was no service, nothing. I realized then that patients who die of addiction just drop off the face of the earth as if they never existed. That was so painful to me.
I then attended a talk in 2017 by Dr. Peter Leighton, who was a primary care provider at Central Maine Healthcare who also went into addiction medicine. He gave a talk on opioid addiction and its treatment with buprenorphine. It was just a one-hour talk at one of our medical staff meetings at the hospital. It was so influential to me, and the data he presented was so influential. At the end, he said, “How many of you are prescribing buprenorphine in your practice?” There might’ve been two or three among over a hundred people there. And then he said, “To the rest of you, my question is, why not?” I could not answer why I was not doing it.
Shortly after that, I went to an emergency medicine conference in Denver, and an emergency physician gave a 10-minute talk on how he’s starting to use buprenorphine in the emergency department. I said to myself, “This is something I could do.” So, I took the eight-hour X waiver course that was required the next month. Once you know how effective treatment is and how many people are out there that need treatment, you cannot not do it. You just have to do it. That’s how I got interested in it. Eventually, that interest increased as I treated more and more patients, and I got involved with Tri-County Mental Health as a per diem provider. My involvement in addiction kept increasing, and my emergency medicine decreased until I finally stopped emergency medicine.
Why is low barrier medication for opioid use disorders important and what are the key elements of this approach that you think other providers should embrace?
I have become more and more a proponent of low barrier treatment. More and more studies have shown that low-barrier treatment saves lives and decreases the risk of overdose deaths. I think it’s very important. I am involved in a low barrier treatment program at the family medicine residency at Central Maine Medical Center. It is so enjoyable to do the low barrier treatment, to be able to see the patients improving in front of your eyes, and even if they’re still using substances, to see them still be engaged and come every week, even if they’re still using it, is pretty amazing to see.
What I recommend to any program that wants to look into low-barrier treatment is to look at your process of how you start a new patient. Eliminate any process that delays the patient seeing the provider. If they require a lengthy intake with lots of paperwork about their address, medical history, and insurance information, eliminate that. They don’t need to do that before they see the provider, it can be after they see the provider. If you require a drug screen for people with addiction prior to being seen for treatment, just eliminate it. It’s not going to change your treatment right away.
If it takes a long time to get an appointment, that patient is at risk of dying while they’re waiting. You wouldn’t allow a patient with a heart attack to wait for an appointment. Eliminate that wait. If you can get buy-in, do a walk-in on-demand treatment; that is the best, though I will admit that’s really, really hard. Take my practice, for instance; I’m only at the residency one day a week. When they have patients that come in, not during that time, someone else has to do it. Fortunately, many of the faculty have been willing to bridge the patient until they can see me. At Tri-County Mental Health Services I’m the only provider that really does addiction treatment or MOUD, and I may be in Lewiston, Rumford, Oxford, Bridgeton, and Farmington on different days. If I’m in Farmington and they’re in Lewiston, I’ll see them by video for their first visit to decrease their waiting time.
Do they need counseling prior to treatment? Well, it turns out to be no. It doesn’t necessarily affect the risk of overdose deaths in the short term. If the counseling doesn’t add to the benefit in the short term, just eliminate it until the patient decides they want to do counseling. In the low barrier treatment program we have, there’s no requirement for counseling right away, but eventually after a month or two, the patients want counseling, they ask for it.
Of course, health insurance can be a barrier. Fortunately, MaineCare is really good for treating patients with opioid use disorder. If they have MaineCare and with the expansion of MaineCare, a lot of people do have it available, that can be really helpful.
What are your recommendations for connecting emergency care to the continuum of care?
It all comes down to making things very simple. For the emergency department provider, when they’re first seeing the patient, having an order set and a defined process for how they start the patient, how they do screening, what labs they order, and what medications they order. If it’s just a checklist in your order form, it is really helpful because you want to make it simple and easy for the provider. The provider is seeing 20 other people, make it easy. Develop a system of a warm handoff or as warm as possible from the ED provider to outpatient treatment.
The easiest way to do that is to decrease the choices. Instead of giving the ED a list of 10 different places that they can send for treatment, have two, one online and one in-person. The ED provider doesn’t have to make a lot of choices; they can just say to the person, “You want it in person, or do you want it online?” And give them those choices. Having a direct way into the medical record is really good. If it’s all in the same healthcare system, have one click for the emergency provider to communicate to the outpatient program that they’re sending this patient. We have streamlined that process at Central Maine Medical Center so they can refer to the low barrier treatment program at the residency. It’s not one-click yet, but we’re really working hard to do it. All the emergency providers have my phone number, and they’re free to call me at any time or text me to let me know or ask questions. Make it easy.
What is important for primary care providers to know about addiction?
First and foremost, the patients you have right now in your patient panel have addiction problems, you don’t have to go searching for new patients. You don’t have to put up a sign saying, we’re treating addiction, no ads. Look at your patients; they’re there. So, develop a screening process and start slow. If you’re just getting into this, treat one or two patients and put your toe in. Addiction is part of primary care, so it does not need to be specialty care. Yes, you can have addiction specialists for consultations for tricky cases, but you can do it as a primary care provider. You can do it.
The treatment of most addictions is not more complicated than other illnesses you already treat. It’s not more complicated than hypertension, diabetes, or arthritis. Once you start doing it, you’ll realize it’s as easy as any illness or no harder than other cases. Yes, you’re going to come upon cases that are difficult where it helps to have an addiction medicine specialist to use for consultations. But most of this care is not that difficult.
The other thing is that addiction treatment saves lives much more than treating diabetes, hypertension, and high lipids. Physicians in studies look at the number of patients needed to treat to save a life. The number needed to treat opioid use disorder with buprenorphine to save a life is about 60 patients. You treat 60 patients; you’re going to save one life. The number needed to treat hypertension to save one life is about 10,000. You’ll never see a number lower than with opioid use disorder. The number needed to treat opioid use disorder with buprenorphine to stop their use of non-prescribed drugs is two. If you treat two patients, one of them will stop. There’s no other treatment like that. The number needed to treat for a heart attack and put a stent in to save a life is more than the number needed to use buprenorphine to save a life. It saves lives.
The last thing I will say is that treating addiction is so rewarding. Seeing your patients improve, seeing their lives improve, is the neat thing. To see them get back with their families, to see them start working, to be productive members of the community, and to see them start enjoying life again is such a pleasure. No patients are more appreciative of their care than patients who suffer from addiction.
I received Christmas cards from my patients and text messages just saying, “Merry Christmas,” “Happy Holidays,” “Happy New Year,” and “Thank you very much for all you’ve done for me.” I cherish each one of them. I want to save them all. The last thing I would like to say is that I’m on the Maine Recovery Council, where we are trying to decide how to spend the money from the opioid settlements. When we talk about how we’re going to spend money on treatment and how to get more patients into treatment, I really think the key to getting more patients into treatment is getting more primary care providers to offer treatment. I don’t think you need to hire more addiction specialists. I think that influencing primary care providers to offer medication for opioid use disorder to their patients is the key to improving treatment.