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Easing the Opioid Withdrawal Burden

Treating patients with opioid use disorder has been top of mind for frontline practitioners since the opioid epidemic began, but as it has only gotten worse the last few years, new treatment solutions are being tested.

As a statewide approach to reducing the impact of opioid addiction, physicians have joined SC MAT Access to bring medication-assisted treatment (MAT) to emergency rooms, primary care offices and obstetrician offices.1

MAT combines behavioral therapy and medication as an evidence-based pharmacotherapy for patients with an opioid addiction. Using methadone, buprenorphine or naltrexone, physicians can target the opioid receptors in the brain to ease the effects of withdrawal, curb cravings and begin the opioid addiction recovery process.

Physicians at MUSC are working with a grant from the South Carolina Department of Health and Human Services in conjunction with SC MAT Access funding from the SC Department of Alcohol and Other Drugs of Abuse Services (DAODAS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) to increase education and access to MAT throughout the state.

“It’s by no means a one-size-fits-all approach,” said Carolyn Bogdon, MSN, FNP-BC, CPTC, a board-certified family nurse practitioner at MUSC who has coordinated the MAT-ED program from its onset. “It’s very individualized to the patient, and this project allows us to treat them as such.”

A patient’s chance of relapse changes based on many factors, including their age, duration of drug use, employment status and marital status,2 but it is estimated to be between 40 and 60%, on average.3 By changing how a person’s brain responds to opioids and lessening the burden of withdrawal, physicians can lower this risk. Characterized by nausea, depression, agitation, anxiety and intense cravings, withdrawal is highly uncomfortable and can be life-threatening.

Methadone is a synthetic opioid agonist that occupies and slowly activates a person’s opioid receptors without providing any feelings of euphoria. It is taken in daily doses strictly at methadone clinics and provides relief for four to eight hours per dose. Buprenorphine is the first medication to treat opioid use disorder that can be prescribed in a primary care office or a hospital. It is also a long-acting partial opioid agonist, meaning it activates the same receptors as full agonists but less strongly.4

The third medication, naltrexone, is an opioid antagonist that works by blocking activation of the opioid receptors. It prevents the rewarding effects of opioids but does not treat withdrawal or curb cravings. It can be prescribed by a licensed health care provider after a patient has abstained from opioids for seven to ten days and is also used to treat alcohol use disorder.4

In the past, patients had to make it at least a week on their own without opioids before they could begin treatment. But now, with SC MAT Access, patients can improve their odds and start treatment immediately in multiple places in the region.

Treatment immediately after overdose

With the help of DAODAS and SAMHSA, MUSC is leading a pilot program to address opioid addiction straight from the emergency room.

“Previously, we would just treat the acute overdose,” said Lindsey Jennings, M.D., who is an assistant professor in the Department of Emergency Medicine at MUSC and a physician champion for the program. “And then give them a referral for outpatient treatment and hope they follow through.” The next available appointment might not be for a week, and the patient would have to either abstain from opioids or avoid an overdose in that time period. This standard of care is still practiced in many hospitals across the country, but with the new program, MUSC has shown that treating addiction straight from the emergency room has a real impact on helping opioid users recover.

Researchers at Yale School of Medicine published a paper in the Journal of the American Medical Association on a similar clinical trial back in 2015, which showed that 78% of patients treated with buprenorphine in the emergency room were still engaged in treatment after 30 days, compared to 37% in the group that received only a referral.

Even with these results, treatment for opioid addiction hasn’t changed much in the years since. Many providers don’t like the idea of trading one medication for another, even if the replacement medications are not addictive.

Under the pilot program, patients at risk for addiction are screened for substance use. If the results are positive for substances like methamphetamine, marijuana, cocaine, alcohol or opioids, a recovery coach will come in and speak with the patient.

“Recovery coaches are often in recovery from illicit substances themselves,” said Bogdon. “And can bring a different perspective to the conversation, which is by design.”

If a patient is interested in overcoming their addiction, physicians will prescribe buprenorphine. After the initial dose, the patient is referred to a fast-track provider who will see them the next day. These providers must have additional training and obtain a DEA number in order to prescribe buprenorphine to these patients.

With buprenorphine administered in the emergency room, patients can avoid painful withdrawal symptoms and get a jump start on their recovery. This program has since expanded from MUSC to Tidelands Waccamaw Community Hospital and the Grand Strand Memorial Hospital as well as Spartanburg. Between these sites, over 7,000 patients have been screened for potential substance abuse across the state. Of those patients, 765 patients screened positive for opioid use disorder, and 80% of inducted patients arrived to their next-day appointments. Over 60% of those patients were still in treatment after 30 days, according to Bogdon.

Using peer recovery coaches in the project has also proven effective in both combatting the stigma around addiction and engaging with high-risk patients, but one of the drawbacks to the pilot is making sure there are enough fast-track providers to treat these patients.

“This project has absolutely changed the culture of how we treat addiction in medical settings,” said Kelly Barth, D.O., Department of Psychiatry and Behavioral Sciences associate professor and member of the MUSC-DAODAS team. “Having life-saving medications for opioid use disorder available in the emergency room not only enables patients to get started on the treatment they need when they need it, but it also empowers health care providers to be a positive part of our response to the opioid crisis.”

Treatment during pregnancy

The opioid crisis is mirrored in pregnancy according to Constance Guille, M.D., a psychiatrist and associate professor in the Department of Psychiatry and Behavioral Sciences at MUSC and member of the SC MAT Access team.

Guille’s current primary clinical research focus is opioid misuse and opioid use disorder in pregnancy. By working with psychiatry and obstetrics providers at MUSC and after interviewing pregnant women and their providers throughout South Carolina, Guille facilitated the development of a program that is delivered both in person and via telemedicine in obstetric practices across the state and is aimed at reducing opioid misuse in pregnancy.

Women who are both pregnant and misusing opioids present a hard-to-treat crossover. When a woman comes into the emergency room, she leaves a department with more experience handling opioid misuse and is sent to obstetrics, where fewer physicians are trained to treat addiction. People who do have training in treating opioid misuse are also not always comfortable treating pregnant women.

“It’s a group of people who often don’t have a lot of providers willing to take them on and manage them,” said Guille. Which is why the program is so specific to the needs of that population – to provide access to evidence-based treatments that help appropriately manage patients through pregnancy and postpartum.

Buprenorphine and methadone can be used to treat pregnant women with opioid use disorder, but naloxone cannot. Multiple studies show no birth anomalies after treatment with buprenorphine, and some show that buprenorphine may present less risk than methadone.5 Infants experiencing withdrawal immediately after birth, referred to as neonatal abstinence syndrome (NAS), also appear to suffer less severely if the mother was treated with buprenorphine during pregnancy.

One way the SC MAT Access team delivers care via telemedicine is through county drug and alcohol treatment centers. Patients with or without insurance can go to these state-funded centers for treatment, but the centers are often not trained or approved for MAT. Members of the SC MAT Access team will then travel to meet these pregnant patients and prescribe buprenorphine and start MAT.

“As one of the strongest departments of addiction sciences in the country, MUSC is a place where we’re going to provide access to evidence-based treatments and implement them,” said Guille. And targeting a population that is often hard to treat allows her to do that.

Treatment in primary care offices

Another part of SC MAT Access is academic detailing, which connects providers with the extra training and certification needed to provide MAT. Clinical pharmacists from MUSC meet with primary care providers in different communities throughout the state to discuss opioid use disorder and the different treatment options.

 “We help providers put clinical evidence into daily practice,” said Sarah Ball, Pharm.D., assistant professor in the Department of Medicine at MUSC and member of the SC MAT Access team. “We are promoting monitoring strategies for safer opioid prescribing as well as expanded access to medication-assisted treatment.” But it’s also more than that. These visits are interactive, where the clinical pharmacists are listening to the providers’ needs and then engaging them in discussions around treatment options for their patients.

These discussions can range from providing resources for a patient referral to discussing that provider’s interest in being trained to prescribe MAT or becoming a fast-track provider with the program.

As many patients interact with their primary care providers more than they interact with the emergency room, it’s important that these providers can help those interested in recovery before a potential overdose happens. “You are not there just to teach,” said Ball. “You’re finding out what barriers exist to treating their patients and supporting ways they can incorporate MAT.”

Academic detailing started out in a few counties in South Carolina and has now expanded to incorporate others and is just another way MUSC is working with other entities to change the way opioid use disorder is treated.

Between projects that address MAT in the emergency room, MAT during pregnancy and MAT in primary care offices, MUSC is expanding access. “We have so many initiatives around this topic here at MUSC,” said Ball. “And this uniquely collaborative team at MUSC has done an effective job of bringing these individual projects together in a way that continues to promote MAT for patients in South Carolina.”

Citations

1. DAODAS/SAMHSA. SC MAT ACCESS. scmataccess.org.
2. Chalana H, et al. J. Addiction. 2016;2016:1-7. doi:10.1155/2016/7620860.
3. NIH. How effective is drug addiction treatment? NIDA. drugabuse.gov.
4. NIH. How do medications to treat opioid use disorder work? NIDA. drugabuse.gov.
5. Jones HE, et al. Addiction. 2012;107:5-27. doi:10.1111/j.1360-0443.2012.04035.

Progressnotes Summer 2019


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