Beyond the ER: Opioid Overdoses Spur Call for Care Reform

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By Mary Anne Pazanowski

The opioid epidemic is spurring a discussion on what hospitals should be doing beyond merely stabilizing patients who come in due to overdoses.

Federal law requires most hospital emergency rooms to provide an appropriate medical screening for and to stabilize people presenting with emergency medical conditions.

Once those conditions are met, hospitals have satisfied their legal obligations under the federal Emergency Medical Treatment and Labor Act, which was intended to prevent them from dumping patients who couldn’t afford to pay. They have no further legal liability at that point, according to attorneys who counsel hospitals on EMTALA compliance.

But do hospitals, and the medical profession in general, have greater policy or social obligations to provide additional treatment options for people who come to their emergency departments with drug overdoses? It is a question that has become more prominent in light of the opioid epidemic.

Physicians who spoke with Bloomberg Law said health-care providers can and should do more. They shared some of their ideas for helping end a public health problem that, from 2001 to 2016, cost the country an estimated $1 trillion, and could cost an additional $500 billion by 2020, according to Altarum, a nonprofit health systems research and consulting organization headquartered in Ann Arbor, Mich.

The drugs at the center of the opioid crisis include prescription pain medications, like oxycodone (brand name OxyContin), heroin, and synthetic opioids such as fentanyl—either alone or as used to cut heroin.

ER’s ‘Critical Role’

Hospital emergency departments play a “critical role” in addressing the opioid crisis, Dr. Lipi Roy told Bloomberg Law. Roy specializes in addiction medicine and substance abuse and is an assistant professor at the New York University School of Medicine, New York. The ER is the “first place people go for care” following an overdose, she said.

The numbers bear this out: From July 2016 through September 2017, there were 142,557 hospital ER visits in 45 states that involved suspected opioid overdoses, according to the Centers for Disease Control and Prevention. The largest increases were in the Southwest, Midwest, and West, the CDC said. The opioid overdose ER visits increased by nearly 30 percent, from the third quarter (July through September) of 2016 to the same quarter of 2017. One reason was the number of repeat visits.

It isn’t uncommon for a hospital ER to treat an overdose patient one day, only to have the same patient return the next—or even later the same day—suffering a second overdose, Lawrence E. Singer told Bloomberg Law. Singer is director of the Beazley Institute for Health Law and Policy at Loyola University School of Law in Chicago and teaches a course focusing on health care access.

Singer recently led a student group on a field trip to study access to care for patients with opioid addictions in communities in Southern Ohio, just across the Ohio River from Kentucky. He came away “hopeful,” because those communities have “pulled together to address” issues associated with opioid addiction.

Where health-care providers’ responsibilities to these patients stop and start, however, is difficult to measure, he said. “Striking a balance is extremely difficult,” he said.

EMTALA’s Limits

Dr. R. Corey Waller, an addiction, pain, and emergency medicine specialist who has cared for overdose patients in hospital emergency departments, said there are limits to what ERs currently can do. He believes, however, emergency care providers can do better.

The EMTALA statute, in theory, is helpful, Waller said. But its stabilization requirement refers only to treating the immediate emergency medical condition. That isn’t sufficient to treat opioid or any other type of substance abuse, he said. Waller is the senior medical director for education and policy at the National Center for Complex Health and Social Needs/Camden Coalition of Healthcare Providers in Camden, N.J., and is a member of the American Society of Addiction Medicine.

The treatment people receive in the ER “has no bearing on what happens afterward,” Waller said. Follow-up treatment is especially crucial for people who overdose on opioids, given their high rate of repeat overdoses.

Amending or changing EMTALA, however, isn’t the answer, according to Dr. Anthony Ng, a member of the National Council for Behavioral Health’s Medical Director Institute. Ng is the chief medical officer at Acadia Hospital and chief of psychiatry at Eastern Maine Medical Center in Bangor, Maine. He favors creating “better hand-off procedures” that focus on treatment beyond the initial emergency.

Improving Care in ER

Roy had a few suggestions for improving ER care for opioid overdose patients, beginning with connecting them with substance abuse counselors before they leave the hospital. She pointed to Project ASSERT, a program piloted by Boston Medical Center to address the needs of substance abuse patients in the emergency room.

Project ASSERT puts nonclinical peer counselors and substance abuse educators in the ER to identify substance abuse patients and begin a conversation that will lead them to get the help they need. It is intended to bridge the gap between emergency care and treatment for substance abuse behavior. The counselors help connect patients with substance abuse treatment centers.

Waller would like to see hospitals take more aggressive measures. Ensuring ERs have addiction specialists on site, or readily available, is a good start, he said. Hospitals should have specific policies and procedures and train their staffs to deliver evidence-based treatment for addiction, he added.

One drawback, Waller said, is that most hospitals don’t have any beds dedicated to addiction treatment, meaning there is no opportunity to admit these patients unless the overdose has caused some other medical problem. Transfer to a treatment facility can be hit or miss, depending on the resources available, he said. Again, most hospitals don’t have their own such facilities.

Hospitals need to “focus beyond the initial emergency,” Ng said. “Better hand-off procedures are needed, he said. That is, ERs “need diversion options,” such as a crisis bed for keeping high-risk patients in the facility longer to reduce the possibility of a repeat overdose.

Ng also recommended hospitals have a psychiatric and/or social services team in the ER to make an evaluation and provide a consultation. This could be done through a telehealth provider that specializes in addiction treatment or behavioral health, he said.

Beyond the ER

Breaking an opioid addiction is “a life-long process,” Singer said. It requires a high level of commitment by both the patient and the community. Ng said the best way to treat addiction, in his opinion, is to provide a “continuum of care.”

Treatment begins in the primary care physician’s office, Ng said. These physicians are on the front lines and may be able to identify high-risk patients before they get to the ER, he said. They can educate patients about the dangers of opioids and other substances, and they should follow recommended prescribing practices for these drugs.

Roy recommended that the medical community think about addiction treatment the same way it thinks about treating any other chronic disease. There are about 23 million people with substance abuse problems in the U.S., but only about 10 percent are receiving treatment. Statistics show that people who receive effective treatment get better, she said.

Convincing people, including doctors, to think of addiction as a disease, not a sign of moral failure, will help lower the barrier presented by the stigma associated with drug addiction, she said. There are several good Food and Drug Administration-approved medications that can be used to treat addiction, she added.

There are several resources for doctors to learn more about these medication-assisted treatments, or MAT. The federal Substance Abuse and Mental Health Services Administration, for example, has a web page devoted to helping providers identify and treat opioid use disorders with MAT.

FDA Commissioner Scott Gottlieb told a U.S. House committee Oct. 25 that his agency is looking at ways to broaden the use of MAT, or the use of drugs such as methadone and buprenorphine, in conjunction with counseling, to help people overcome addiction to opioids.

Professional Education, Training

Medical professionals’ lack of training and education in addiction treatment is a flashpoint for Waller. Of the 10 percent of patients who receive addiction treatment, only about half get the latest evidence-based care, he said. Applying that statistic to any other chronic disease would be unacceptable, he said.

Additional training and certification is key, Waller said. There are about only 6,000 board-certified addiction treatment doctors in the country, compared with 30,000 board-certified cardiologists, he said. He would like to see more state licensing agencies or the Drug Enforcement Administration mandate a minimum level of training, at least for doctors who are certified to prescribe opioids. Doctors who prescribe these medications should know how to treat people addicted to them, he said.

Waller’s other recommendations included reforming health information privacy protections to make it easier for doctors to track opioid use and prevent potentially dangerous situations. For example, a patient who shows up in an ER with a broken bone likely will be prescribed a painkiller. If that patient is in a methadone treatment program—and doesn’t mention it due to the stigma involved—there’s a high risk the doctor will increase the patient’s odds of overdosing.

Waller also suggested that ERs screen even nonoverdose patients for addiction disorders. Studies have shown that up to 40 percent of ER patients have addiction disorders—the highest percentage of the population outside the prison system, he said. Not only would this help with prescribing problems, it could help professionals recommend treatment options at earlier stages, he said.

Lack of Resources

There are several barriers to providing addiction care outside the ER, beginning with a lack of resources. ERs generally refer their opioid overdose patients to inpatient or community-based outpatient facilities. The type and quality of care available, however, varies greatly, the physicians said.

Inpatient treatment centers provide the highest and most effective level of treatment, but they are very expensive, Singer said. While some private payers cover the cost, it usually is for only a limited amount of time.

Community-based outpatient counseling centers are an option, but many communities don’t have any, or have facilities with long waiting lists, Ng said. It is a particular problem in his community. “Patients may be willing to get help, but are unable to do so,” he said.

Paying for the services also is a barrier to getting treatment. The Affordable Care Act requires treatments for behavioral health to be in parity with payments for other medical treatments, but the funding still isn’t the same, Ng said.

Most hospital ER visits have been covered by Medicaid, at least in states that have expanded Medicaid coverage under Obamacare since 2014. But Medicare and Medicaid coverage of nonhospital based treatment is limited, as is the amount of money available from private payers. “Payers at all levels need to take greater responsibility,” Roy said.

By the Numbers: Costs

According to the federal CDC, opioid misuse in the U.S. costs about $78.5 billion per year. The figure includes health-care, addiction treatment, lost productivity, and criminal justice-related expenses.

Emergency health-care services account for a large share of those expenses. About $215.7 billion from 2001 to 2017 was spent on health care, primarily for emergency room visits, naloxone treatment (an overdose antidote), ambulance use, and treatment of associated diseases or complications, Altarum said.

In one of the hardest-hit areas of the country, the average cost of treating an opioid overdose patient in the ER is about $2,300, a spokeswoman for a Baptist Health, a large hospital system in Kentucky, told Bloomberg Law. Baptist Health treated about 1,300 opioid overdose patients in the last year, she said.

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