Suboxone use in the ER rare, but could help opiate addicts begin long-term treatment


Spokesman writes-

First, there’s the anxiety. Chris used to wake up with it and feel so awful he didn’t think he could get out of bed.

“You just want to crawl out of your skin,” he said.

Then come hot and cold sweats, nausea, diarrhea and vomiting. It’s like having the worst case of the flu, the kind that might send a person to the emergency room – but there’s almost nothing an ER doctor can do.

Withdrawal from heroin and other opioids is a painful process that leads many addicts to the hospital in search of care. Chris, who asked that his last name not be used to protect his privacy, said he’s gone to the emergency room more than once hoping for relief. Most of the time, he’d get anti-nausea medications, fluids and maybe an anti-anxiety pill, which would mask his worst symptoms for a bit, but did nothing to help with his addiction.

“There was nothing they could do. They treated the symptoms,” he said. Before long, he’d be out of the hospital and looking for heroin or another opiate on the streets, just hoping to feel better.

“Nobody really wants to be using. We just have to,” he said.

But at Providence Sacred Heart Medical Center, that’s no longer the case. The hospital began a trial program this summer, led by Dr. Darin Neven and University of Washington medical student Ariana Kamaliazad, to give patients buprenorphine in the hospital to stabilize them before referring them to medication-assisted drug treatment.

It’s a novel approach that’s still uncommon in hospitals. Neven said he’s only aware of one other Washington hospital that does the same thing.

“Addiction medicine is very much ignored in the medical world,” Neven said. “It’s still viewed as a moral failing and providers don’t have enough time for it.”

‘I hope all the hospitals start doing it’

About 34 patients were referred to treatment over the course of the two-month study at Sacred Heart, Kamaliazad said. The team plans to publish research after seeing how many patients referred stuck with a treatment program.

A randomized clinical trial conducted by the Yale School of Medicine from 2009 to 2013 found giving patients buprenorphine – more commonly known by the brand name Suboxone – in the hospital made them more likely to stay in treatment for at least 30 days. Seventy-eight percent of patients given the drug were still in treatment 30 days later, versus just 37 percent of those given a simple referral to treatment. The group given buprenorphine in the emergency room also reported using heroin fewer days than people in other groups.

Chris was one of about 30 patients who started daily treatment at the Spokane Regional Health District’s opioid treatment program over the summer, thanks to a referral from the hospital.

“I hope all the hospitals start doing it,” he said.

Replacement drugs

Buprenorphine and methadone are the two drugs used in treatment to help alleviate withdrawal symptoms while patients get counseling and other services to help them stop abusing heroin or prescription painkillers.

Medication-assisted treatment focuses on getting people to stop using illicit drugs by giving them replacement opioids in a controlled, safe setting, in addition to counseling.

“The Suboxone just stabilizes your brain chemistry so you can start to be receptive,” Kamaliazad said.

Providers who work in addiction medicine say it’s much more effective than simply telling patients to stop using drugs cold turkey. For a drug like heroin or oxycodone that alters brain chemistry and causes intense physical withdrawal symptoms, that’s not realistic, said Dr. Matt Layton, the treatment program’s medical director.

“The relapse rate is ridiculous,” Layton said.

Layton said he sometimes hears criticism that treatment programs like his are “replacing one addiction with another.” Replacement drugs like Suboxone are addictive in a chemical sense: People who stop taking the drugs without tapering off of them will experience withdrawal. But medication-assisted treatment is now widely accepted, with the FDA and the Department of Health’s Substance Abuse and Mental Health Services Administration publishing information on treatment guidelines and best practices.

Replacement drugs are far less likely to be abused, Layton said, and allow people to hold jobs and maintain normal lives. Instead of searching for heroin or pills on the streets and shooting up with dirty needles, people can come to a clinic once a day, swallow a pill or some liquid and be on their way.

“We replace a lifestyle with another,” Layton said.

‘On their own time’

Neven said he wanted to start treating people in the emergency room to make it easier for addicts to get treatment when they’re ready for it. Patients seeking treatment at the health district or similar clinics often find monthslong waiting lists. While they’re waiting for a slot to open up, they may overdose on heroin or end up in the hospital with a life-threatening heart infection from using a dirty needle.

“An addict is ready when an addict is ready on their own time, and that usually doesn’t coincide with making an appointment and going to that appointment in a week or two,” he said. “If a person loses the opportunity to get stabilized, they can die from their addiction.”

Federal law requires doctors to have a special license to prescribe buprenorphine, but makes an exemption for physicians who administer the drug to treat acute withdrawal symptoms while referring patients to ongoing treatment.


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