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Facing the opioid crisis means culture change for hospitals

December 01, 2019
Opioid pill bottle 250x250

In 2018, more than 2,000 people in Massachusetts lost their lives to opioid use disorder (OUD). While state-wide the numbers went down slightly, western Massachusetts saw a sharp increase in deaths. People in our communities face unique barriers to care, including socioeconomic status (like income, education, safety, and social support), a shortage of treatment facilities, and continued stigma surrounding OUD.

Baystate Health is taking a multifaceted approach to care for these patients that includes education, prevention, and treatment—and culture-change across the organization.

“We’re changing how we approach patients with OUD, and working to expand services for them and remove barriers to treatment,” says Dr. William Soares of Baystate Medical Center’s Emergency Department and OUD Task Force.

Care from the front lines

For patients with OUD, the Emergency Department (ED) is often a last resort. Some patients are brought in after an overdose. Some have suffered a complication due to injecting drugs. Others come in wanting help and don’t know where to go.

“We have radically changed the way we approach patients with OUD in the ED,” says Dr. Soares. “We used to send them away with just a list of resources, telling them to call around for care. Now we talk to them about their needs, start effective medication treatment and help link them to community resources. In doing so, we decrease barriers and improve adherence to care. And that is key to saving lives.”

Suboxone, a treatment for opioid addiction

Buprenorphine (Suboxone) reduces cravings for opioids and is a highly effective treatment for OUD. Medication therapy has proven to be successful when provided on demand in the ED to those with OUD. A 2015 Yale study found that buprenorphine treatment started in the ED doubled the rate of patients still in treatment after 30 days. In response to mounting evidence, Massachusetts passed legislation in 2018 requiring that EDs offer buprenorphine and connect patients to outpatient services.

In order to make buprenorphine available as part of routine ED care, Baystate Medical Center needed a cultural shift. Providers had to learn to screen, appropriately treat, and discharge patients with a plan for continued therapy.

Patients can now start buprenorphine in the ED and receive a prescription until they start with outpatient treatment. In the last six months at Baystate Medical Center, nearly 40 patients have gone through the ED Buprenorphine Protocol.

“For many patients, they’re grateful that we are able to talk to them about their opioid use and offer effective treatment,” says Dr. Soares.

Vital follow-up care

When a patient is discharged from the ED on the Buprenorphine Protocol, a team of follow up nurses and mental health professionals set up a follow-up outpatient appointment. They also help with barriers to outpatient treatment, like transportation, insurance, or financial issues.

“This is an incredibly at-risk population,” says Dr. Soares. “If they survive an overdose, their risk of dying within one year is between 5-10%. It’s like sending someone home who’s having a heart attack. We have to do what we can to ensure they don’t fall through the cracks.”

EMBED Trial

Caring for people with OUD can be challenging in the fast-paced environment of the Emergency Department.

In an effort to meet this challenge, Baystate Health is one of five hospital systems involved in the EMBED (EMergency Department-Initiated BuprenorphinE for Opioid Use Disorder) trial, a National Institutes of Health (NIH) funded research study. EMBED’s goal is to increase use of buprenorphine in the ED by removing burdensome documentation and other barriers to treating OUD.

Participation in the trial is helping Baystate Medical Center to streamline the ordering process for ED providers to prescribe buprenorphine in the ED. TechSpring and Baystate Health are working together to develop an enhanced system that helps busy emergency doctors decided and deliver the best treatments for patients with OUD.

Helping those not ready for help

Baystate also has resources for people who are not yet ready to quit. With these patients, the goal is to keep them alive and healthy. “We tell them: ‘every time you inject, you’re rolling the dice,’” Soares says. His team, in collaboration with local organization Tapestry Syringe Access, provides resources as well as harm-reduction supplies, alcohol swabs, saline, Band Aids, and other materials to keep people safe.

“We try to do a lot of gentle teaching: ‘If you are going to still inject drugs, let me show you that you can avoid an infection, an overdose, or death,’” says Soares.

Inpatient Addiction Consultation Service

The need to improve care among hospitalized patients with addictive disorders was the impetus for the development of Baystate Medical Center’s Inpatient Consultation Service.

The program is staffed by Dr. Stephen Ryzewicz of Baystate’s Hospital Medicine Program, along with a social worker and a nurse practitioner. The service helps providers better understand the complexities of opioid and other substance use disorders, and collaborates with primary teams in managing addiction and its complications.

“The field of addiction medicine has advanced greatly in the last 20 years,” says Ryzewicz. “Addictive diseases were not well understood, and you often need specialized providers to assist in their management. We now have the resources to better serve our patients.

Stopping the revolving door

In addition to educating care providers about addiction related topics, The Inpatient Consultation Service team also:

  • Assesses patients in the hospital for substance use disorder and its effects
  • Helps manage withdrawal
  • Starts patients on medication treatment in the hospital
  • Assists with the discharge/follow-up process and linkages to outpatient treatment

“At discharge, it would sometimes be like a terrible revolving door. People would go home, relapse, come back,” says Ryzewicz. “Now they leave and we provide what we call ‘a warm hand off.’ We have people to advocate for them, people to follow up, to support them and help them make connections in order to and get started on the road to recovery.”

“We’re reducing the barriers,” he continues. “We’re identifying patients with OUD more quickly. We’re preventing readmissions and deaths. This is an area that has been tremendously underserved and underresourced. We can do better and we are doing better.”

Learn more about Baystate Health's work to address the opioid crisis.