Beyond Buprenorphine: Models of Follow-up Care for Opioid Use Disorder in the Emergeny Department

Abstract

Recent evidence shows that emergency physicians (EP) can help patients obtain evidencebased treatment for Opioid Use Disorder by starting medication for addiction treatment (MAT) directly in the Emergency Department (ED). Many EDs struggle to provide options for maintenance treatment once patients are discharged from the ED. Health systems around the country are in need of a care delivery structure to link ED patients with OUD to care following initiation of buprenorphine. This paper reviews the three most common approaches to form effective partnerships between EDs and primary care/addiction medicine services: the Project Alcohol and Substance Abuse Services and Referral to Treatment (ASSERT) model, Bridge model, and ED-Bridge model. The ASSERT Model is characterized by peer educators or community workers in the ED directly referring patients suffering from OUD in the ED to local addiction treatment services. The Bridge model encourages prescribing physicians in an ED to screen patients for OUD, provide a shortterm prescription for buprenorphine, and then refer the patient directly to an outpatient Bridge Clinic that is co-located in the same hospital but is a separate from the ED. This Bridge Clinic is staffed by addiction trained physicians and mid-level clinicians. The ED-Bridge model employs physicians trained in both emergency medicine and addiction medicine to serve within the ED as well as in the follow up addiction clinic. Distinct from the Bridge Clinic model above, EPs in the ED-Bridge model are both able to screen at-risk patients in the ED, often starting treatment, and to longitudinally follow patients in a regularly scheduled addiction clinic. This paper provides examples of these three models as well as implementation and logistical details to support a health system to better address OUD in their communities. [

“It wasn’t here, and now it is. It’s everywhere": fentanyl’s rising presence in Oregon’s drug supply

“…To rebuild and maintain trust between these communities, addressing burnout, trauma, and fatigue among professional first responders and healthcare providers due, in part, to increased exposure to fentanyl-related overdose events is imperative [9,44]. Care and intervention following a non-fatal fentanyl overdose can establish an avenue for continued care, and connection to post-overdose services, such as initiation on MOUD, connection to peer recovery support specialists, and access to medical and social care [45,46]. These results add to the existing literature by highlighting that hesitancy to engage with law enforcement and healthcare providers remains a factor that influences overdose response practices, despite increasing exposure to fentanyl-related overdoses and increasing fentanyl prevalence in the Western US drug supply.…”

Physician-Perceived Barriers to Treating Opioid Use Disorder in the Emergency Department

“…Available outpatient clinics that continue MAT are independent of emergency medicine physicians’ abilities and scope of practice, but maintaining close relationships with these facilities and widespread distribution of information on available resources is critical to MAT’s success. Many EDs have had success in starting their own ED-based MAT clinics but have required extensive hospital support [ 18 ].…”

“…While the practicality and success of utilizing the ED to initiate MAT have been demonstrated in previous works [ 18 , 19 ], large-scale support of and participation with this model is lacking. Medications to start MAT can be difficult to access even for highly motivated individuals, mainly due to a shortage of prescribers and treatment programs [ 8 ].…”

Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel

“…138 A recent review by Martin et al further describes models to establish maintenance treatment on discharge; including the Substance Abuse Services and Referral to Treatment model, bridge model, and emergency department-bridge model. 139 These models may provide useful guidance in implementation and logistical details to support health systems in better addressing OUD in their communities.…”