Background on Opioids

Making EDs and hospitals an access point for opioid addiction treatment

The drug overdose death toll for 2019 broke all previous records for New Mexico and the USA.  Unfortunately, the drug overdose death counts in 2020 will clearly surpass the 2019 records.1  Drug overdose is the number one killer of Americans between the ages of 20 and 50.,  The vast majority of overdose deaths involve opioids.  While the primary killer among opioids has evolved from prescription opioids to heroin to fentanyl, overdose deaths from all forms of opioids continue to rise.  Accompanying the rapid rise in illicit opioid use, the prevalence of benzodiazepine, cocaine, and methamphetamine misuse has risen dramatically as well.,  Furthermore, the exploding prevalence of opioid use disorder (OUD) over the last decade has led to an exponential increase in injection drug use, such that injecting (rather than smoking or “snorting”) cocaine and methamphetamine is now commonplace.  With this evolution, fentanyl and methamphetamine have become the leading drivers of drug overdose deaths in New Mexico.  Importantly, for many patients, the development of multiple substance use disorders (SUDs) begins with OUD, and successful treatment for other SUDs often hinges upon the treatment of opioid use disorder.

Unfortunately, historically, there has been little guidance for emergency clinicians (or physicians providing inpatient medical care) on how to best identify and treat patients with signs and symptoms of OUD – other than saying “no” to requests for opioid prescriptions.  Tragically, emergency clinicians routinely face opioid use disorder complications, such as overdoses, infections, and traumatic injuries, but current standards of care do not address the underlying substance use disorder. Consequently, current emergency department (ED) treatment of these complications usually does not facilitate the entry into OUD treatment nor impact patients’ risk of mortality or future injury.

However, EDs (and hospital inpatient units) can be key access points for starting addiction treatment.,  The ED, specifically, is a site increasingly recognized as a portal for initiating medication treatment for OUD.,,  Fortunately, in some centers in New Mexico, emergency clinicians are using buprenorphine not only to treat acute opioid withdrawal, but to initiate medication for addiction treatment (MAT) and to connect patients to outpatient clinics to continue their treatment and recovery.

Buprenorphine is one of the key medications employed as Medication for Addiction Treatment (MAT), sometimes referred to Medication for Opioid Use Disorder (MOUD), and previously referred to as “medication assisted treatment (MAT)”.  Other MAT medications are methadone and naltrexone.  MAT is life saving and life transforming.  Patients with OUD who continue MAT for one year have a nearly 60% percent mortality risk reduction compared to OUD patients who do not receive MAT.  Furthermore, MAT has been shown to be eight times more effective in reducing overdose mortality than non-medication-based treatment programs.17  The World Health Organization (WHO) recognizes MAT as the most effective tool in reducing the spread of HIV and Hepatitis C.,,,,,,,,,,,,  MAT has been demonstrated to reduce hospitalization, ED utilization,,, as well as rates of crime and incarceration.,,,,  Beginning MAT in the ED – ED buprenorphine initiation – has been demonstrated in multiple studies to profoundly improve the rate at which ED patients enter OUD treatment.12,13,14,15 

New Mexico is embarking on a new project, the New Mexico Bridge, to assist hospitals throughout New Mexico, as they develop programs for buprenorphine initiation and linkage to OUD treatment in their EDs and inpatient units.  Beginning with Holy Cross Medical Center in Taos, the New Mexico Bridge program will collaborate with several hospitals over the next two years, with a focus on rural and underserved communities, as we assist them while they develop guidelines and pathways for OUD treatment initiation with buprenorphine in the ED (and inpatient units), along with links to outpatient treatment for long-term recovery.

In addition, New Mexico Bridge will provide guidance and support for the development of peer support programs or partnerships in the ED (and hospital), to further improve the capability to link patients to ongoing treatment.  The Bridge Program will also aid in the development of coding and billing resources to aid in cost recovery, as well as data tracking tools to monitor OUD patient prevalence, frequency of buprenorphine utilization, frequency of buprenorphine prescribing, and rates of linkage to care.









9 2019#:~:text=Drug%20 overdose%20deaths%20in%20the,by%20drug%20category%20and%20state.

10 NMDOH Bureau of Vital Statistics and Health Statistics death data 2020 data provisional through July as of 10/14/20

11 Berg M, Idrees U, Ding R, et al. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department.  Drug and Alcohol Dep 86 (2007) 239–244

12 D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial  JAMA. 2015 Apr 28;313(16):1636-44

13 Kaucher K, Caruso E, Sungar G, et al.  Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program. Am J Emerg Med. 2019 Jul 30

14 Hu T, Snider-Adler M, Nijmeh L, Pyle A.  Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers. CJEM. 2019 Jul;21(4):492-498

15 Edwards F, Wicelinski R, Gallagher N, et al.  Treating Opioid Withdrawal with Buprenorphine in a Community Hospital Emergency Department: An Outreach Program.  Ann Emerg Med. 2020 Jan;75(1):49-56

16 Kakko, et al. 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomized, placebo-controlled trial. Lancet. 2003 Feb 22;361(9358):662-8

17 Ma J, Bao YP, Wang RJ, et al. Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis. Mol Psychiatry. 2018 Jun 22

18 Fraser H, Zibbell J, Hoerger T, et al. Scaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic. Addiction. 2018 Jan;113(1):173-182.

19 Metzger DS1, Donnell D, Celentano DD, et al. Expanding substance use treatment options for HIV prevention with buprenorphine-naloxone: HIV Prevention Trials Network 058. J Acquir Immune Defic Syndr. 2015 Apr 15;68(5):554-61

20 Springer SA, Larney S, Alam-Mehrjerdi Z, et al. Drug Treatment as HIV Prevention Among Women and Girls Who Inject Drugs From a Global Perspective: Progress, Gaps, and Future Directions. J Acquir Immune Defic Syndr. 2015 Jun 1;69 Suppl 2:S155-61

21 Metzger DS, Woody GE, O’Brien CP, et al. Drug treatment as HIV prevention: a research update. J Acquir Immune Defic Syndr. 2010 Dec;55 Suppl 1:S32-6

22 Kresina TF, Bruce RD, McCance-Katz EF. Medication assisted treatment in the treatment of drug abuse and dependence in HIV/AIDS infected drug users. Curr HIV Res. 2009 Jul;7(4):354-64

23 Metzger DS, Zhang Y. Drug treatment as HIV prevention: expanding treatment options. Curr HIV/AIDS Rep. 2010 Nov;7(4):220-5

24 Bone C, Eysenbach L, Bell K, et al. Our Ethical Obligation to Treat Opioid Use Disorder in Prisons: A Patient and Physician’s Perspective. J Law Med Ethics. 2018 Jun;46(2):268-271

25 Norton BL, Beitin A, Glenn M, et al. Retention in buprenorphine treatment is associated with improved HCV care outcomes. J Subst Abuse Treat. 2017 Apr;75:38-42

26 Bernard CL, Owens DK, Goldhaber-Fiebert JD, et al. Estimation of the cost- effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis. PLOS Med J.

27 Sullivan LE, Metzger DS, Fudala PJ, et al. Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users. Addiction. 2005 Feb; 100 (2):150-158

28 Wammes J, et al. Cost-effectiveness of methadone maintenance therapy as HIV prevention in an Indonesian high-prevalence setting: A mathematical modeling study. International Journal of Drug Policy, 2012 Sept; 23 (5), 358-364

29 Williams AR, and Bisaga A. From AIDS to Opioids — How to Combat an Epidemic. N Engl J Med 2016; 375:813-815

30 Bruce RD. Methadone as HIV prevention: High Volume Methadone Sites to decrease HIV incidence rates in resource limited settings. International J of Drug Policy. 21 (2), Mar 2010, 122-124

31 Lo-Ciganic WH, Gellad WF, Gordon AJ, et al.  Association between trajectories of buprenorphine treatment and emergency department and in-patient utilization.  Addiction. 2016 May;111(5):892-902

32 Schwarz R, Zelenev A, Bruce RD, et al.  Retention on buprenorphine treatment reduces emergency department utilization, but not hospitalization, among treatment-seeking patients with opioid dependence.  J Subst Abuse Treat. 2012 Dec;43(4):451-7

33 Mohlman MK, Tanzman B, Finison K, et al.  Impact of Medication-Assisted Treatment for Opioid Addiction on Medicaid Expenditures and Health Services Utilization Rates in Vermont.  J Subst Abuse Treat. 2016 Aug;67:9-14

34 Skeie I, Brekke M, Lindbaek M, et al.  Somatic health among heroin addicts before and during opioid maintenance treatment: a retrospective cohort study.  BMC Public Health. 2008 Jan 31;8:43

35 Hasanovic M,et al. Cost-Benefit Analysis Of The Opiate Substitution Treatment With Buprenorphine/Naloxone In Bosnia And Herzegovina.  Global Fund for UNDP in Bosnia and Herzegovina. April 2017

36 Russolillo A, et al.  Associations between methadone maintenance treatment and crime: a 17-year longitudinal cohort study of Canadian provincial offenders.  Addiction, 2017: 113, 656–667

37 Oliver P, et al.  The effect of time spent in treatment and dropout status on rates of convictions, cautions and imprisonment over 5 years in a primary care-led methadone maintenance service. Addiction 2010; 105: 732–9

38 Dolan K, et al. Four-year follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection.  Addiction 2005; 100: 820-828

39 Horn B, et al.  The economic costs of jail-based methadone maintenance treatment.  Am J of Drug & Alcohol Abuse. 2018; 44: 611-618