Suboxone use in the ER rare, but could help opiate addicts begin long-term treatment
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.
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.
Neven took advantage of that exception, training other emergency room doctors to administer a single dose of Suboxone to patients before referring them to treatment. Because of budget constraints, they could only refer two people per day and sometimes had to turn patients away.
“We had a couple days without getting any calls and then one day we had nine,” Kamaliazad said.
The health district has long used another drug, methadone, to treat people addicted to opioids. The two drugs work in similar ways, by binding to opioid receptors in the brain, but they’re slightly different.
When heroin binds to opioid receptors, it triggers the release of brain chemicals that cause a person to feel high. Methadone activates the same receptors, stopping withdrawal symptoms, but it won’t get someone high at doses used in treatment. If a person takes more methadone, it will continue activating receptors, just like heroin – there’s no natural “ceiling” to the drug’s effects.
In practical terms, that means it’s a good choice for people who have built up a high tolerance for heroin over a long period and need large replacement doses to feel normal again. But that also makes methadone easier to overdose on if it’s abused.
Buprenorphine, in contrast, only partially activates the brain’s opioid receptors – just enough to stop withdrawal symptoms, but not enough to get high. The drug has a “ceiling” after which taking more won’t increase the effect, making it nearly impossible to overdose on. It’s also a good choice for people who have lower tolerance to opioids because they haven’t been using as long.
Suboxone can be prescribed by a doctor’s office
Chris was on the health district’s waiting list for the methadone program earlier this summer, and struggled to stay well without medication. He starting using heroin in his early 20s when he was homeless and traveling around with friends, but got clean and spent 11 years working and leading a normal life.
In 2014, he relapsed after turmoil with his girlfriend pushed him into a deep depression. He got Suboxone through an intensive outpatient program last year and was able to stay clean for a while, but dropped out because the program required nine hours of group counseling per week, something he couldn’t continue while holding down a job.
He had stockpiled some Suboxone and tried to wean himself off of it, but started feeling awful when he got down to just a half-milligram per day. Eventually, he ran out of the drug, and the withdrawal symptoms came back. He tried to buy Suboxone on the street when he could, but continued using heroin to feel well again.
Now, Chris has a job working for a food service company. He said he’s happier to be on Suboxone than methadone because he’s used it before and eventually wants to taper off completely. He had to go to the emergency room three times in withdrawal before there was a spot available for him at the health district.
Methadone has been used to treat heroin addiction since the 1960s and is cheap: A bottle of the liquid, enough to treat about 50 patients at the health district for the day, costs just $36, said opioid treatment program director Julie Albright. Federal guidelines require the drug to be dispensed in daily doses at approved clinics, though patients who are successful may be granted medication to take home in lockboxes as a privilege.
The FDA approved Suboxone in 2002 and a generic version in 2013. Unlike methadone, it can be prescribed in a regular doctor’s office, as long as the doctor gets a special license and training. But many patients still find treatment difficult to access. An individual doctor is capped at 275 patients, a number that was raised from 100 this summer. Many doctors are unwilling to take Medicaid patients at all, and only 53 doctors within 100 miles of downtown Spokane are licensed to prescribe the drug, according to a Department of Health database.
Cost the biggest barrier to Suboxone treatment
At the health district, the barrier to more widespread use of Suboxone has been financial. A month’s supply of generic buprenorphine for one patient is $240, a savings compared with the $500 cost of brand-name Suboxone, Albright said.
Some health district patients are able to pay for their own treatment, either out-of-pocket or through private insurance, but the bulk of them are Medicaid patients funded through a contract with the Spokane County Behavioral Health Organization (BHO), using state money.
The BHO caps the number of Medicaid patients who can get treatment for opioid addiction at the health district at just under 600, regardless of which drug they’re prescribed, leaving about 150 patients on a waitlist. BHO pays the district $15.25 per patient per day for treatment – enough to cover methadone along with counseling and other services, but not enough to fund Suboxone treatment.
Albright hopes to expand access to Suboxone treatment and is exploring contracts through the companies that provide Medicaid insurance to get coverage. She’d also like to see more county dollars to raise the cap on the number of patients she can treat.
Tonya Spern, the county’s integrated behavioral health care manager, said the BHO is considering whether to expand or change the contract with the health district to include buprenorphine treatment. Other treatment providers funded by the county also provide buprenorphine to patients.
Until that happens, the health district will keep treating the 20 patients who have continued on Suboxone from emergency room referrals through the pilot project, but can’t take new patients.
Aim is to start treating addiction in the ER
Neven doesn’t want the program to die, so he’s begun referring patients to Ideal Options, a physician practice specializing in addiction medication. The founder, Dr. Jeff Allgaier, is a former emergency room doctor who went into addiction medicine after seeing the pain many addicts were in when they came into the emergency room.
Ideal Options operates 10 clinics in Eastern Washington, Idaho and Montana. The Spokane clinic is the largest and serves about 600 people with opioid addictions, about 450 of whom are on Medicaid, Allgaier said. In the few weeks they’ve been partnering with Sacred Heart, they’ve gotten about 20 referrals from patients who got their first dose of Suboxone at the hospital. Nearly all are on Medicaid, and many have other health problems.
“These are the folks that are the most difficult to get a physician in the community to take care of,” Allgaier said.
Neven said buprenorphine is gaining traction, but is likely to continue being slowly adopted by the medical community. He’d like to see more emergency doctors embrace it.
“My hope is that we can start treating addiction in the ER,” he said.