Colorado MAT

Colorado MAT Part 4: Buprenorphine in the Emergency Department

  1. Treatment with buprenorphine is easier, less time consuming and far more effective for management of opioid withdrawal and OUD than standard care with clonidine, IVF, haldol and other symptomatic therapies.
  2. Induction with buprenorphine is easy, requires no IV or labs, and is usually accomplished in 1-2 hours. It requires a chair, not a hospital bed.
  3. To identify patients who are candidates, be sure they’re in sufficient opioid withdrawal using clinical impression or the COWS scale, obtain a history of type of opioid use and time of last use and any prior experience with buprenorphine, and confirm patient consent for buprenorphine induction.
  4. Precipitated withdrawal is a risk with induction if a patient is not sufficiently in withdrawal. Consensus on the treatment of precipitated withdrawal will require further study. Some protocols recommend stopping buprenorphine if withdrawal symptoms worsen, while others recommend treatment with additional doses of buprenorphine in addition to symptomatic meds.
  5. Patients should be discharged with overdose education, naloxone and a plan for close follow-up with a warm handoff to an OTP or OBOT.
  6. For adolescents 16 years old or older with OUD, buprenorphine is an option. For pregnant women, buprenorphine is a life-saver for both fetus and mother.
  7. ED providers can be part of the solution to the opioid epidemic. Consistent appropriate use of buprenorphine in the ED has the potential to transform ED care of patients with OUD.

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Colorado MAT Part 3: Medications for MAT in the ED

  1. There are three MAT drugs available to treat addiction: naltrexone (brand name Vivitrol), methadone (brand names Dolophine or Methadose) & buprenorphine (brand name Suboxone, Subutex, and Sublicade).
  2. The only MAT drug appropriate for initiation in the ED is buprenorphine.
  3. Buprenorphine is a semi-synthetic opioid which acts as partial agonist at the mu receptor. Buprenorphine does not produce as much euphoria or as much of the respiratory depression seen with other opioids. It has a quick onset and long half-life and is usually administered sublingually. The most commonly used formulation of buprenorphine is mixed with naloxone for one reason and one reason only – to prevent diversion and IV drug use. When taken orally, the buprenorphine effect is predominant; when taken IV, the naloxone effect is predominant
  4. Any ED provider can administer buprenorphine in the ED for up to 3 consecutive days in order to bridge a patient to addiction services.
  5. X-Waivers allow you to prescribe buprenorphine from the ED, which is a great service you can provide your patients, particularly in rural communities. In 2019 ACEP will be producing an ED physician specific X-Waiver training which will focus exclusively on ED-based care.

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Colorado MAT Part 2: Medication Assisted Treatment

  1. Medication Assisted Treatment or (Medication for Addiction Treatment) is an important frontier in ED care of patients with Opioid Use Disorder. Naltrexone, methadone and buprenorphine are the medications approved for the treatment of OUD.
  2. Addiction is a disease that is widely misunderstood and rarely taught in medical school.
  3. It is a dangerous myth that the best treatment of all addictions is simply abstinence.
  4. The evolving consensus around OUD is that is best treated with medication. An opioid addiction should be treated with an opioid agonist.
  5. MAT is shown to substantially decrease mortality and morbidity for OUD.
  6. The treatment gap for OUD is egregious–as high as 75% in Colorado.
  7. Emergency department providers can be part of the solution to this problem by understanding and, when indicated, initiating proper treatment for OUD.

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Colorado MAT Part 1: Understanding Addiction & Opioid Use Disorder

  1. Addiction is widely misunderstood by the public and by many healthcare providers. It is not taught in most medical schools.
  2. Combating the opioid epidemic will require providers to understand Opioid Use Disorder (OUD) and its treatment.
  3. Addiction is a chronic, relapsing disease with extraordinarily high morbidity and mortality. It is the transition from controlled to impulsive and compulsive drug intake.
  4. Physiologic dependence is just one aspect of addiction. The behavioral and social derangements seen in addiction are the major source of harm for people with substance use disorders.
  5. Addiction is not a personal failure of will. The role of genetics and environment are enormous.
  6. It is more useful to think of addiction as a kind of “brain failure.” Dopamine and different dopaminergic systems are severely affected by drug use, resulting in chronic changes and even death to areas of the brain.
  7. We do not  stigmatize patients with diabetes or CHF for life choices contributing to their disease, nor do we refuse them care or make their care conditional on their behavior. We treat them.
  8. Opioid use disorder is a treatable disease. It is time that ED providers start treating it.

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