New Opioid Treatment Protocol Facilitates Timely Access to Care
IMAT and Emergency Department Pave the Way
The opioid epidemic continues to have a devastating impact across the country. Every day in the United States, 78 people die from an opioid overdose; this number has nearly quadrupled since 1999. Here in San Mateo County drug-related deaths accounted for 2% of all deaths in 2017.
Meeting the Challenge to Provide Adequate Resources
The County has responded to this challenge in a number of ways, including the creation of the Integrated Medication Assisted Treatment (IMAT) program. The IMAT effort includes a team of case managers embedded within San Mateo Medical Center’s Emergency Department and the Primary Care Interface team. In addition, the County opened their first addiction medicine clinic, the San Mateo Medication Assisted Treatment (MAT) Clinic, run by HealthRIGHT 360, in 2016.
In the fall of 2017, the clinic expanded their outreach and engagement efforts to serve those with opioid use disorders (OUD) and has seen a significant increase in the number of patients treated. The increase can be attributed to the county-wide effort and commitment to expand access to care. County residents no longer have to go outside the county for OUD services. The graph below illustrates the growing demand for care for OUD services (purple line).
The number of OUD-related clinic visits surged last year from 474 to 1357 clinic visits compared to the prior year – an increase of 300%, while the number of unique new OUD patients receiving services nearly tripled from 41 to 108 from last fiscal year.
Enhanced Collaboration Accelerates Timely Access to Care
As the demand for services continues to rise, the County continues to respond. An enhanced collaboration between BHRS’ IMAT Team and the San Mateo Medical Center (SMMC) was formed. Beginning February 1, SMMC officially changed the Emergency Department’s (ED) standard protocol for treating opioid use disorder to include the administration of buprenorphine to patients determined to be in an active opioid withdrawal. This represents a big shift in ED practice.
The Emergency Department staff are in a unique position to interact with and serve those struggling with opioid use disorders and addiction. They often see patients brought in following an opioid overdose and have an opportunity to initiate treatment with those clients right there in the ED. Trainings for ED staff were held under a partnership with California ED-Bridge, a statewide program administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) that helps emergency departments get up to speed with treating opioid disorders. This treatment starts with the administration of buprenorphine, a medication which reduces withdrawal symptoms and cravings. In addition, this evidence-based practice has been shown to increase the likelihood of the patient engaging in treatment post-discharge from the hospital.
“When they get the buprenorphine, they feel better in about 20 minutes and our case managers are then able to engage them, can have a productive conversation, and link patients to services. It’s amazingly helpful,” BHRS IMAT Supervisor Mary Taylor Fullerton says.
The IMAT case managers embedded in the SMMC Emergency Department have been critical in helping those wanting treatment. The ED physicians and staff can immediately connect their patients to continuing support. The case managers work one-on-one with patients – offering education about addiction treatment strategies and referrals to ongoing recovery resources beyond the emergency room. This linkage frequently includes a direct referral and intake at the MAT clinic. The case managers coordinate insurance issues, transportation, and referrals to primary care, mental health and/or substance use treatment. “We kind of have [IMAT case managers] at our fingertips although as they become busier, accessibility to them diminishes,” says an SMMC provider. They also provide educational support to the primary care providers, helping to bridge the gap between the client and provider.
MAT Pays Off
The County’s efforts are paying off. County statistics show a reduction in the utilization of inpatient hospitalizations, emergency department (ED), and psychiatric emergency services (PES) visits when patients receive medication and immediately engage with the IMAT program (see chart below). Over a three-year period, the integrated approach to care has resulted in a sharp decrease in the utilization of costly emergency services for the IMAT clients, including hospitalizations. In addition, there has been a noteworthy increase of linkage to less costly out-patient services.
Because of the enhanced collaboration between the ED and the IMAT team, 72% of the patients seen at the MAT Clinic last year for opioid use disorder engaged for more than 90 days in treatment. This data helps dispel the stigma surrounding those with opioid use disorder who are often labeled as medication-seeking and unmotivated.
When patients and physicians nationwide were surveyed by the Substance Abuse and Mental Health Services Administration (SAMHSA) about the effectiveness of buprenorphine, they reported an average of an 80% reduction in illicit opioid use, along with significant increases in employment, and other indicators of recovery.
Filling the Gap Through Expansion and Needed Improvements
Thanks to a new grant from California ED-Bridge, the IMAT team is now expanding this program, which will hopefully increase accessibility. IMAT team members are also working to streamline the intake process and further reduce the time it takes to connect patients with addiction medicine services and behavioral therapies. The San Mateo MAT Clinic, which focuses solely on addiction medicine in an outpatient setting, has extended their service offerings to include patient walk-in hours. There have been dozens of successful transitions of patients stable on buprenorphine back to their primary provider, which then opens up space at the clinic to able to see new patients – a promising trend.
Another challenge is increasing the number of physicians/clinicians who can prescribe buprenorphine. In order to prescribe or dispense buprenorphine physicians/clinicians must complete eight hours of required training and secure a waiver. Only about 6% percent of medical practitioners in the U.S. possess this waiver. San Mateo County is not immune to this challenge and still struggles with having an adequate number of providers able to treat opioid use disorders. The County sponsored a waiver training in last month for County staff which is expected to significantly increase the number of waivered prescribers here. A bill currently being considered by Congress - the Mainstreaming Addiction Treatment Act – would remove the waiver requirement for health care providers. If the bill passes, it would make it easier for providers to prescribe buprenorphine and could greatly expand access to Medication Assisted Treatment.
As millions of Americans continue suffering through the pain of opioid addiction and tens of thousands die from overdose each year, Fullerton and her team continue to educate and outreach to those in need, and work on expanding the capacity to serve them. With fatalities from overdose now being the leading cause of death for Americans under 50 and only 1 in 5 individuals with an opioid use disorder getting the treatment they need, San Mateo County and the IMAT team are on a mission to change that.