Overdose deaths from opioids continue to rise in the U.S. and it is challenging for many people with substance use disorder (SUD) to access lifesaving, evidence-based treatment. Emergency departments (EDs) are on the frontlines of the overdose crisis, providing 24/7 acute care for the needs of people experiencing overdose and other drug-related medical needs. New models housed in or adjacent to EDs — called “bridge clinics” — offer timely evidence-based treatment, including initiation of medications for opioid use disorder (MOUD), and linkages to ongoing care in the community.
The CA Bridge program in California has supported the rapid implementation of the evidence-based bridge clinic model at more than 180 hospital EDs across California. In each hospital, a lead clinician and a substance use navigator — often with lived experience of SUD — play key roles on interdisciplinary teams to help patients initiate care and access follow-up services.
The Better Care Playbook spoke with Arianna Campbell, PA-C, director and co-principal investigator for CA Bridge and an ED and addiction medicine physician assistant to better understand how the bridge model came about and how it works.
Q. Why is it important to treat OUD treatment in EDs? What gaps in care or barriers to care does this address?
A. People who are using substances don't have many touch points to get access to care.
We were treating OUD as some sort of outsider thing — where you make an appointment with a specialist, sometimes with long waiting periods — and not integrating it into medical care.
We were treating OUD as some sort of outsider thing — where you make an appointment with a specialist, sometimes with long waiting periods — and not integrating it into medical care. The ED is the only 24/7 entity that doesn't require you to have the right insurance, and insurance card, ID, an appointment, etc. We wanted to make sure we were equipped to address SUD in the ED, address stigma which has been a barrier, and make it easier for people to get care.
Q. What does treating OUD in the ED look like? And in the bridge clinics?
A. The ED is like a fishbowl. We see the health care system from the inside and people see us from the outside. We know where the gaps are because we see people who can’t access care. The reason we had nearly 110,000 overdose deaths last year is because our system is not working enough for the people who need rapid access to care.
We built the bridge clinic across the street from the ED, because we needed a lower barrier clinic for people with substance use needs that we see in the ED or primary care, who need greater stabilization.
For example, a bridge clinic is for people with OUD who may be just initiating MOUD, or people with polysubstance use or co-occurring behavioral health disorders that a primary care physician maybe isn't comfortable treating. Then, when they're stabilized they can go back to primary care. This offers a harm reduction approach and an approach similar to the way we address other high risk medical conditions.
We've also identified where there are the highest overdoses in our county, and they are in a very remote rural area, so I am now working one day a week in that very rural health clinic to provide SUD treatment in an area with big barriers to access.
Q. What does that staffing model look like for this approach?
We knew we needed a person from our own community to serve as a low barrier touchpoint, and have found this position so incredibly important that people are asking for it to be 24/7.
A. The staffing model in our ED is like other EDs, but we have a substance use navigator who has a strong foundation in harm reduction. Our navigator is also a certified drug and alcohol counselor who offers harm reduction supplies and motivational interviewing, which are both evidence-based. We knew we needed a person from our own community to serve as a low barrier touchpoint, and have found this position so incredibly important that people are asking for it to be 24/7. We're very proud that we started 250 patients on buprenorphine last year, which is a lot for a rural hospital.
From the bridge clinic side, staffing includes medical care providers and a substance use navigator, who can assist the person with a range of needs including housing or transportation. At the bridge clinic there is a medical provider, a substance use navigator, and a nurse, who is responsible for injectables.
Q. Can you talk me through what a workflow could look like?
A. It starts with signage in our ED lobby to inform patients that we offer treatment for opioid use disorder. Initiating a pathway in triage, the nurses can make a referral to our substance use navigator. And then usually it's a team effort between the clinician and the navigator.
Patients always have a choice, whether it be for treatment, harm reduction resources, or follow-up care. The medical providers ask questions to determine if medications for OUD are appropriate and we offer the patient a choice to initiate medication. The navigator offers guidance to the patient on these treatments, follow up care, and explores other needs. We openly offer take-home naloxone and have signage in our ED to let people know about it. Often, the offering of naloxone opens the conversation to engage someone in treatment. The navigator will follow up with the patient the next day and in the future as well, to make sure that the patient did not hit any barriers to follow-up care.
Q. How would you advise clinical or administrative staff who need to make the financial case for implementing this in their hospital to their CFOs or CEOs?
A. Two things — data and stories. Every month we hold a SUD committee meeting and the first thing we do is look at data. We look at how many people are being identified with opioid use or alcohol use disorder, stimulant use disorder, etc., and look at how many of them are being given treatment, are being referred, and are going to their follow-up appointment.
What we found is when our navigator was involved in the care of a patient, it reduced their risk of readmission at least five-fold and up to ten-fold.
The hospital has a big focus on decreasing readmissions. When we started looking at readmission data of people with co-occurring SUDs in our facility — it's huge. It's in the same realm as co-occurring diabetes in terms of re-admission risk and so then we looked at interventions. What we found is when our navigator was involved in the care of a patient, it reduced their risk of readmission at least five-fold and up to ten-fold.
Also, sharing patient stories are important. There are many big wins in this work. For example, a patient I treated, continued their treatment and made major strides in their life related to that. They came by the ED, hugged me, and told me, “You saved my life.” People need to know how powerful this work can be. Making sure people know that we are saving lives can be so powerful.
Q. What are the biggest policy barriers that you see to model, such as the bridge clinic?
A. If you look back on the history of addiction medicine policy, we have to acknowledge the connection of policy to racism and stigma. We can't continue to support the system of care that has limited access to medications and medical care for people who use drugs, and which takes a carceral view of SUD that wants to control people who use drugs, rather than seeing it as a treatable medical condition.
We can't continue to support the system of care that has limited access to medications and medical care for people who use drugs, and which takes a carceral view of SUD that wants to control people who use drugs, rather than seeing it as a treatable medical condition.
For example, methadone is a highly effective treatment, but how it is delivered in methadone clinics is stigmatizing and disruptive to people’s lives. They require you to show up and wait in line every day to have someone watch you take it, a very public reminder of your past drug use. Buprenorphine can be prescribed from any medical setting as a schedule III medication, but many people think it is someone else’s job to prescribe it. If we acknowledge the importance of access to buprenorphine, we give people actual choice and opportunity to get a treatment that allows them to reach other goals in their lives. “Okay, give people choice of medications, look at their other medical needs, explore harm reduction. Give people some agency in their own care.”
Q. Are states doing anything to help support Medicaid beneficiaries being able to access opioid treatment like bridge clinics that you can think of?
A. One problem is all the hoops you have to jump through to get enrolled into Medicaid, which now covers MOUD, including buprenorphine which is delivered a less supervised way than methadone.
A game changer for us in California is emergency Medicaid. If somebody who's experiencing a lot of instability and is in need of emergency care, the idea is frictionless access. A person can make a decision at two in the morning to access emergency care and enroll in Medicaid, if eligible, immediately in the ED. They see that H sign on the highway where there's a hospital and they go there, and they're signed up for Medicaid, and so the visit is covered for them. They are also handed a piece of paper indicating their coverage info to cover their prescription at the pharmacy.
So, any policy that makes Medicaid easy for people to get, especially emergency Medicaid, has been a game-changer. When we start this at other hospitals across the country, we ask them what they have for the uninsured, and access to emergency Medicaid makes an enormous difference.
Q. Is there any last thing that you want to add?
A. To get wider acceptance, bridge clinics and offering MOUD in EDs needs to be integrated into quality, and to be a quality measure you need evidence. We have evidence that the medications reduce mortality. We know that if you give buprenorphine in an ED or hospital setting, it doubles the likelihood of a person being in treatment in a month. The administration of this medication is easy, it is easy to administer since it dissolves in the mouth or can be prescribed and started at home.
A lot of people say, “I don't want those people in my hospital.” But they're already there, they're just not being treated with evidence-based care. And they're not “those people.” They're human beings.
Finally, MOUD in EDs and referrals to bridge clinics improve care and will improve your hospital's image. I think a lot of people say, “I don't want those people in my hospital.” But they're already there, they're just not being treated with evidence-based care. And they're not “those people.” They're human beings. It could be your sister, your brother, your mom, your dad, your kid. The medicine is not the problem, it is not challenging. It is not hard. It is stigma. You can make an enormous difference in your hospital, and you can report on what you're doing to save lives in your community. It's really important work that makes for better person-centered care and better overall medicine.