Peers Enhance Referral to Treatment in Emergency Departments

The peer workers who staff the Medical University of South Carolina's (MUSC's) hospital emergency department go by the title “patient navigators,” and they are making progress in helping substance use disorder patients negotiate what can normally be a stormy, unfulfilling experience of care.

Karen Hartwell, MD, associate professor at MUSC's Department of Psychiatry and Behavioral Sciences, spoke Thursday at the Rx Drug Abuse & Heroin Summit to discuss the navigators' role in helping to initiate buprenorphine treatment in the ED setting for patients with opioid use disorder (OUD).

A program that has been rolled out to South Carolina coastal counties with proportionally high numbers of opioid overdose deaths is showing how peers can make inroads with patients in a fragile state, and do this cost-effectively. “This frees up nurses, social workers and doctors in the ED,” Hartwell said regarding one important effect of the peers' presence.

These individuals in long-term recovery are trained in motivational interviewing techniques and can directly administer to patients the widely used screening tools for drug or alcohol use disorders. Out of more than 1,700 individuals receiving an OUD diagnosis at multiple sites as a result of the South Carolina emergency department intervention, just under 500 have ended up being initiated to buprenorphine treatment, Hartwell said.

More patients in the near future may be able to take advantage of additional medication options, such as a monthly injectable formulation of buprenorphine already on the market and a weekly injection that should be available later this year, she said.

The COVID-19 crisis has temporarily moved the peers out of the ED setting, but they are still able to reach individuals through a telehealth platform, Hartwell said. She expressed hope that the current crisis-driven relaxation of restrictions such as the requirement for an initial face-to-face patient encounter before initiating buprenorphine treatment can become permanent. ”I'm all in favor of reducing barriers,” she said.

Initial data promising

Hartwell said early worries among ED doctors that the initiative would flood their settings with OUD patients have proven unfounded. On the encouraging side, around half of patients initiated on buprenorphine at the ED are staying in treatment at the 30-day mark.

She cited preliminary financial data for the first 37 MUSC patients to have gone through the program, showing an average 23% reduction in annualized hospital events and an average annual savings of $8.270.

Financial hurdles remain, however. Reimbursement for peer services in South Carolina lags behind that of neighboring states, Hartwell said. She added, more broadly, that in any non-expansion state under Medicaid, planners of such efforts will have to identify at least one site that can access federal or state funds for continuation of outpatient medication treatment for OUD, since many patients have limited insurance.