This Duel Pandemic Needs Emergency Care- COVID-19 & The Opioid Crisis
Updated: Feb 12
My emergency department colleagues and I are in year two of a duel pandemic. The devastating social, emotional and economic effects of COVID-19 are exacerbating the scale of what was an already out of control opioid use disorder crisis that is playing out in emergency departments like mine across the country. More than 40 states reported increases in opioid-related mortality in 2020, and that stacks up with what my colleagues and I are experiencing in our Philadelphia ED.
As an emergency physician, treating OUD can be physically grueling- I’ve been attacked and spit on, and one patient actively, and uncontrollably withdrawing from heroin, flooded our emergency department by clogging the sinks with sheets and physically sat in the sink like an agitated and scared bird, trying to cool her fully aroused skin. It can be emotionally debilitating for our patients, their families and for our providers.
The faces of the patients- teens and young adults, seniors, parents, friends- I’ve worked to resuscitate after an overdose, haunt me. Many survive. Some don’t.
I remember a young man in his twenties who was found unconscious on the street in South Philadelphia. He had been injecting heroin and still had a homemade tourniquet on his arm when he was brought into the ER. He was cold and his heart had stopped. First responders gave him CPR en route to the hospital and my team and I got his heart beating again. We sent him to the ICU to recover. He died on Mother's Day without ever regaining consciousness or saying goodbye to his family.
I also remember another patient who was unresponsive when he was brought in by his distraught brother after they ingested an unknown powder several hours prior. His brother, still intoxicated himself, was at his bedside in the ICU when he died.
My fellow ER doctors have so many stories like this. I am frequently left wishing I could do more or that the patient had come to my emergency department earlier. But what often leaves me crying at night is the knowledge that but for the cumbersome treatment barriers and outdated stigma that keeps patients from getting the care they need.
Stigma costs lives. Stigma can kill.
And stigma doesn’t just come from your next door neighbor judging your husband or daughter with Opioid Use Disorder, stigma is pervasive in the medical field as well.
OUD treatment needs to be comprehensive, but access to care can start in the ED. But one of the best tools we have to offer- Suboxone and its generic buprenorphine/naloxone which is prescribed for the treatment of opioid dependence- is out of reach for many patients and providers because of outmoded prescribing restrictions. Buprenorphine is effective, safe and reduces opioid cravings as well as withdrawal symptoms. In order to prescribe buprenorphine, physicians are required to have an “X-waiver”, a requirement that takes many hours as well as Drug Enforcement Administration (DEA) registration and ongoing compliance.
I am X-waivered, and have seen how Suboxone can lead to patient success: a road to sobriety, a life off the streets and a place back in society with family and true friends. But the requirement can lead to misconceptions and stigma about medication-assisted treatment and other clinicians are unwilling to pursue an X-waiver, leading to less providers and less access to treatment options for patients. Only 2.2% of physicians in America have an X-waiver and most of us, 90.4%, practice in urban areas leaving many in suburbs and rural areas without access to buprenorphine treatment as an option.
There were more than 81,000 drug overdose deaths in the United States in the 12 months ending in May 2020, the highest number of overdose deaths ever recorded in a 12-month period. And in certain parts of the country, drug overdose deaths outpaced COVID deaths. Those with a substance use disorder are at increased risk for contracting COVID-19 and have worse outcomes than those without substance abuse disorders. With increased attention rightly focused on tackling COVID, immediate action is needed to tackle the opioid epidemic as well. Many emergency physicians like myself hoped a recent change in guidelines could prove to be a game changer. This January, the U.S. Department of Health and Human Services effectively removed the X-waiver for physicians registered with the DEA who treat no more than 30 patients with buprenorphine. For emergency medicine physicians like myself, the patient limits did not apply to the January rule change as so many with OUD seek access to care though the ED. However, despite praise from the American Medical Association and physicians like me, the X-waiver rule change was shelved within weeks of its announcement due to legal concerns over implementation.
I understand caution. I understand prudence when it comes to medical guidelines. But in this case, bureaucratic delays could delay treatment for those who need it most and I urge swift reconsideration of the buprenorphine rule rollback.
The X-waiver change alone would lead to second chances. I've seen it happen before with Suboxone. Another one of my patients was found on the street in Center City and given Narcan by a police officer. The Narcan immediately reversed the effects of the man’s overdose, but he was on the verge of hypothermia when he was brought into the ER. I intubated him, warmed him up, and started a Narcan drip. He made it through that night because of the police officer, Narcan and our crisis support team. But he’s still alive today because he was prescribed Suboxone and connected to a good rehabilitation program and excellent peer support services.
To combat the opioid crisis, providers and patients need additional tools like greater parity for mental health care, more telemedicine treatment options, and more beds available in rehab settings. We need greater access to Narcan and its generic naloxone to save the lives of those experiencing an overdose, and we need more effective preventative drug education to potentially prevent OUD to begin with. More controversial options like needle-exchange programs and the decriminalization of substances of abuse need to be on the table too. And more physicians and care providers need to be willing to treat those with OUD.
Like many illnesses, there is no one cure for OUD, but changing the X-waiver would be a major step, and it is one that will save lives. And in this duel pandemic where my colleagues and I have seen too much death and are surrounded by too much sadness, we need a change that will allow us to provide care to more patients in a compassionate, comprehensive way.
Kevin M. Baumlin, MD, FACEP, is the Chair of Emergency Medicine at Pennsylvania Hospital, and Vice Chair of Emergency Medicine for the Perelman School of Medicine. Dr. Baumlin is Co-Founder of OAK Street Initiative.
Opinions expressed in this article do not represent those of the University of Pennsylvania Health System or the Perelman School of Medicine.