When people overdose on opioids and are revived— as happened to Prince six days before his death— the experience is far from pleasant. Naloxone (Narcan), the antidote that reverses the deadly effects of the drugs instantly ends any lingering opioid high, replacing it with the fear, anxiety and nausea of withdrawal. While in this distressed state, it’s nearly impossible not to ruminate on the closeness of death and the damage addiction can do.
That’s why it is an ideal time to offer treatment, especially since without it, many people remain at high risk of overdosing again. (The horror of the experience, however, is why easy access to naloxone doesn’t encourage extra risky use: you’d have to be a truly perverse masochist to deliberately OD and risk not only death, but being ripped from the peak of your high and thrown into withdrawal).
Indeed, the hours or days when people are hospitalized after overdose are perhaps the best opportunity to start people on maintenance medication. This not only rapidly relieves withdrawal but is also the only approach known to cut the overdose mortality rate by 50-70% or more. Maintenance is the indefinite, possibly lifelong, use of opioid drugs like methadone, buprenorphine (Suboxone) or even heroin itself— and no other treatment including inpatient rehab and 12 step programs has been found to have its life-saving impact.
But sadly, smoothly coordinated care is rarely what happens. Most people who get medical treatment for overdose are simply released after they’re stabilized without so much as a referral for further help— or, as happened in Prince’s case, they leave against medical advice. Some who overdose are even arrested for drug possession or on prior drug-related warrants when police accompany the ambulance that responds. From the hospital, they’re then taken to jail, where withdrawal is frequently left completely untreated, sometimes with deadly results.
During a crisis in which overdose is now killing more people than car accidents, this is an outrage. There’s no need to mandate treatment entry after overdose, as some politicians have suggested— this could deter people from seeking help when avoiding it could be fatal and mandatory treatment can clog the system with people who won’t benefit while leaving those who are ready for it on waiting lists. But it is also absurd that we don’t voluntarily offer the best care we have to anyone who wants it in the aftermath of an overdose, on the spot.
This strategy of offering immediate medication treatment has been studied in a randomized clinical trial published in the Journal of the American Medical Association in 2015. 329 patients were included. Of this group, 104 were simply provided a referral to further treatment, 111 were given referrals along with a brief motivational therapy aimed at encouraging them to follow through and enter care and 114 were prescribed buprenorphine right then and there.
Not surprisingly, the buprenorphine patients were twice as likely as those who were simply offered treatment referrals to still be in treatment a month later, and they reduced their illegal opioid use from an average of five days a week to an average of just one. While 78% of them were still in treatment, fewer than half of the other two groups remained engaged— and their drug use was reduced by far less than in the group who got buprenorphine immediately, according to Dr. Gail D’Onofrio, lead author of the study, and a professor of emergency medicine at Yale.
This research is in line with a large body of prior data showing that ongoing treatment with buprenorphine or methadone is the most effective treatment for opioid problems in terms of reducing use, crime, HIV and other diseases and saving lives.
“Considering that opiate overdoses have dramatically increased over the last 15 years, this type of intervention is desperately needed,” says Dr. Omar Manejwala, an addiction psychiatrist and author of Craving: Why We Can’t Seem to Get Enough.
So why aren’t we implementing this approach in every American E.R.? Surprisingly, there is no barrier to the first step needed to do so. E.R. doctors are already allowed to prescribe up to three days of maintenance medication to tide someone over until they can enter treatment—and far more of them should be doing so when patients come in suffering from withdrawal, whether or not they’ve overdosed.
But the real problem is the lack of availability of longer term care. Only 30,000 doctors are licensed to prescribe buprenorphine— and they are limited to 30 patients in the first year, and 100 thereafter, no more. Since the idea is for patients to stay on medication for a few years at least, these slots quickly fill. Worse, only 10,000 of those doctors actually do have the paperwork to prescribe for 100 and many of them don’t even see any patients. Further, methadone access is restricted to special clinics, nearly all of which are located in dangerous neighborhoods because NIMBYism keeps them out of others, even though they actually cut crime rather than raise it.
According to a study published in the American Journal of Public Health in 2015, even if every currently certified doctor saw the current maximum of patients, 1.3 million patients still wouldn’t have access to maintenance— and far from every doctor prescribes, let alone sees the maximum. The Obama administration recently proposed raising the patient limit from 100 to 200, but this seems both unlikely to meet demand or be enough to solve the problem.
“Immediate treatment in the emergency with buprenorphine for a patient withdrawing or after an overdose is critical to save more lives and engage more people in treatment, but only if the 100 patient limit is eliminated and people have somewhere to go for maintenance,” says Dr. Molly Rutherford, a family doctor who treats addiction in Kentucky, which is one of the hardest hit states. She also notes that many E.R. doctors may also be unaware that they are legally able to provide emergency maintenance.
We have the tools to cut the overdose death rate by half— the question is why we aren’t using them.