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A clean-cut man in his early 30s buttons the jacket of his tailored suit as he strides to the head of a conference table at Massachusetts General Hospital.
"Hi, I'm Mike, and I'm a recovering heroin addict," the man tells a dozen emergency department (ED) physicians gathered to learn about buprenorphine, a drug used to treat heroin addiction.
Mike is here to confirm, in the flesh, the findings of study after study that show buprenorphine saves lives. (We agreed to use just Mike's first name because he's worried about how drug history would affect his employment.)
Mike's story of the four worst years of his illness is disturbingly familiar: He had no place to call home, he says he committed felonies to get money for heroin, and he spent tens of thousands of dollars of his family's money on residential programs that banned buprenorphine and other medication-assisted treatment (MAT).
The abstinence approach, without MAT, works for some, but research has shown it has an increased risk of death when compared to buprenorphine. And that approach didn't work for Mike. He went back to heroin again and again.
He had asked three doctors for buprenorphine -- common brand name: Suboxone -- before finding one who would prescribe it. Now on the medicine, Mike says he feels normal and can finally manage his addiction.
"If I had started with proper therapy right away I’d probably have my MBA right now. I’d probably already be married. I’d probably have a better relationship with my family, " Mike tells these physicians. "I mean in four years a lot can happen and it can be devastating, trying to recover from that."
Mike is the final speaker for these doctors, who are completing a buprenorphine training at MGH. Doctors who want to prescribe this FDA-approved addiction treatment medication must finish an eight-hour course and secure a waiver from the federal government. Those hurdles are one reason a relatively small number of physicians treat patients using buprenorphine. It's rarely available in emergency rooms, a common meeting place for drug users and medical providers.
"If you come in with diabetes that's out of control or horrible blood pressure, we can give you medication, we can help," says Dr. Ali Raja, executive vice chairman of the Department of Emergency Medicine at Mass. General. "But having somebody come in and ask for help with their opiate addiction and saying, 'No, I'm sorry, there's nothing we can do,' that's exceptionally frustrating."
'We Can't Wait'
At MGH this week, that's changing. The hospital has just become the first ED in Massachusetts to offer buprenorphine to patients with an opioid use disorder who want to start treatment on the spot. There will be at least one doctor in the ED, 24/7, trained in a protocol that guides patients through the transition from active drug addiction to managed addiction with MAT. It's a basic, but profound shift for an ED after decades of offering little more than a list of detox programs, phone numbers and maybe assistance making calls.
"I really hope patients come," Raja says. "I want to be known as the place where they can come."
Mass. General is not the first ED in the country to prescribe buprenorphine. A poll conducted by the American College of Emergency Physicians last year found 66 doctors who say their emergency room offers MAT.
But Dr. Gail D'Onofrio — who chairs the Department of Emergency Medicine at Yale New Haven Hospital, the first hospital ED to offer MAT — says very few EDs currently offer MAT round the clock to any patient who might need it.
She is encouraged by the growing interest.
"The thing about opiate addiction and overdose is it just takes one and someone will die," because fentanyl and other synthetic opioids are so potent," D'Onofrio says. "It's very scary. If we have someone in front of us who has this problem and this disease, we need to start initiating treatment immediately. We can't wait."
D'Onofrio's research shows that patients who began buprenorphine in the ED had a more than 50 percent better chance of staying in treatment for two months (the length of the study) than those who did not.
Mass. General signing on to offer MAT will get the attention of many hospitals around the country, says Dr. Joshua Sharfstein, an associate dean the Johns Hopkins Bloomberg School of Public Health.
"What makes the MGH initiative very important is, you have an extremely prominent hospital saying that we expect our doctors to be able to take care of opioid use disorder; this is not a condition of some other system, this is for us," Sharfstein says.
Mass. General ED patients will not follow the common path to recovery, which includes five to seven days in a detox program and weeks or months in often-expensive residential care. Prescribing buprehorphine in the ED is the first step on what the hospital hopes will be a seamless route to continuous, home-based care.
At MGH, patients who either ask for treatment or who show signs of an addiction to opioids will be assessed and, if appropriate, given a two-day supply of buprenorphine and a graphic instruction sheet (above). Some will take their first dose (8 milligrams) in the ED, but only if they're having at least three symptoms of withdrawal, "such as jitteriness, vomiting, nausea or anxiety," says Raja." When you're feeling like this," he plans to tell patients, "that's actually a good thing, because buprenorphine doesn't work when you're high."
Controversy Over Buprenorphine
Buprenorphine, heroin and fentanyl bind to some of the same opioid receptors. Buprenorphine will push heroin off those receptors, triggering an immediate withdrawal. Doctors suggest a gradual transition to buprenorphine saves lives by curbing the cravings for more powerful drugs.
"The more you wait, the better the buprenorphine will work," Raja says.
There are many reasons why buprenorphine has not, to date, been widely adopted by physicians, including those in EDs. Most physicians learn very little during medical school about how to treat addiction patients. For decades those patients have checked into residential programs outside the medical system. Many of those programs ban buprenorphine because they object to using a drug to treat a drug addiction.
Former U.S. Health and Human Services Secretary Tom Price jumped into that controversy last year.
“If we’re just substituting one opioid for another, we’re not moving the dial much,” Price told the Charleston Gazette-Mail. “Folks need to be cured so they can be productive members of society and realize their dreams.”
Nearly 700 physicians and researchers fired back, urging Price to "set the record straight: medication-assisted treatments meet the highest standard of clinical evidence for safety and efficacy."
But while a half dozen emergency rooms in Massachusetts prepare to join MGH in prescribing buprenorphine, some law enforcement officers are concerned about diversion. They worry patients would leave an ED with a supply of buprenorphine and sell it on the street. Some drug users take buprenorphine, without a prescription, to stave off cravings. Others take the drug, in large doses, to get high when they can't get heroin.
MGH will give patients just a two-day supply, which Massachusetts Chiefs of Police Association President Steve Wojnar says shouldn’t be a problem, especially if the patient is connected to follow-up medical care.
“If it’s just somebody walking in off the street, getting something and going out the door, that might be different,” says Wojnar, who is also police chief in Dudley. “But if the person is serious about some kind of treatment … if it’s a way to get them to start that help, that could be a positive.”
Some state lawmakers say most, if not all, hospitals should offer treatment on demand.
At a State House hearing earlier this year, Sen. John Keenan, a Democrat from Quincy, asked Gov. Charlie Baker and his health and human services secretary, Marylou Sudders, if the administration is open to requiring EDs to use MAT. After all, said Keenan, we expect EDs to treat heart disease, asthma and diabetes.
Sudders said she supports emergency rooms that prescribe buprenorphine, but would not mandate they do so.
"We’re not in the position to require every hospital in the commonwealth to start medication-assisted treatment," Sudders told Keenan. "They don’t have the capacity to do it. What they would need to have is that warm hand-off to someone to start the treatment."
MGH's Bridge Clinic
At MGH, that "warm hand-off" is to a small program called the Bridge Clinic. It's where patients will go from 9-5, seven days a week, while they slip into the early stages of withdrawal. The Mass. General ED is too busy to hold them. Those who are discharged from the ED in the evenings or overnight will be instructed to start buprenorphine at home and return to the Bridge the following day.
"Without the Bridge Clinic, our work in the emergency department would be an exercise in futility," Raja says.
The clinic took shape three years ago, as overdose deaths in the state reached new record highs.
Dr. Sarah Wakeman, medical director of MGH's Substance Use Disorder Initiative, noticed a dangerous gap in care. Patients who wanted to start buprenorphine were waiting months to see a doctor who could prescribe it. The Bridge Clinic opened, Wakeman says, so that patients could start this life-saving therapy right away.
"But what we quickly realized is that there are many other ways that the system was failing patients," she says. "I think we’ve really fundamentally mismatched our treatment approach to what we know about the illness, which is that people are in crisis."
Wakeman was disturbed to hear about providers who refused to see patients who showed up late for appointments or whose insurance had lapsed during the chaos of heroin use. Many patients with a substance use disorder still get booted out of programs if they admit to or show signs of a relapse and drug use.
"Our Bridge Clinic quickly expanded to be a low-threshold, treatment on demand, come as you are clinic where the primary goal is to welcome people and connect with them and build a relationship," Wakeman says. "That might be a cup of coffee or a conversation, or it might be starting buprenorphine that day."
Patients can drop in at the clinic any day, no appointment needed, under the influence or not, just to charge their phones or see a doctor. There's a nurse on staff, a recovery coach, two women who help patients with housing, insurance and other details of life, and an office manager, all employees of Mass. General. The hospital spent an additional $100,000 on supplies and operating costs for the clinic last year. The Bridge offers yoga, meditation, peer group meetings and art therapy.
A total of 463 patients checked in for at least one visit last year.
'I Wouldn't Be Alive If It Wasn't For Them'
There's one exam room where medical director Dr. Laura Kehoe sees patients. The cabinets are stocked with typical first aid supplies, as well as naloxone, the drug that reverses an overdose, and kits that include the tools of active drug use: syringes, cookers and cottons.
"A large portion of our patients are actively using while they're here," Kehoe says. Supplying them with clean needles and such helps "lower their consequences while they're still struggling."
Surveys show most drug users relapse frequently during recovery — at about the same rate as patients with diabetes, asthma or other chronic diseases.
Bridge patients often use of combination of substances: cocaine, anti-anxiety pills or alcohol. Kehoe treats all these addictions. Patients might gain control of one but not the others. Kehoe asks her patients for urine samples, but not so she can catch and punish them.
"Rather than kicking them out when they actually need more care, we say, 'OK, well let’s shift gears and work on that, let’s break down, why are you using, what are the triggers, what’s going on?' " Kehoe says.
A notebook in the clinic reception area is filled with grateful, heartfelt tributes to the Bridge staff. Ricky Scimeca has become a devoted patient.
"I wouldn’t be alive if it wasn’t for them," says Scimeca, 28, a barber from Boston.
Scimeca says he’d been kicked out of seven or eight treatment programs before he overdosed a year ago and showed up at the Mass. General ED. Scimeca’s mom and a social worker walked him to the Bridge Clinic.
"They welcome the worst of the worst addicts, not that I was any better," he says. "But even though I didn’t feel like I wanted to get clean at that point, I still had hope."
Dr. Kehoe helped Scimeca translate that hope into an agreement about the life he wanted back and the steps he could take to get there. Scimeca remembers the moment he bought in.
"When I sat in this room and I saw that Dr. Kehoe cared more for me than I did for myself," says Scimeca, his shoulders tightening in a sob.
Scimeca has relapsed once in the year he’s been on buprenorphine. He’s back to cutting hair and offers free cuts to former veterans, like himself, at a homeless shelter.
"The high that I got from doing that was way greater than the high I got from doing drugs and alcohol," Scimeca says, "and I think by doing that it will continue to keep me sober."
Scimeca still sees Dr. Kehoe once a week, which is not typical. The idea is that the Bridge Clinic will stabilize patients after a few months and transition them to a primary care doctor who’ll help manage their illness. After a few years, patients may switch to naltrexone, a drug that blocks their opioid receptors altogether.
Taking Notice Of MGH
Addiction treatment programs are taking notice, as Mass. General maps a seamless route to outpatient addiction care that includes: treatment on demand in the ED, the hospital’s Bridge Clinic, 55 primary care doctors who are waived to prescribe buprenorphine, as well as nurse practitioners and physicians in many other areas of the hospital network.
"It’s a significant development. Hopefully we’ll see other hospitals follow suit," says Vic DiGravio, president of the Association for Behavioral Healthcare, which represents more than 80 mental health and addiction treatment programs in Massachusetts. "For even better outcomes, it's going to be important to make sure these individuals are connected with other supports, like counseling, like outpatient therapy to maximize their opportunity to achieve recovery."
The big challenge now, says MGH's Dr. Wakeman, is undoing the old addiction care models.
"Notions of tough love, that being kind to people is enabling behavior, or that people have to hit rock bottom — that’s how people die. That’s why we’re in the midst of an overdose crisis," she says.
Wakeman's next project is a Bridge-style clinic for new mothers managing an addiction. State data out last year shows a sharp increase in overdoses among new mothers with an opioid use disorder in the six- to 12-month period after birth.
There’s growing interest in urgent care-style clinics to combat the opioid epidemic. Boston Medical Center opened Faster Paths Addiction Urgent Care Center in August of 2016. In its first year, 1,275 patients were seen.
“It's exceeding my expectations, but our expectations were pretty high. We knew there was a need for this,” said Dr. Alex Walley, associate director of Faster Paths.
The clinic is expanding hours and adding nurse practitioners who can prescribe buprenorphine. Some patients don't like the idea of using a drug to treat a drug addiction so the clinic also offers an abstinence approach. Walley says there's no wrong door to treatment.
We're going to encourage people to consider a medication because we think, especially in the setting of fentanyl and the overdose crisis, that that's what's going to keep them safer,” said Walley. “But the patient gets to decide what path they want to go down and we're going to offer them all the options that we have access to.”
Walley says the Faster Path team is adding some services it didn’t anticipate, like rides to the Registry of Motor Vehicles. Patients who don’t have a picture ID can’t retrieve their medication from a pharmacy so staff help the patients get to the RMV. And Boston Medical Center is collaborating with some residential programs after realizing that some patients need a lot of structure in the early period of recovery.
The Bridge Clinic and Faster Paths are the models for another half dozen such urgent care clinics proposed in Massachusetts as providers work to make treatment as available as street drugs.
This segment aired on March 7, 2018.
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