Our hospital created an evidence-based pathway to prescribe medication, as part of an addiction treatment protocol, for patients seeking to overcome their opioid addiction. In December of 2018, MGH Emergency Department initiated the ‘Get Waivered’ campaign leading to 95% of all MGH ED faculty on staff obtaining their DEA-X waiver, a federal requirement to prescribing buprenorphine. In contrast, nationwide only 1% of all emergency physicians nationwide have this waiver. A multidisciplinary team including physicians, addiction specialists, pharmacists, and others planned for over a year before implementing the dual pathway ED-initiated buprenorphine protocol on May 1, 2018. The primary aim is to give patients access to this medication when they present to the ED.
Option 1 in the pathway is the ‘Take Home’ protocol for patients not in opioid withdrawal but seeking treatment for their OUD. . Pre-packaged, pre-labeled bottles of ‘To-Go’ buprenorphine/naloxone are stocked in the ED. When an eligible patient is ready for discharge, MGH ED providers can prescribe two days’ worth of the medication in a small package with instructions on how to dose the medication. An ED pharmacist dispenses a ‘To-Go’ buprenorphine kit (six 8/2 mg sublingual films) and provides comprehensive counseling on home induction. Additionally, the pharmacist dispenses nasal naloxone and provides counseling on its administration for an opioid overdose. The patient is then discharged with guidance to follow up at a specialized addiction Clinic the next day for ongoing care. The patient can then self-administer buprenorphine when they begin withdrawing at home and have clear guidance on how to re-dose themselves as needed prior to follow up at the addiction Clinic. This allows patients to have the medication they need at the point of care instead of requiring them to follow up at the pharmacy to fill their prescription.
Option 2 in the pathway is the ‘ED Administration’ protocol. This option is available for patients in opioid withdrawal in the MGH ED and can take their first dose of buprenorphine while they are still in the hospital. Patients are observed for clinical improvement and discharged with instructions on how to follow up at the addiction Clinic. These patients also receive nasal naloxone with counseling from an ED pharmacist. The ‘To-Go’ buprenorphine and nasal naloxone are given to the patient free of charge (Hayes 2012).