by Bobby Redwood, MD, MPH

George Orwell’s 1984 really gave big brothers a bad rap. Sure, you can view the Healthcare Effectiveness Data and Information Set (HEDIS) as our government overlords squeezing the art (and fun) out of emergency medicine…but I tend to view their role as that of a real big brother. Big brothers can be overbearing, they smack us when we’re acting the fool, but they also keep us out of trouble and help us navigate tricky areas of our practice.

Enter HEDIS measure “FUA”: Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence.

We all know that the opioid epidemic in Wisconsin is getting out of hand and we all see these patients suffering from maladaptive behavior, overdose, and withdrawal. From the 20,000-foot view, in 2016, 20.1 million Americans over 12 years of age (about 7.5% of the population) were classified as having a substance use disorder and in 2017, 70,200 Americans died from an opioid overdose. When and how is this epidemic going to end? No one knows when it will end of course, but we have a pretty good idea how the ED can help:

• We can order fewer opioids in the ED (i.e. ALTO programs) 
• We can prescribe fewer opioids (i.e. WACEP’s opioid prescribing guidelines)
• We can embrace harm reduction techniques (i.e. over-the-counter nalaoxone, needle exchanges, etc.)
• We can get patients access to Medication-assisted treatment or MAT (i.e. buprenorphine, methadone, or vivitrol) 

As luck would have it, our big brother HEDIS is here to help us stay on track in terms of getting patients access to MAT. The two rates reported in the 2017 FUA measure are:

• ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
• ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

The literature unequivocally shows that timely follow-up care for patients with OUD who were seen in the ED is associated with a reduction in substance use, future ED use, and hospital admissions. Unfortunately, the 2017 HEDIS data on FUA has just been released and only about 10% of adult OUD patients are getting follow-up care within a week of their ED visit and only 13% are getting that care within 30 days of their ED visit. We can do better and the solution is an ED to MAT care pathway.

The arguments against starting an ED to MAT care pathway are abundant: its not the ED’s role, we can’t get started without PCP follow-up spots, the burden of getting a DEA X-waiver is unreasonable, my ED is going to turn into a buprenorphine clinic, etc, etc, etc.

I’ll let you all in on a secret… an ED to MAT care pathway is fulfilling for providers and is not hard to operationalize:

• Step 1: Find two primary care physicians in your area who can reserve two Monday appointments and two Tuesday appointments for patients requesting MAT.
• Step 2: Ask patients to stop using their opioids 48 hours before their allotted appointment time and provide them with a starter prescription of clonidine 0.2mg BID (#10) and Zofran 4mg ODT prn (#10) to help stave off early withdrawal symptoms.

If your ED group is willing to get X-waivered, you can get more sophisticated and actually prescribe a buprenorphine starter pack from the ED. To learn how this all works:

• Check out WACEP/WHA’s webinar: Buprenorphine 101: Demystifying Medication Assisted Treatment in Wisconsin (link); and/or 
• Register for the WACEP Spring Symposium, where we break down the details of an ED to MAT care pathway at our hot topics roundtable.
• For an easy to follow protocol, check out this excellent resource that applies to both the ED and clinic setting. 

2019 is going to be the year for ED to MAT care pathways in the Wisconsin. Your hospital administrators have likely already heard about the FUA HEDIS measure and (if it has not already) it will likely be showing up in your ED soon. We at WACEP urge you to stay ahead of the curve and start saving lives now: watch the webinar, print out the protocol, go to the conference, and get your X-waiver! Let’s make our big brother proud.

The new ACEP MOC Center is the "easy button" for MOC! It's a One-Stop-Shop to keep it all together and on track for all things MOC. See what you have to do to stay certified AND what resources ACEP has to help you do it. 

ABEM has made (at least) three big changes in the way they present MOC information to diplomates – 1) they launched a new website, 2) they changed the names and order of the MOC components, and 3) they changed the language they use to describe them (no more "Part" anything). ABEM also announced an alternative to the ConCert Exam, which they'll pilot in 2020 and launch in 2021. 

The new ACEP policy statement, Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline, was approved by the Board in September 2018 and has been endorsed by several other organizations. Read the policy here. 

ACEP has a number of web-based tools for you to use at the bedside.  From sepsis, to acute pain to agitation in the elderly – we’ve got you covered!   

• ADEPT - Confusion and Agitation in the Elderly ED Patient 
• ICAR2E - A tool for managing suicidal patients in the ED 
• DART - A tool to guide the early recognition and treatment of sepsis and septic shock
• MAP - Managing Acute Pain in the ED
• BEAM - Bariatric Examination, Assessment, and Management in the Emergency Department. For the patient with potential complications after bariatric surgery

Jeffrey Pothof, MD, FACEP
President

Wisconsin emergency physicians, welcome to the February edition of the WACEP newsletter.  I hope all of you are as eager is I am to attend the WACEP Spring Symposium and 27th annual Emergency Medicine Research Forum.  We have secured a great venue in the Harley-Davidson museum and have some top-notch programming ready to go.  I hope to see all of you there April 3rd and 4th.  If you haven’t already registered, sign up today.

A handful of years ago I had an opportunity to hear Maureen Bisognano, then president of the Institute for Healthcare Improvement (IHI), deliver a keynote address at the Institute’s national forum in Orlando.  It was simple enough.  Instead of asking your patient “what’s the matter?”, we were challenged to ask our patients “what matters to you?”  This seemingly small change in words, can lead to a much deeper understanding of the patient and will improve the care you deliver.  I’ve used this approach in the ED and anecdotally can say it’s been effective in illuminating why a patients come to my ED, and allows me to better meet their needs.  Each patient brings to the ED a different set of life circumstances, they have their own fears and they have their own logic for seeking us out. 

By asking “what matters to you?” I discovered that the 35yo sitting in front of me worried sick about an episode of seemingly benign chest pain wasn’t the anxious hypochondriac I was suspecting, but instead was the child of a parent who passed away from sudden cardiac death at the same age.  What mattered to my patient was knowing that the same thing wasn’t happening to him.  The conversation we had around his fear was more impactful to him than the negative troponin or perfect ECG I was banking on.

By asking “what matters to you?” I witnessed one of my patients tear up and disclose the long history of intimate partner abuse she was suffering from.  I wouldn’t have figure that out by asking what was the matter with her abdominal pain.  Instead of ordering a CT scan, we conversed on how no one deserves to be treated that way, and I was able to share resources to try and make an inflection point in her life.

Many of you have similar stories where an encounter took an unexpected turn, and you experienced one of those moments where you connected more deeply with a patient.  A time when you made a difference not through anything you learned in medical school or residency, but because you took the time to listen and understand the human condition.

I challenge all of you on your next shift, or perhaps on all your shifts, to ask your patients not only what brought them in today, but what matters to them today.  I’d love to hear how this impacts your practice so if you are willing, share your stories with me. 

Looking for a deeper dive in Buprenorphine training? Here are some complimentary educational offerings:

• Between February and August, a series of ten complimentary buprenorphine X-Waiver courses are being made available to all eligible prescribers in Wisconsin. The training, presented by the Wisconsin Society of Addiction Medicine (WISAM) in partnership with Wisconsin DHS, is designed to increase treatment capacity for opioid use disorders in Wisconsin. Learn more and sign up for a course.
• "Buprenorphine 101 Demystifying Medication Assisted Treatment in Wisconsin" is an ED-focused webinar available on demand. View webinar. 
• "Developing an ED Initiated Buprenorphine Program" is an ED-focused webinar available on demand. View webinar. 

Beginning in 2019, the Wisconsin EMS Board has adopted a quarterly meeting schedule. State EMS meetings are open meetings and WACEP members are welcome to attend as members of the general public and/or at the Physician Advisory Committee.

Dr. Aurora Lybeck, WACEP Board member, regularly attends the meetings and encourages additional WACEP participation. Dr. Riccardo Colella, current Wisconsin State Medical Director, and Dr. Steven Zils, chair of the EMS Physician Advisory Committee, are both WACEP members. 

The EMS Board and Committees will meet in 2019 as follows:

• March 5/6
• June 4/5
• September 3/4
• December 3/4

The committees of the Board will meet on the first day (Tuesday) and the full Board will meet on the second day (Wednesday). Links to the Agendas and meeting minutes will be posted when available.

Julie Doniere, MD
WACEP Board of Directors

I know… another article about opiates.  Bear with me, I am writing this because I am anxious to start some conversations about treatment of opiate abuse.  Specifically, I am eager to hear about what is happening in the ED’s across Wisconsin.  

In my practice, I feel like the biggest challenge is finding treatment for those patients that are seeking help with their opiate abuse.  Current practice is often symptomatic treatment, a referral list, and a “good luck!” We see people at their most vulnerable. We are either taking care of them after overdose, identifying their abuse disorder by looking at old charts, or being there when they realize they have a problem and present themselves to the ED. 

There are some caveats to opiate treatment. Opioid addiction does not respond to the same treatments as alcoholism.  Abstinence therapies do not typically work.  These patients have a desperate need to avoid withdrawal. 

This is where buprenorphine can be helpful.  While incorporating bup into my treatment in the ED, I have encountered multiple misconceptions about the drug:

Myth #1: You can’t administer Buprenorphine in the ED without an X-Waiver. 
BUSTED: Any ED physician or midlevel provider can use buprenorphine in the ED to treat opiate withdrawal.  The patient can return to the ED for 3 days In a row to get buprenorphine. 

Myth #2: Buprenorphine is a scary drug and will throw my patient into withdrawal.
BUSTED: Well, kind of busted.  Buprenorphine will cause withdrawal symptoms.  It should be given only to that subset of patients who are already in withdrawal; the COWS scale can measure this, I use MDcalc.  When a patient has a COWS scale of 8 or greater, buprenorphine can be given.

Myth #3: Every opiate addicted patient in the county will be inundating my ED for buprenorphine.
BUSTED: ED’s that have initiated buprenorphine have seen a decline on drug seeking behavior. 

Myth #4: We are trading one addiction for another.
BUSTED: The goal of medical assisted treatment is to trade addiction for dependency.  Abstinence from opiates is the goal.  While buprenorphine is an opiate agonist, it works primarily to control withdrawal symptoms so that individuals have more control over their cravings and avoid the risky use of opiates. 

By no means is this article meant as a fully informative review of buprenorphine in the ED.  I am not smart enough for that!  If you are interested in a deeper dive into the role of buprenorphine in the ED, please view one of these two webinars:

• Developing an ED Initiated Buprenorphine Program (View) 
• Buprenorphine 101 - Demystifying Medication Assisted Treatment in Wisconsin (View)

The following information about ED dosing concepts is thanks to Dr. Donald Stader, an ED doc in Colorado:

In a news feature aired last summer on WEAU Channel 13 in Eau Claire,  new WACEP Board member Nate Blankenheim, MD  was interviewed in an exclusive look inside the new Marshfield Medical Center Eau Claire Emergency Department. Doctor Blankenheim talked with the reporter about the new facility and tried to teach him how to put on a cast. Watch video.

January 17, WMS Medigram

The State of Wisconsin Medical Examining Board modified the Opioid Prescribing Guideline at its monthly meeting in Madison on Wednesday. Expressing a desire to be less proscriptive in the “Discontinuing Opioid Therapy” section of the guideline, the Board has removed specific clinical suggestions for situations when opioid therapy leads to evidence of addiction risk or is proving ineffective.

The section’s first two subsections have been shortened, while the third section remains the same:

Discontinuing Opioid Therapy
a. If lack of efficacy of opioid therapy is determined, safe discontinuation of opioid therapy should be performed.
b. If evidence of increased risk develops, safe discontinuation of opioid therapy should be considered.
c. If evidence emerges that indicates that the opioids put a patient at the risk of imminent danger (overdose, addiction, etc.), or that they are being diverted, opioids should be immediately discontinued and the patient should be treated for withdrawal, if needed. Exceptions to abrupt opioid discontinuation include patients with unstable angina and pregnant patients. These patients should be weaned from the opioid medications in a gradual manner with close follow-up.

The Board also added a new general provision near the top of the overall guideline:

2. It is best practice for a practitioner to consider guidelines within their specialty when prescribing opioids.

The remaining guideline provisions were renumbered to reflect this addition. The new guideline became effective upon Wednesday’s vote approving the changes.

In other action, the MEB elected its leaders for 2019. They are the same as in 2018, with Ken Simons, MD, reelected chair, Tim Westlake, MD, as vice chair and Mary Jo Capodice, DO, as secretary.