The emergency department at UVM Health Network – Elizabethtown Community Hospital and its Ticonderoga Campus, led by David W. Clauss, MD, seeks to reduce stigma and erase judgment when treating patients with opioid use disorder. Watch the video highlight or read the full interview below.
How has the perception around opioid treatment changed over time?
So there’s been an evolution in what we see in the emergency departments (ED) related to substance abuse and particularly related to opioid abuse and opioid addiction. And there’s also been an evolution in the way we think about these diseases, the treatment options that we have and the way we approach people who come to us for our care.
Several decades ago, the medical community, in addition to the general community, really thought of opioid addiction through the lens of criminal activity. And more and more we’ve really understood that substance use disorder and addiction is a medical process – is a medical disease – and that we clearly were not able to eliminate this issue through prosecution and through incarceration.
How has opioid use affected your own community?
Aside from seeing general patients in the emergency department, more and more often I was seeing young people the age of my own children, and members of the community whom I knew were in high school, who had been caught up in opioid use and opioid addiction. It was a very personal process for me to realize that this is not happening to others, this is happening to our own community.
How did this influence the way your Emergency Department and staff handle these patients?
The way our thinking has evolved over time is that some time ago, we would deal with the immediate medical issue at hand whether that was medical treatment for an overdose, for an infection related to drug use, or for violence related to drug addiction and then release the patient. Over time, we became aware that the underlying cause of the emergency department visit wasn’t really being addressed adequately.
And so we evolved toward recognizing that there’s an underlying substance use disorder that would benefit from being addressed. But even then, initially, we were recommending to the patient that they seek treatment and not really playing an active role in linking them to services.
Why is it important for emergency medicine physicians to connect patients to opioid treatment services?
One of the integral parts of addiction is that an individual who’s affected by addiction, particularly opioid addiction, has a very significant change in their motivations. They come to the emergency department for various reasons. They may come to us for an overdose, withdrawal from the drug, or a secondary problem like infection, but they may not really feel like they’re ready to enter into treatment.
We need to help them to understand the root problem, but link them to help in the moment. Sending someone out the door with a recommendation that they seek services for treatment of substance use disorder results in a very low frequency of that individual following up effectively. In contrast, sending someone out the door with a concrete plan for follow up results in improved compliance and improved rate of follow up, and, ultimately, entry into treatment. Offering initiation of services in the moment in the emergency department and linking them in real time with real people who can help them optimizes the chances that they’re going to follow through, that they’re going to actually be able to enter into services.
With any substance use disorder, it is very challenging for the individual to enter into treatment and to follow up and stay in treatment. Relapse is very common. It’s part of the disease and we need to recognize that. And so we needed to really change the way we were offering services to patients. And so that’s what we’ve done in a number of different places in the network to try to bring the available services to the patient at the point of contact, in the emergency department, and try to optimize the chance that we can engage them and have a productive outcome.
What community resources are you utilizing in the Emergency Department?
We have people from Turning Point who are wonderful about being immediately available to sit down and talk to the person about their issue with substance use when they’re in the midst of the emergency department visit to discuss how opioids are affecting their life, what is available for treatment and help in a real time and getting them connected to services.
What changes have you made within the Emergency Department?
We are increasing the level of services that are available right here on site. We are doing far more direct referrals to treatment and identifying individuals who are appropriate for initiation of medication assisted treatment (MAT), in the emergency department. And initiating that either in the emergency department or setting up a home initiation linked to short-term follow up with substance abuse specialists. We’re trying to really optimize the power of that emergency department visit to get that individual into treatment.
What are some of the unique opportunities and challenges in a rural location like Elizabethtown?
I’ve had the privilege of being involved with some great initiatives here at UVM Medical Center Emergency Department. But in my role as Director of Emergency Services in Elizabethtown, with both the Elizabethtown and the Ticonderoga Campus, it’s a very different environment. We are working in a geographically challenged area with fewer personnel available and a lower patient load.
Trying to reproduce these great things that are being done elsewhere in the network, in a low frequency setting in Elizabethtown, has really been my challenge. And the way to accomplish that is to number one, take all the good things that are being done at UVMMC, in Plattsburgh at Champlain Valley Physicians Hospital and at Central Vermont Medical Center and figure out how to provide the same services in Elizabethtown. And that’s primarily by partnering with other people, and our network emergency departments, to make use of their protocols, to not reinvent the wheel when we know that something already works. And partnering with community organizations that have a stake in this.
Can you share specific examples where a partnership approach has been successful?
So we, in Elizabethtown, we have a generous grant from the Alliance for Positive Health, to provide Naloxone kits. Free, no questions asked, to anyone who presents to the emergency department, patient or not that feels that they would, they or a family member or a friend, would benefit from them having access to a Naloxone kit to reverse overdose of opioids.
In addition to that, we are partnering with our primary care physicians in the area, several of whom have already started prescribing buprenorphine in their primary care practices, just within the last few months. If we identify people who would benefit from treatment in the emergency department, we can identify where to send them and where they can receive care close to home. Because anytime you place a barrier, whether it is economic or geographic, to someone seeking services, you know there’s going to be a fall-off in follow up.
We’re partnering with St. Joseph’s Treatment Center in Saranac Lake, New York, which has offices in both Elizabethtown and Ticonderoga, to make use of their expertise in substance use disorder and for follow up for our patients for counseling, for wraparound services. At Elizabethtown Community Hospital, we have very dedicated, very interested community partners that we’re joining with to put all these pieces together. We can try to offer all the services that we can, to try to minimize the impact of the opioid crisis in this community.
How has opioid prescribing changed in the ED?
We are working to try to actively minimize the number of opioids that we prescribe from the emergency department. We know that the percentage, if you look overall, the percentage of opioids that are prescribed from emergency departments nationally, actually is less than 5% of total opioids. However, we are frequently an individual’s first exposure to opioids. And not only are we a first exposure to opioids, if we are in the habit of prescribing generous prescriptions for opioids to someone, who may only need a few days’ worth, then we have the risk of those opioids sitting in the medicine cabinet at home and available not only to that patient later at time for nonmedical use, but for family members or visitors to the home or anyone else, for diversion of those drugs.
While we try to minimize the number of opioids that we prescribe, we’re being mindful of the fact that we have a responsibility to treat pain appropriately in the emergency department. When someone comes in, we are actively working to explore with them whether opioid abuse is affecting them or a family member. We’re trying to link them to services in the moment, make use of that emergency department visit to do everything we can to try to optimize access to treatment and initiation of treatment when appropriate.
And then the Naloxone kits, very generously provided by the grant from Alliance for Positive Health, for anyone who feels that they, their family members or their friends, may benefit from this medication in the event of an overdose. Without barriers to distribution, without judgment, to try to minimize the devastating effect of overdose with both death and disability related to it.
How has the emergency department changed to acknowledge or overcome the stigma surrounding opioid abuse?
We want to create an environment where people know that individuals affected by opioid addiction are welcome. That we want to help them, that we are open to helping them and that we’re not going to be judgmental in doing so. And so providing these different aspects of help not only provides the help in a concrete way, to those folks that we identify, but my hope is that it’s going to make individuals more willing to actually seek help.
Opioid addiction is accompanied by so much social stigma, so much shame and so much negative judgment on the part of healthcare providers, law enforcement, and the public in general. All of those factors represent very real barriers to people seeking help. And so the more we can do to present a welcoming, nonjudgmental atmosphere where people feel comfortable answering questions accurately about substance use, but also feel welcome coming to us and saying, “I’ve got a problem. I need help”, increases our chance of being able to provide that help.
How have you created an atmosphere of nonjudgment in the ED?
Well, staff education, to be honest, and behavior modeling. I’m privileged with being in the position of being the Director of the Emergency Department actively modeling the approach that this is a disease that has devastating effects on the individual, that we do have effective treatment approaches to it, and that the only way to accomplish that is to be welcoming to the patient who needs us.
The medical community is often on the front lines. Would they be the first to recognize opioid use as a disease?
Actually, I think that is accurate. To be honest, I think it is accurate that the medical community leads the way in this. Even with that, we’ve got a long way to go to truly cancel out the biases that we have against people who have substance use disorder.
An interesting thing is that in emergency medicine we see people at their worst moments and in the moment we have a choice to make. Do we shame this person while we’re providing care? Or do we make this as welcoming an environment as possible and try to really optimize the level of care that we can provide? And I’m very proud to work with emergency medicine providers, throughout the network, who do a wonderful job of this. Having said that, I think we all continue to have a long way to go to eliminate some bias with regards to addiction and some of the behaviors that come with the disease of addiction.
Have you felt an evolution in your care and has this changed outcomes?
Oh, I have no question that it has changed outcomes and if I think back to the rate of recurrent visits with, in the past, seemingly with no positive movement between those visits, compared to what we are offering patients now, I don’t think there’s any question that we have made progress in addiction.
The disease of addiction often comes with behaviors that can make it challenging to make a connection with the person, particularly in that moment. When someone comes to the emergency department, often in one of their worst moments, our job is to figure out how we can best help them. We can’t help them if we react negatively to how they present to us. We can’t help them if we pass judgment on the condition that they’re suffering from. And we can’t help them if we shun them, related to the behaviors that they present with.
What we need to do is we need to recognize that people with addiction come to us for very real help and come to us in crisis, just like the other patients in the emergency department. And it’s our job to recognize that we may not be seeing people at their best, but to figure out how we can address their issue most constructively, with respect and with compassion.
Are there any benefits that you see providing this type of care in a smaller community hospital setting, like UVM Health Network – Elizabethtown Community Hospital?
In a small community like Elizabethtown or Ticonderoga, it is the norm that staff in the emergency department know this individual or know members of their family. Now that’s a wonderful thing for many of the conditions where people come in and people feel very welcomed with that. The problem is, it can really amplify the shame for someone who is presenting with substance use disorder and with opioid addiction. And so it is especially important for people in a small town, who have grown up together, to maintain a positive, constructive, compassionate, nonjudgmental attitude when someone presents for help. Because they’re presenting to people that they’ve known for many years, very often.
Now the flip side of that, is that this is a unique situation, in a small town with an emergency department, members of the emergency department staff do know these patients and can make a deeper connection and actually can be particularly instrumental in providing support. If we use that encounter in a compassionate, nonjudgmental way to really figure out how we can best help the person.
This video was produced by Emily McManamy, with the UVM Health Network.
(Editor’s note: This question-and-answer session has been edited for clarity and length).