Penn Medicine is on the frontlines of the opioid crisis. Thousands of patients with opioid use disorder (OUD) visit our downtown emergency departments (EDs) each year. In 2018, more than 1,100 people died of accidental overdoses in Philadelphia, and the city's drug overdose death rate was among the highest in the nation - more than triple that of its homicide rate.
Treating OUD is not easy. Historically, rehab and detox were the standard treatment, but the success rate for these modalities alone is only 5 to 10 percent. ED visits for OUD present a critical opportunity to link patients to evidence-based interventions, such as medication-assisted treatment (MAT) and peer support from certified recovery specialists (CRSs).
When we started this work, MAT and CRS services were significantly underutilized. On average, 175 patients with OUD visited the ED at Penn Presbyterian Medical Center (PPMC) each month. Of those, only ten were started on MAT, and only four were referred to a CRS.
The Center for Opioid Recovery and Engagement (CORE) provides comprehensive support for ED patients struggling with OUD by focusing on three key touchpoints.
Identification and engagement: CORE leverages an algorithmic patient identification system to identify OUD patients in the ED in real-time and alert care team members using secure text messaging. When a patient is identified, a CRS intervenes to discuss treatment goals and options.
ED treatment: If the patient is amenable, a physician gets them started on Buprenorphine, or bupe, a medicine that can be administered in the ED. Bupe lowers the potential for opioid misuse, diminishes withdrawal symptoms, and increases safety in overdose cases. Research shows that ED-initiated bupe can double patient engagement in treatment 30 days after discharge.
Support after discharge: Before patients leave the ED, follow-up appointments are scheduled and "bridge scripts" placed to cover medication needs in the short-term. After discharge, CRSs act as role models, mentors, advocates, and motivators to promote long-term recovery. CRSs check-in with patients via text or call and conduct rounds out in the community.
CORE ensures that ED patients struggling with OUD consistently receive evidence-based treatment to promote long-term recovery.
With CORE's new patient pathways in place, the number of ED patients started on bupe has increased threefold, and CRS involvement has increased twelvefold at Penn Medicine's downtown hospitals. We're also seeing more patients in treatment at 30 days - 68 percent compared to less than 5 percent pre-launch - and fewer returns to the ED within 30 days of discharge. It is estimated that CORE prevents more than 180 overdoses each year in Philadelphia.
CORE is the standard of care in the EDs at PPMC, Pennsylvania Hospital, and the Hospital of the University of Pennsylvania, as well as the Hall Mercer Crisis Response Center.
In the future, the CORE team aims to increase its bandwidth and extend its reach to new clinical settings.
COVID-19 puts OUD patients at significantly higher risk as many of the services they depend on (drop-in clinics, group meetings, etc.) have been severely scaled back or stopped entirely. In addition, CORE's primary sites for patient engagement – hospitals and EDs – have changed dramatically.
In response to these challenges, the CORE team developed a virtual bridge clinic to enable providers to engage, monitor, and deliver care to OUD patients remotely. CRSs provide support and connections to ongoing treatment as they would in-person, and thanks to temporarily relaxed regulations surrounding the prescribing of bupe, CORE providers can issue prescriptions for MAT over the phone. This work is possible thanks to a generous contribution from the William Penn Foundation Special Gifts Program.