Building bridges to buprenorphine
Teaming substance use navigators with hospital clinicians helped one hospital better tackle substance use disorder.
It was a conversation with a primary care physician that led Arianna Campbell, DMSc, MPH, PA-C, to begin championing prescriptions of buprenorphine in her hospital.
“One of our outpatient internal medicine partners was prescribing buprenorphine for opioid use disorder and just said they were really struggling getting people in … and so they were wondering if we would be willing to start buprenorphine in our emergency department and hospital,” said Dr. Campbell, an emergency medicine physician assistant at Marshall Medical Center, a rural hospital in Placerville, Calif.
She and her colleagues began providing buprenorphine in their facility, and as word spread, other institutions throughout the state wanted to get involved. Dr. Campbell and others working in emergency and hospital medicine pooled their time, talent, and resources and used federal opioid response funds to develop CA Bridge, a program of the Public Health Institute's Bridge Center, which helps improve access to buprenorphine in hospitals throughout California. The program also focuses on prescribing naltrexone for alcohol use disorder.
Marshall Medical Center's program through CA Bridge began in 2017, and in 2019, the effort expanded to include a substance use navigator (SUN) to work with the ED and hospital team. A specific academic degree wasn't required for the position, but the navigator did need to know how to talk to patients who use drugs and to be comfortable recommending medications, Dr. Campbell said, since CA Bridge uses a medication-first approach.
To evaluate the effect of all these efforts, Dr. Campbell and her colleagues looked at the records of 781 patients who were hospitalized with a diagnosis of alcohol use disorder or opioid use disorder in 2023.
Overall, 26.6% of patients received a SUN consultation. Initiation of medications for opioid or alcohol use disorder was more common if patients had a consultation (15.7% vs. 7% if they didn't get consults) and 30-day unplanned readmission rates were lower (4% vs. 10.9%, respectively). The study results were published Oct. 20 by the Journal of General Internal Medicine.
Dr. Campbell recently spoke to ACP Hospitalist about this successful team effort to treat substance use disorders.
Q: How did hospitalists get involved with the program?
A: To involve our hospitalists, we had to figure out how they worked. It was important to attend their meetings and learn about their workflow. We learned we needed more hospitalist-specific resources, like a hospital buprenorphine initiation guide.
We've also done a lot of education, and it's ongoing. It's not a one-off type of thing. We do a monthly meeting where we review cases and we talk about current trends. For example, the most recent talk I did was about kratom, what it's looking like in our community, how people are accessing it, and how to treat withdrawal. We cover current events, and then we always, every meeting, talk about buprenorphine, because we're repetitively trying to integrate this into people's thinking. We talk about alcohol use disorder and treatment, and we continue to look at the evidence and how we can provide better access to care. We just got injectable naltrexone on formulary in our hospitals so that we can administer that to people with alcohol use disorder.
We're just continuing to push forward, just like we do with other high-risk conditions, like sepsis and stroke. As we receive more information and evidence, we really try to integrate it into our practice and communicate that regularly to our hospitalists and our hospital staff.
Q: Do the navigators and hospitalists work together?
A: Hospitalists can put in an order for a SUN consult, and the other thing we do is ask them to make a diagnosis. I can tell you, personally, in emergency medicine, I wasn't necessarily making the diagnosis of a substance use disorder because I really wasn't doing much about it before I started this program. We've started making that diagnosis more frequently because we're ordering consults where you pair making this diagnosis with adding a resource that's going to help the patient and help the hospitalist figure out disposition and what to do next.
The navigator will go see the patient and they'll talk to the hospitalist and say, “Hey, this is what I'm seeing. This is what they're talking about. They're suffering. Maybe they have more withdrawal than has been realized. These are the medications that worked for them before.”
The other thing is that if a hospitalist maybe has a gap in knowledge, or doesn't feel comfortable with a medication, the navigator is able to connect them to resources, say, “Hey, I can get someone on the phone who can talk to you about this,” or … “I have this physician who has a lot of experience. Let me connect you with them,” or “There's this hotline that you could call right now and get some advice.”
Q: What is the feedback from patients on these efforts?
A: Patients feel heard. I have taken motivational interviewing courses multiple times. I really do try to practice trauma-informed care. I have done a lot of growth, education, leadership, trying to figure out how to make better connections and relationships with patients. That being said, our navigators can go into a room and get a different set of information than I can, and that has been incredibly helpful to actually get to the root of the problem.
We think that there's a massive undercount still, with people who don't talk to us about their drug and substance use. Why would they if they think they're going to receive worse care or be treated poorly? But when you have a navigator who comes in, sits with somebody, and advocates for them, they think, “OK, somebody's got my back here.” … We've seen increased volume of the number of people we're treating for substance use disorder, and I think it's just based on people feeling more comfortable disclosing their struggles to our navigator, and then her being able to provide the framework to communicate that to our hospitalists and our emergency department clinicians.
Most people who are admitted to the hospital who have a substance use disorder say they want treatment. Even if people say no in the emergency department, if they're admitted, most often on day two or three, they'll say, “You know what? Yeah, I am interested,” and that's where a navigator says, “OK, they're ready.”
Q: How has buy-in from clinicians been?
A: I did have to, as a champion, really support the role. You can't just hire a navigator. You also have to pair them with an insider clinician who's just going to say, “This person is really important. They're going to help you. They're going to help your patient. This person is going to make your practice more fun.”
Research shows that physicians find greater job satisfaction when treating substance use disorder. I get very heartwarming testimonials from the hospitalists. I can think of one in particular whose initial instinct was to just take anyone with opioid use disorder off opioids entirely but who now regularly works with the navigator and prescribes buprenorphine. He came to me recently and said, “I can't believe what a difference this has made, how much better our relationships are with our patients, how people respond to it, what we're able to do for people.”
Q: What's the most important take-home message for hospitalists?
A: You can treat substance use disorder as a hospitalist. You don't need to be a specialist. This type of treatment is going to make a difference for your hospital, for your community, and if you have the option to have a navigator, make sure they are trained the right way. Make sure they're connecting people with medications, make sure they're connecting people with evidence-based care, just like you would for any other medical condition. People can recover from substance use disorder. It's on us to create this change.
