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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Podicy. I'm your host, Rob Lott. As health affairs readers know, September marks the release of our theme issue all about the opioid crisis. Many of the articles examine the powerful benefits of medication assisted treatment for addiction, treatments such as buprenorphine. One persistent challenge in this space has been getting more of the people who could benefit from that treatment to actually commence the therapy and stick with it.
Rob Lott:It's a challenge that is made all the more difficult by the complex fragmented nature of our health system. Of course, this reality has policymakers and clinicians asking if it's possible to reduce barriers to access. It's a tough question, and it's the subject of today's health odyssey. I'm here with Doctor. Amy Muhlen, a professor in emergency medicine at UC Davis Medical Center and chief of the division of Addiction Medicine there.
Rob Lott:She is also a founder and principal investigator of an organization called BRIDGE, which has supported the implementation of low threshold emergency department initiated medications for opioid use disorder, and they're bundled with harm reduction efforts and patient navigation. Doctor. Mullen is also the co author of an article in the September issue describing that very model and evaluating its impact. I can't wait to, look under the hood of this model, learn more about it, and about its potential, for scale. Doctor Amy Mullen, thanks for joining the podcast.
Aimee Moulin:Thank you for having me. Appreciate the opportunity to talk about this.
Rob Lott:Absolutely. So before we learn a little more about the model, I thought maybe you could give us some context. Can you describe the sort of typical experience for a patient with opioid use disorder in the emergency department prior to the implementation of a program like Bridge? How likely were they to be started on medication? Why wasn't initiation more common at that time?
Aimee Moulin:Yeah. I think, medication initiation for opioid use disorder in emergency departments prior to the program was exceedingly rare. I think very few emergency physicians were prescribing buprenorphine. I think I probably knew everybody who did personally. That's that's how rare I think it was.
Aimee Moulin:If you think back to 2016 at that time, remember buprenorphine was considered dangerous. You had to have a special license. You had to have an X waiver. And treatment for opioid use disorder, substance use disorders was considered a very specific specialty, problem and definitely not something that the emergency department felt like was something that was within their purview. So I think when we started, the typical treatment for someone who even overdosed and tried to die in emergency department was to let them walk out without any treatment.
Rob Lott:Wow. Okay. So, maybe you can tell us a little bit about your experience in that time. What were you doing? Tell us a little bit about how you came to found, the Bridge program.
Aimee Moulin:Yes. I had an infant Bridge program at UC Davis. We had hired, probably one of the original substance use navigators, Tommy Trevino. He was a drug and alcohol counselor, had been working in our ED for several years, and his main role was as someone with lived experience, he did a lot of motivational interviewing, coaching with patients in the ED, and helps to link them to outpatient treatment. So I was fortunate in that I saw this differently because I could see the impact that we had in the emergency department because we had someone who was working on this problem.
Aimee Moulin:So I was in that unique experience of being able to see the difference that the ED could make and start to understand the need that was out there. I was also really lucky. You know, health policy is sort of the combination of the possible and some of its timing.
Rob Lott:Mhmm.
Aimee Moulin:At that time, I was the president of our local emergency department, our California emergency physicians. There was a budget surplus in California. And so we went out on a leap and tried to fund ED navigators in every emergency department because that was my goal for my, my policy goal for emergency physician. That was my ten year goal. We were vetoed the first year, but I think that started a conversation at the state level, maybe catalyzed this idea in California that this was something that was possible, and it sort of grew from there.
Rob Lott:Wow. Okay. So, before we go any further, let's learn a little more about the model itself. Can you describe it and maybe how it represents a shift from the sort of earlier scenario described where no one was getting any treatment?
Aimee Moulin:Yeah. I think the main piece, the main shift that we tried to make for emergency departments was that substance use disorders, opioid use disorder is an emergency. It's a life threatening illness, we all know that, the risk of death is high, with an effective time sensitive intervention. This becomes something that emergency departments are really good at. And so shifting the thought process, that mental model from this is an outpatient problem to this is an emergency where there's time sensitive interventions, I think was the main shift that we tried to make for the EDs.
Aimee Moulin:So the model is really about medications first. Someone, everybody is universally offered access to medications for opioid use disorder. Incorporation of harm reduction, individuals with lived experience, that's the navigator to provide that stigma free care. And then, you know, the holy grail, which is the connection to outpatient treatment.
Rob Lott:Got it. And just a few, points of clarification. When you say the treatment is time sensitive, you mean that the sooner the better or
Aimee Moulin:Yeah. Okay. Right. Right. We know that so for example, like someone who we see with a non fatal overdose in the ED has a pretty high rate of a fatal overdose within the next, you know, forty eight hours, one month to one year.
Aimee Moulin:So the sooner that you can mitigate that risk of overdose death with your treatment options, we know that buprenorphine reduces the risk of death, So there's a time sensitivity to that intervention where you can mitigate harms. And, you know, one of the most important harms is death. And so this is this is something where there's a huge opportunity for emergency departments to engage.
Rob Lott:Gotcha. And then tell us a little bit about sort of the balance of the population that are, that is sort of receiving this support. Is this almost entirely folks who arrive at the ED for an overdose? Or are there people who arrive with the flu or, you know, gastritis or something like that? And in the course of treatment, it comes up that they could also benefit from buprenorphine.
Rob Lott:What are you seeing most commonly?
Aimee Moulin:Most commonly, not overdoses. Most commonly, we're accessing people in the ED for other reasons or people who now come into the emergency department because they want help. So we've been able to change the narrative in in a number of locations where people will come in and say, hey. I need help, and I don't know where else to go. One of our tenants was universally offering help, so posting signs and universally offering like, Hey, if you wanted to start buprenorphine, we have that opportunity here.
Aimee Moulin:We did not screen patients and so I think that that's important to say when we look in the context of the study is that we did not screen everybody for opioid use disorder, so we actually are probably not even reaching all of the people who should or could be eligible for buprenorphine treatment in the ED.
Rob Lott:Interesting. Alright. Good question for follow-up study. And that's perhaps a good segue for you to tell us about this study. The paper in the September issue of Health Affairs, tell us a little bit about it.
Rob Lott:What exactly did you study? What outcomes did you measure?
Aimee Moulin:We were looking at essentially implementation of this model in California EDs. We had a pretty rapid ramp up where we tried to reach all of the emergency departments across the state of California. And this paper looked pretty much at how well we were able to do. So we measured a couple things. One were encounters with navigators.
Aimee Moulin:So the number of people who had an encounter with a navigator for any reason could be alcohol use disorder, stimulant use disorder, or opioids. The number of buprenorphine treatment options that happened in emergency departments, so buprenorphine was either administered or prescribed in the ED, those two outcomes we measured from grant reporting. So that is data that the EDs reported to Bridge as a part of the grant process. The other one was we looked at buprenorphine prescriptions by California emergency physicians using our prescription drug monitoring program in the state. So we were able to identify emergency physicians based on sort of episodic prescribing patterns and look at the number of prescriptions in that database that were written by ED physicians, and then we're able to kind of track that and see what percentage of people were able to get a second prescription kind of as a marker of follow-up that they stayed in care.
Rob Lott:Got it. Okay. And then tell us what you found. What were, some of your top line findings?
Aimee Moulin:Yeah. I personally think the most important piece of this is the volume, is a hundred and sixty five thousand navigator encounters, encounters, almost forty five thousand people treated with buprenorphine, and then of the people who got a prescription in the ED, about thirty six percent received a second prescription. I think the key part here, though, is is the volume, that emergency departments in a relatively short period of time are able to reach a high volume of high need patients. So I think that is, I think, the key takeaway. I think the other piece of that is to remember we didn't screen.
Aimee Moulin:So to think that this is about the unmet need for substance use treatment in our communities, because we were able to reach that many people just by saying to a handful of them, Hey, did you want help? Imagine if we screened or if there was broader efforts to reach the need in our populations.
Rob Lott:Great. Well, I want to learn a little more about, sort of your reaction or your response to those findings. But first, let's take a quick break. And we're back. I'm here with Doctor.
Rob Lott:Amy Muhlen, who's describing her paper in the September issue of Health Affairs. So just a moment ago, you highlighted some of the findings, including just the sheer volume as well as the fact that this is in the context without screening. There might be a lot more people who could benefit down the road. Obviously, as someone so intimately involved in this program and who's been such a big part of its implementation, I'm sure you had some expectations going into this research study, and I'm curious if the study confirmed your suspicions or if there were any surprises, when the initial results came back.
Aimee Moulin:Yeah. I you know, as you mentioned, I was really a part of the implementation, so I knew that we were reaching a lot of people. What I was surprised at was the second prescription, because the people that we are starting on buprenorphine, I mean, is not a population that one would think out of the gate has high rates of follow-up. There's high rates of the primarily Medicaid population. A lot of people are experiencing homelessness.
Aimee Moulin:These are folks who did not previously have access to care. The ED was their primary place of care. So at the face of it, this is not a population that you would think would would be able to be engaged in care. And so I was actually really surprised that thirty six percent of the people got that second prescription.
Rob Lott:That's great. Let me I'm gonna be, take a cynical viewpoint just for Mhmm. A moment. And, as thirty six got the second prescription, that means, what, sixty four percent did not. And I guess one way, again, cynical way of looking at it is that like, maybe it's not worth all those sort of false starts, if you will, that like lot, there's a lot of sort of foregone treatment.
Rob Lott:Is that something you're thinking about? What's the sort of response? Is it sort of better to get 36% than 0%? Or how are you approaching that question?
Aimee Moulin:I think you bring up a good point, right? There's sixty four percent out there that did not get that second percent prescription, so there's room for improvement, right? There's a huge population out there that we could better design our connections to outpatient treatment, they're imperfect, and there's a lot of improvements that we could make in that outpatient treatment setting to make it more accessible and friendly to move the needle on that number. So I think you're absolutely right to point that out as to say like, hey. There's a large percentage of people out there that we could be doing a better job of reaching to make sure that they're able to stay in care.
Aimee Moulin:And I think that's also another area where further research, like, how can we do a better job of making connections between the ED and outpatient care. But then also to remember, you know, substance use disorder, relapse is common. There's a lot of false starts, and that is just sort of part of the disease trajectory. And so, you know, every we always say in my hospital, like, a day without fentanyl is a day without fentanyl. So even if there's one day when someone is able to kind of start that journey towards recovery, that's a good day.
Rob Lott:That's a great way to look at it. In recent years, maybe the last year or so, the overall, the national numbers are that we're actually seeing a bit of a decline in, opioid overdose mortality. And I'm wondering if you have a sense of how programs like this may be contributing to that decline.
Aimee Moulin:I would love to think that we're reaching people at a scale that we're decreasing mortality, But I just I mean, I don't think that we're there yet.
Rob Lott:Mhmm.
Aimee Moulin:I I think that, though, to to some extent, we've been following the high mortality numbers and absolutely right. Right? Because people are dying at a completely unacceptable rate and continue to even though they've flattened out a little bit. But those numbers are so high because fentanyl is so lethal. And that is not even a a sum total of the population we need to reach.
Aimee Moulin:Right? We need to reach the people who are struggling with substance use disorders, fentanyl, alcohol, stimulant use disorder, and that marker is because fentanyl is so lethal, but it is not at all a sum total of the people who we need to reach. So I I think we are a long way from providing treatment at scale to really address the problem.
Rob Lott:Well, you just mentioned scale. That's a great segue. Thank you. I know the model you said ramped up pretty quickly in California. Can you talk a little bit about the challenges behind that expansion, perhaps some of the barriers to scale, and what we might expect to see, as that scaling takes place beyond California across the country?
Aimee Moulin:Yeah. I think two things. One, I think a huge obstacle for ED implementation is two. One, the it's not my problem, viewpoint that we talked about at the very beginning of this is a subspecialty problem, and I can't have any impact as an emergency physician. I think we've pretty much, looking at outcomes, beat that one to death.
Aimee Moulin:So I I think that we've shown that that one's not true. The other one that I hear a lot is we don't see those patients here. So I think there's stigma, we don't see those patients here, but also there's sort of that you don't see what you don't see. So if you don't want to see this problem in your patient population, you want to ignore it, you don't want to address it, you won't see it. So that I think is a common refrain.
Aimee Moulin:We don't see those patients here. And, you know, once you kind of get someone to start to look, it's just not true. I mean, it's it's an emergency department. Right? You you see these patients.
Aimee Moulin:They're everywhere. And the other part is there's that othering of those patients are not my patients. Yeah. So stigma is a big barrier to implementation, and I think a big barrier to treatment.
Rob Lott:Do you have a sense that programs like this might help begin to eat away at that stigma or address it?
Aimee Moulin:Yeah. You know, I you know, as as much as I'm sort of talking down about emergency departments, we have to recognize, like, they switched really fast. I mean, the practice change that occurred in emergency departments in California is pretty unprecedented. To have this broad of implementation change in this short period of time, I think, was really impressive. And, so I have to say once we were able to start to address some of those issues, my colleagues in emergency medicine did have an open mind and changed longstanding beliefs pretty quickly.
Aimee Moulin:I credit the sort of implementation technique of the navigators. So we put someone in there who was focused on this who sort of modeled that destigmatized behavior. And then because the patients had such good results, I think that changed the hearts and minds of a lot of my colleagues.
Rob Lott:Well, yeah, nothing better than positive results to make someone reevaluate their priors.
Aimee Moulin:Try to combine, you know, data with stories. That's that's really how you change belief.
Rob Lott:I bet. I I can imagine also that, in a way, the navigator is sort of helping the emergency medicine clinician sort of lightening their load a little bit, whereas you're sort of almost asking rather than asking them to do more, you're offering them a a way to do more with less, if you will.
Aimee Moulin:I yes. A 100%. I think the other policy change is funding streams to support navigators, people with lived experience in emergency departments. Because at the face of it, right, this is a terrible place to engage in substance use treatment. It's busy, it's chaotic, there's no privacy, everybody's in and out.
Aimee Moulin:So having the navigator really fixes that gap. You have someone who's there with lived experience who can meet the patient where they are, have that conversation with them, be a patient advocate. So it it, one, helps the patient, but also, as ED physicians are busy and the ability to sit down and talk to someone, I think is something, one, we're not trained in very well and two, because of the time sensitive nature of other patients coming in, it can be very stressful for the ED physician. They're not very good at it. Navigators are really fantastic and make a huge difference.
Rob Lott:Wow. What do you see as the most potentially fruitful policy changes that could take place or be implemented over the next few years that might lead to further expansion of the Bridge program and programs like it?
Aimee Moulin:I think it's really funding models to support ED navigators. Bringing people with lived experience into emergency departments is game changing revolutionary. Bringing people in who focused on that linkage, as you mentioned, there's the 64%, so paying a lot of attention to providing that linkage to care, overcoming a lot of the, as you mentioned, that fragmented system in addition to a lot of the social barriers around transportation, communication, having someone who can focus on that and address it for a patient population, but that, of course, needs to be supported and funded by our healthcare system. And then, you know, taking a step back to think about why do we have a system that is so hard for people to access care? Like, the payment structures that we have, particularly around what is considered a specialty service, really makes it impossible for people to access care.
Aimee Moulin:I'm sometimes surprised that anyone is able to make it through all the hoops that we put in front of them. As a as a health care system, like, the way we've designed care is really almost to keep people out. And if you look at our outcomes, we're we're we're we have the system we have designed.
Rob Lott:Fair enough. Well, that's a a great, prescription, if you will, for the future in areas for, for future study as well. Doctor Amy Mullen, thanks so much for joining us here today. I had a great time chatting with you.
Aimee Moulin:Thank you. Appreciate it.
Rob Lott:To our listeners, thanks for tuning in. If you enjoyed this episode, please leave a review, share it with a friend, subscribe, and tune in next week. Thanks, everyone. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.