A new clinical program launched in Washington last week aims to help facilitate medications for opioid use disorder (MOUD) in emergency rooms across the state.
The program, called ScalaNW, is funded by opioid settlement and abatement funds and was designed by the Washington State Health Care Authority (HCA). Its goal is to serve as a bridge between ER docs and outpatient help by equipping clinicians with tools to initiate MOUD and connect patients to community-based care. Ultimately, it will aim to save the lives of patients with opioid use disorder by increasing treatment rates and reducing overdose deaths.
Between 2019 and 2021, the number of people in Washington who died of opioid overdoses doubled. Even though medications like methadone and buprenorphine have been proven to cut the risk of overdose death in half, they remain prescribed in fewer than 9% of nationwide ER visits for suspected opioid overdose. MOUD regimens also increase retention in treatment while decreasing opioid use and overall health system costs.
ScalaNW's website hosts evidence-based protocols for clinicians on determining how and when to provide MOUD. The program also collaborates with the University of Washington Psychiatry Consultation Line to offer 24/7 live clinical support. It also offers scheduling help, through the Washington Recovery Helpline, to create follow-up appointments for patients at community clinics before they are discharged. In order to take advantage of the scheduling line, as well as assistance with policies, billing, implementation and education, hospitals must sign up with the ScalaNW network.
To build out the program, HCA solicited feedback from hospital clinicians, clinics and professional organizations. The program drew inspiration from two existing others—California’s Bridge and New York’s MATTERS.
A large reason MOUD has historically been under-prescribed is that, prior to 2023, the Drug Enforcement Agency required clinicians to complete special training to prescribe buprenorphine. These requirements were removed at the end of 2022, and experts say now is the time for organizations to standardize treatment protocols to broaden access to the lifesaving medications.
“We have unprecedented access to this now, to these tools,” Chris Buresh, M.D., assistant program director at UW’s School of Medicine emergency medicine residency program, told Fierce Healthcare. “This is a life-changing thing.” Buresh, a practicing physician at UW Harborview Medical Center and Seattle Children’s, helped develop the medical protocols for ScalaNW.
Methadone is a bit trickier but is still a lifesaving medication that some patients will prefer over buprenorphine, Buresh noted. Federal rules allow for hospitals to provide methadone to treat opioid withdrawal, but it must be started on a low dose that is not usually enough to adequately manage withdrawal.
Hospitals can send a patient home with a three-day supply of methadone and must refer them to an opioid treatment program in that time frame. Those programs are the only facilities legally authorized to dispense methadone for ongoing treatment and are notoriously inconvenient for patients. “For a lot of parts of the state, and I would say the country, those opioid treatment programs, or OTPs, are a considerable distance away,” Buresh said. “From a practical, logistical standpoint, it is just not an option for people.”
Since the removal of the requirements in late 2022, hospitals have still been hesitant to prescribe MOUD, in part due to a lack of experience. “No one ever does it, so they don’t know how to do it,” Buresh said.
“That practice isn’t established in their department—they may not have seen it, they may not have used it,” echoed Liz Wolkin, ScalaNW's program manager. Emergency departments often don’t have real-time support for providers who have clinical questions. And, if someone comes in the middle of the night and needs a referral, outpatient clinics aren’t typically open. Now, with ScalaNW, the appointment can be made any time in five to 10 minutes.
For methadone in particular, hospital docs are required to pick it up at the pharmacy themselves and then give it to the patient. The “process is just not smooth for the pharmacy or for the provider, which means it’s a lot less likely to happen for the patient,” per Buresh.
But even if hospitals are ready to prescribe MOUD, that doesn’t mean patients will be ready. At the county hospital where Buresh works, he might see up to eight people per shift that would benefit from MOUD. But only about 1 in 8 will be ready to start.
“We don’t want to be pushy about it, we just want it to be there when people are ready,” Buresh said. Regardless, EDs have a moral imperative to make the offer and to be ready if it is accepted, he added. “That’s our job … to be there for people, to meet them where they’re at.”
Buresh is hopeful that some day, this will become the standard of care. ScalaNW is the first major step for Washington. “It really simplifies the process, and I think it kind of removes excuses for not dealing with this,” Buresh said. “If we can deploy these correctly, we should be able to legitimately bend the curve on these overdose deaths.”
The program plans to roll out the first group of hospitals who joined in August. So far, ScalaNW counts 15 enrolled sites, including hospitals and EMS agencies. HCA has seen a resounding response from clinics in joining the network. “We have had really, really positive responses. A lot of times, this is a population that community providers want to reach,” Wolkin said.
“That is a gift we don't always have tools at our disposal that are that effective for any health condition, so being able to have it for one that is so deadly … is an amazing resource,” Wolkin said.