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March 28, 2019

An Interview with Dr. Alister Martin from the Get Waivered Campaign

Type: Announcements

This month the NCIBH spoke with, Alister Martin MD, MPP, an emergency physician and chief resident at Massachusetts General Hospital. Dr. Martin is one of the founding members of the Get Waivered Campaign, an initiative that aims to promote access to medication therapy for opioid addiction by increasing the number of physicians waivered to prescribe treatments.

Could you tell us a brief history about your interest and work in opioid use disorder? How was the Get Waivered Campaign first established?

I was a medical student at Harvard Medical School and left for two years to go to the Kennedy School of Public Policy. I found my way into state politics and, in 2013, worked for the governor of Vermont for about a year. His office initiated a big push to revamp the way the state took care of patients who were struggling with opioid addiction. I was blown away by the comprehensive hub-and-spoke model that was being used. When I started my emergency medicine training at Massachusetts General Hospital and Brigham and Women’s Hospital, I walked in thinking, “The states have figured this out so hospitals must be way ahead of them!”

I was shocked when my first patient with opioid use disorder came to the emergency department while I was on service. Her story was that she’d fallen down the stairs at her son’s daycare facility and broke her ankle. She had surgery and was sent home with oxycodone. She started using the pills for pain control but then discovered weeks later she couldn’t feel normal without them. At this point she’d run out of her prescription, so she borrowed from friends, family and eventually ended up purchasing pills from a dealer. This was eight weeks after her ankle surgery. Long story short, her husband confronted her and made the decision that they’d seek help at the ER, assuming that we could help. I remember being in that room hearing her story and thinking, “This is great. You came looking for help and we’re going to do it!”  

I drew up a plan to admit her to the hospital so that she could access addiction services. I presented that plan to my attending physician and he said it sounded great but that wasn’t how things worked. He said I had to discharge her and that they couldn’t treat addiction in the ER. It took me a couple of weeks to figure out this wasn’t unique to Mass General. The overwhelming majority of emergency departments in the United States do not have a medication based protocol for those seeking addiction services - in fact, one survey found that 93% of physicians worked in a department where medication therapy was not even available.

I don’t know what happened to that woman after I discharged her, but my hope is that she found her way into treatment. In many respects the solution that we created – Get Waivered –and the subsequent protocol we put in place, which is now Massachusetts state law, was created specifically for patients like her.

What are some strategies for overcoming barriers to prevention, screening, and treatment of patients with a substance use disorder?  

Physicians have to own their share of the work. Because of the rise of opioids like fentanyl and carfentanil what we’re seeing now across the country is a rise in patients presenting to emergency departments looking for a way to get their addiction managed and potentially overcome. This in itself is an opportunity for physicians to start the patient on the road to recovery. When I started in residency four years ago, there was a lot of debate over whether or not physicians should be involved in recovery treatment. Thankfully, because of work by trailblazers like Sarah Wakeman and Gail D'onofrio we have the evidence that has allowed us to begin to win that debate –  I think physicians in the ER now understand that it’s something they need to be treating.

Physicians still do have several major barriers that our behavioral economics inspired Get Waivered campaign uncovered. The first was the social norms surrounding the waiver process itself. We did a series of departmental interviews and found that many of our practitioners were struggling with this concept of “Is this a disease we should be treating in our department?” Even more specifically, “Is getting waivered something our staff is doing?” Our solution was to recruit our well loved and respected department chief to be the first provider waivered. Our chief then selected five other influential senior faculty members. The other forty or so other attending physicians saw leadership get waivered and began to understand that this was a disease they could and should be treating. We wanted our physicians to feel proud about Getting Waivered,  so we held a pinning ceremony for those who completed the course, led by the heads of the addiction department. Local media covered the event, and we also publicized it on Twitter. This was all done to make doing the ‘right thing’ observable which is a concept from the field of behavioral economics.

Physicians initially didn’t want to go through the hassle of an 8-hour course, so we had to make getting waivered as simple as possible. We created a website that was very straightforward and clearly outlined the steps needed to Get Waivered. We even had one volunteer coordinate all the scheduling, since that is often one of the most challenging aspects of a physician’s day-to-day. At the beginning of the program, 1 out of 50 or so physicians chose to get this training. By the end of the program, 95% of our department had chosen to Get Waivered.  

Another barrier we found is unique to emergency medicine, and centers around storytelling. Emergency physicians, by design of the work we do, only see patients when they are in crisis. A patient who is stable, on medication therapy, and has been off of illicit substances for five years has no reason to come to the emergency department. The patients we see in the ER are often the ones who have overdosed, relapsed or have ongoing infections. We begin to build a worldview that this patient population can’t or doesn’t want to get better. We begin to misrepresent the entire community at large. There’s a lack of exposure to the fact that the treatments for addiction are actually effective.

To overcome this, we went out and found stories that would combat this worldview. As the field of behavioral economics terms it, we aimed to make the possibility of helping patients begin recovery more salient. We recruited a physician from Mass General who was in long-term recovery. He lost his license by writing thousands of prescriptions for patients who didn’t exist. Through using buprenorphine to begin his journey, he reclaimed his life, got his license back and is now treating others with substance use disorder. We found stories of patients who were past frequent flyers in our emergency department, who are now on buprenorphine and have their lives back. We brought those patients in to tell their stories to physicians. Imagine the impact on an emergency physician of seeing some of the most difficult patients saying that the quality of their lives are better now thanks to pharmacotherapy. These types of interventions battle the stigma and thus increase motivation for physicians to treat this disease.

What are a few ways primary care providers (PCPs) can either initiate or sustain a patient’s recovery process?

We will truly begin to overcome this when we have skillful collaboration between primary care, addiction medicine, and emergency medicine. And my belief is that until the concept of physicians having to obtain a DEA X waiver is eliminated, primary care doctors absolutely must Get Waivered. They are the linchpin to long term recovery and have to, in the outpatient setting, be able to support these patients on their side of care after ER discharge. We, in the emergency department, are only as effective as our follow-up options. Even if we start a patient on pharmacotherapy in the ER, they’ll go out into the world with only three days of medication. At Mass General we are so lucky to be able to connect our patients with The Bridge Clinic, which is a transitional addiction clinic. Patients continue to receive pharmacotherapy and have access to additional support services. It’s an automatic walk-in system with no appointments and no insurance required. If you show up to the clinic, you’ll get treatment.

Primary care physicians can also partner with local emergency department doctors, so that they can support these patients as they go back into the community and continue assisting them in their recovery. PCPs are the key ingredient because they know patients best. In many cases, they follow these patients for decades and understand the big picture of that patient’s life, whereas ER doctors just get a quick snapshot.

Any thoughts or recommendations for providers who would like to be involved in the campaign?

It starts with stories. The data demonstrates that buprenorphine saves lives, decreases mortality, and decreases readmissions. But the storytelling of how the individual decisions of physicians impact the lives of patients long-term is crucial, especially for providers who don’t think of themselves as people who can treat this disease. It’s important to demonstrate to them what the outcome could be. We need to make that link clearer.

The second thing is creating an easier pathway to Get Waivered. Until the law changes, we have to work within this system. If people need help setting up their own Get Waivered campaign we’re absolutely willing to help. We’ve done it at our own hospital and we’ve now expanded efforts and are collaborating at the state-wide level in Texas led by the incredible Dr. Jennifer Sharpe Potter.

The third thing is creating an easy protocol. At Mass General we have a protocol that providers can easily leverage. They know the dosage. They know how to access the scales to figure out who is in withdrawal and who isn’t, and we’ve made it as easy as possible to give information when appropriate. The field of behavioral economics tell us that if something is difficult to do, it likely won’t be done. I recommend folks who are interested in this to think hard about how to make it easier to follow this protocol, and I’m more than happy to share our notes on that. We’re happy to collaborate and help, whether it be with primary care physicians, ER doctors, or hospital systems. We have somewhere between 120 and 150 people dying every day and the only way we can get through this is by thinking creatively and applying new solutions to what is essentially an old problem.

Similar to what we experienced through the HIV/AIDS crisis, we won’t be able to solve this just in the house of medicine. We have to think about strategically partnering with nonprofits, state and local government, and we’re all going to have to come to the table. There are clearly bright spots around the country, but we must all think collaboratively. To that end, what we have done at Mass General is partner with a nonprofit called ideas42, which is a behavioral economics consulting firm who is helping us improve our protocol leveraging interventions from the field of behavioral economics. Thanks to the support of the Laura and John Arnold Foundation this collaboration is aimed at making evidence based practice standard practice when it comes to opioid use disorder and that sort of translation is what it’s all about.


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