Warm Handoffs: A Practical Approach to Improving Opioid Overdose Relapse

The prescription opioid and heroin crisis is one of the most significant public health crises facing the United States. On average, 115 Americans die each day from opioid overdoses.[1] Hospital emergency departments (EDs) have become inundated with patients experiencing opioid overdoses. Between 2016 and 2017, ED visits for opioid overdoses increased by thirty percent.[2] Unlike patients who come to the ED for a heart attack, who  are immediately referred to a cardiologist once stable,[3] patients who experience a nonfatal opioid overdose are immediately discharged after being stabilized, neglecting the underlying substance use disorder (SUD).[4] A 2014 study found that individuals who visited the ED for nonfatal overdoses presented a high likelihood of future hospitalization and fatal or near fatal overdoses, partly due to the lack of follow-up treatment.[5]

Some states and localities have implemented “warm handoff” strategies, which have been widely successful at getting individuals with SUD into treatment programs. A warm handoff is the process of transitioning a patient with SUD from an intercept point, such as an ED, to a treatment provider, once the patient is stable.[6] Warm handoff case management teams immediately meet with overdose survivors and their families in the ED. The team then works with the survivor to provide a pathway to treatment and recovery, which could include providing a clinical assessment and immediately facilitating the transfer to a treatment facility for medication-assisted treatment (MAT). Since implementing a warm handoff policy statewide in 2016, Pennsylvania has seen an increase in treatment referrals.[7] In 2017, the first full year of the warm handoff program, Pennsylvania reported that fifty-one percent of warm handoff patients were successfully referred for MAT,[8] demonstrating the positive affect warm handoffs can have on the opioid epidemic.

The U.S. House of Representatives recently passed H.R. 6, or the SUPPORT for Patients and Communities Act, which is a comprehensive bill to address the opioid epidemic, including numerous provisions to improve access to MAT.[9] One provision of this bill uses language from Republican David B. McKinley’s (WV-01) and Democrat Mike Doyle’s (PA-14) bill H.R. 5176, or the Preventing Overdoses While in Emergency Rooms Act of 2018. Subtitle I section 7082 of H.R. 6 seeks to provide federal support to states and localities by establishing a grant program to “develop protocols for discharging patients who have presented with a drug overdose and enhance the integration and coordination of care and treatment options for individuals with substance use disorder after discharge.”[10] The country is missing critical opportunities to prevent repeated overdoses by not following through on treatment for patients who have suffered a non-fatal overdose. Studies show that following through with MAT for a patient within seventy-two hours of an overdose is more cost effective than simply handing patients a pamphlet and referring them to outside treatment.[11] H.R. 6 will create a health care model for lowering opioid deaths  and providing treatment for those affected by substance use disorder that can be implemented nationwide. H.R. 6 is currently awaiting approval in the Senate, and there is no indication the president will veto the bill.[12] The warm handoff policy is not the only solution to the opioid crisis, but if implemented across the country, it could majorly curb the opioid crisis.

[1] Understanding the Epidemic, Ctrs. for Disease Control and Prevention (last visited July 21, 2018), https://www.cdc.gov/drugoverdose/epidemic/index.html.

[2] Opioid Overdoses Treated in Emergency Departments, Ctrs. for Disease Control and Prevention (last visited July 21, 2018), https://www.cdc.gov/vitalsigns/opioid-overdoses/index.html.

[3] Heart Attack: Emergency Treatment, UPMC (last visited? July 21, 2018), http://www.upmc.com/patients-visitors/education/cardiology/pages/heart-attack-emergency-treatment.aspx.

[4] Simone Clark & Paul Dargan, Discharge of Patients Who Have Taken an Overdose of Opioids, 19 Emergency Med. J. 247, 250 (2002).

[5] Kohei Hasegawa et. al., Epidemiology of Emergency Department Visits for Opioid Overdose: A Population-Based Study, 89 Mayo Clinic Proceedings 462, 462 (2014).

[6] Shruti R. Kulkarni, J.D., International Conference on Opioids: Warm Handoff: Bridging the Gap Between Overdose and Treatment (June 10, 2018).

[7] Warm Hand-off Summit: Outcome Measures, Pa. Dep’t of Drug and Alcohol Programs (last visited July 21, 2018), http://www.ddap.pa.gov/Pages/WHO-Outcome-Measures.aspx.

[8] Id.

[9] SUPPORT for Patients and Communities Act, H.R. 6, 115th Cong. §§ 1007(b)(1)-(2), 3003(a)(II)(aa)-(cc) (2018).

[10] Preventing Overdoses While in Emergency Rooms Act of 2018, H.R. 5176, 115th Cong. § 2(a) (2018).

[11] Gail D’Onfrio et al., Emergency Department-Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence, 313 JAMA 1636, 1639 (2015).

[12] Press Release, The White House, Statement from the Press Secretary Regarding the Passage of Over 50 Bills by the House of Representatives to Combat the Opioid and Drug Demand Crisis (June 22, 2018), https://www.whitehouse.gov/briefings-statements/statement-press-secretary-regarding-passage-50-bills-house-representatives-combat-opioid-drug-demand-crisis/.