Voices: Dr. Reuben Strayer on a paradigm shift for treating alcohol use disorder patients in ERs.
We've come a long way in our thinking and our tools for opioid use disorder. It's time to do the same for patients who suffer from alcohol use problems.
True story: My first day of medical school, I met a brand new member of the Mount Sinai School of Medicine faculty—an ER doc named Reuben Strayer. The class was an introduction to first aid and dealing with emergencies “in real life”—the kinds of things that you might need to do if someone yelled, “Is there a doctor in the house?”
I knew right away that ER people were my people. They were practical. They were efficient. They dispensed with the fluff and focused on what matters. And they had a dark sense of humor. (There’s no other way to survive in this job.)
And so it is no exaggeration to say that Dr. Strayer is one of the reasons I went into this field. He’s brilliant and weird (and you can’t exactly tell from this video, but he’s also outrageously funny). He’s also something of a celebrity in emergency medicine education circles for his outside-the-box thinking.
Recently, I came across a new white paper in the Journal of Emergency Medicine entitled, “Emergency Department Management of Patients with Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder.” I was immediately taken by it.
Dr. Strayer is the lead author, and the manuscript was co-authored by a team of experts, including a colleague of mine here at Harvard/Brigham and Women’s Hospital.
To my reading, it’s the most comprehensive document ever produced on the subject of the treatment of alcohol-related emergencies. It covers the finer points of managing some very sick patients. But what got my attention—what almost startled me when I read it—is that I had never really considered how we fail to offer alcohol use disorder (AUD) patients anything close to the types of resources (both medicinal and social) that we now routinely offer opioid use disorder patients when we are discharging them from the ER.
We’ve come a long way on opioid use disorder treatment in the ER. But what about alcohol use disorder patients? A Twitter post by Dr. Strayer summed it up:
I want to bring you into his way of thinking, whether you’re in healthcare or not. We’ve got to do better. Dr. Strayer’s paper—directed at physicians like me—is a start. This interview is my way of bringing this topic to a wider audience than just ER clinicians, because it is a topic that everyone needs to think about.
So, I invited him to do a Q&A. A tightly edited version of that interview is available on MedPage Today. The full unedited version of our conversation is here, with your choice of video (at the top of this page), or audio only with a written transcript (below).
If nothing else, take a listen to one of my absolute favorite people in medicine. Few have done more to shape how I think and see the world of medicine than Dr. Reuben Strayer.
Jeremy Faust: Hello, its Jeremy Faust, editor in chief of MedPage Today. Today we're going to be joined by Dr. Reuben Strayer. Dr. Strayer is an emergency physician at Maimonides Medical Center in Brooklyn, and he is the author of emupdates.com. Dr. Strayer is the first author on a new document which is in the Journal of Emergency Medicine, and it's entitled, Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal and Alcohol Use Disorder, a white paper prepared for the American Academy of Emergency Medicine. Reuben Strayer, thank you so much for joining us.
Reuben Strayer: Hi Jeremy. Nice to be with you.
Jeremy Faust: Let me look at a tweet that you posted last week in conjunction with your new article and read it directly right now. You wrote, EM expanded its scope to confront a new opioid addiction crisis, but we've done little to address alcoholism, despite always having had a front row seat to the saddest show on earth. Here is the first comprehensive guidance to the emergency management of AUD. Tell me how did this project get started?
Reuben Strayer: So under the auspices of the American Academy of Emergency Medicine, we, my group have developed a couple of guidelines already. We did one on the management of pain in the emergency department, and then more ambitiously we took on opioid use disorder, which at the time really had very little guidance specific to the emergency department, and almost no emergency physicians versed in the management of OUD. None of us were trained on it. I certainly wasn't trained on addiction-related issues, and certainly not opioid addiction. So we put together basically a task force and came up with a long list of important questions and answered them.
Took a long time to develop, and we're very proud of that guideline. And then a similar group decided to take on a similar approach using the lessons we learned in managing opioid use disorder and how effective we've been able to intervene on both opioid intoxication, opioid withdrawal, and then the underlying addiction in the emergency department, which is an area that emergency physicians have traditionally been very reluctant to engage with. We wanted to take some of those lessons and apply them to an addiction process and in a disease process that we have all been living with, watching in our doors, coming in and out of our doors for as long as emergency medicine has been a specialty.
Jeremy Faust: Before we get to alcohol, take me through where you think OUD, opioid use disorder treatment in the acute setting, the emergency department and other acute settings, where has it gone in the past five, 10 years, and where did it start? Do you see a lot of progress? I think so, but I'm just curious from your perspective from having been there from the beginning, what differences do you sense?
Reuben Strayer: It's been a remarkable journey in opioid prescribing and in the treatment of opioid addiction. So as I mentioned, people my age, your age even had no training whatsoever in opioid addiction and opioid use disorder. Furthermore, when I trained in med school and in residency in the '90s and aughts, we were very firmly under the umbrella of what we now know was industry-generated lies about how to treat pain, the dominant force being the idea that treating pain with opioids could not cause addiction, and furthermore that we were grossly undertreating pain.
So there was a whole now very well-documented litany of efforts on behalf of the manufacturers, Purdue Pharma most famously, but others that also involved regulatory bodies, the fifth vital sign, all this has been very well-exposed and documentaries and lots of work since then, but the result of all that was that I, for example, and all of my colleagues, when I was early in my career and in my training, when someone came to the emergency department with, for example, a sprained ankle, we would routinely discharge them with a prescription for 10, 15, 20, 30 opioid pills, 30 Percocet pills, and that was considered to be humane good care.
We now know we caused a tremendous amount of harm with those prescriptions. So it took us many years to untangle that, and that was the beginning of an awareness that we in emergency medicine have to be part of the solution here. And so we really have bent the curve on opioid prescribing, and we are seeing many fewer new cases of opioid addiction, which is a tremendous win and is going to reap tremendous health benefits over the coming years. However, as has been well-documented, the fact that we're creating fewer cases of new addictions does not help the millions of Americans that have existing opioid addiction.
And what we learned in emergency medicine was that many of these patients seek care only in the emergency department, that the emergency department is their only contact with the healthcare system. And so not only can we treat opioid addiction, the underlying addiction, we must be the ones to address and treat opioid addiction. And I think we've made remarkable strides in that regard, most obviously by destigmatizing addiction, and then offering and initiating the best treatment for opioid addiction right there in the emergency department, buprenorphine, the active ingredient in Suboxone.
Jeremy Faust: Behind your tweet, behind your messaging is a subtext, which is that while that interest has taken foot, while we've gotten better with opioids, we've sort of let another big problem, alcohol use disorder, really simmer and not improve at all. Why do you think that is?
Reuben Strayer: So that's exactly right. And what we're doing with this guidance and this guideline that we just published is, we're trying to bring the same approach to alcohol. The big difference here is that the opioid addiction and overdose crisis is something that came upon us. It happened to us like a meteor hitting the earth, and suddenly we were faced with a new challenge and droves of patients who were obviously affected with opioid use disorder, who were dying from opioid opioid use disorder. And this is something that happened to us relatively all of a sudden.
On the other hand, alcohol use disorder and the myriad consequences of unhealthy alcohol use have been part of emergency medicine practice for as long as emergency medicine has been a specialty, but because it's so prevalent, because the harms are so easily overlooked and so slow-moving, especially alcohol use disorder and the way that it destroys people's lives, not in seconds or minutes, which is what can happen with an opioid overdose, but over years and decades, it's easily overlooked. And so that's what we've done in emergency medicine until now, and I think more generally, that's what we as a society have done with alcohol and nicotine-related addiction and harms.
Jeremy Faust: Coming back to a statistic in your guideline, which is that 5.4% of emergency department patients who have two or more ED visits in a year, 5.4% of them die within a year, and then there's a subset of patients on top of that who have more than five presentations, they're all cause mortality, 8.8% within a year. That's just staggering to me. Now with opioid use disorder, we have buprenorphine, we have bridge clinics, we have all kinds of things, what can we offer our patients in the future for alcohol use disorder so that those numbers aren't anywhere near that in the future?
Reuben Strayer: Well, you're right, Jeremy, that the numbers are staggering, and these patients are some of the sickest patients with the highest mortality that we see come through our doors, and yet we don't think of it that way. We don't think of it as the acute medical emergency that it really is. Unfortunately, we don't have a great replacement therapy for alcohol use disorder like we do with opioid use disorder. Buprenorphine, when you substitute buprenorphine for the patients usually illicitly obtained opioid, you abolish cravings, abolish withdrawal, and you protect the patient from all of the harms associated with using illicitly purchased opioids of uncertain composition and harm. And so you essentially instantly treat the condition and protect that patient as long as they're taking buprenorphine. It really is almost like a miracle drug for OUD. We don't have a similar miracle drug for AUD, for alcohol use disorder.
We don't have a great replacement therapy like buprenorphine is for OUD. So we have to make use of a multifaceted approach to address whatever the harms are that we see these patients coming in with. So for example, patients who are heavy alcohol users and chronic alcohol users often have a variety of co-morbid psychiatric, social and medical problems that we often dismiss because they're, for example, picked up on the street intoxicated, and the usual paradigm for care is to park them in the corner of the department, allow them to return to sobriety, and then allow them to basically walk out and return to their drinking usually.
Jeremy Faust: No, and this is where I think things can change. Now I know with my opioid abuse, opioid use disorder patients, I have something to offer. Either it's a medication or it's a resource, it's a social work consult, it's a clinic, but in the guideline you talk about some of the things we can offer that's better than the standard of care, which is to have patients return to sobriety and walk out and return to the same cycle that we're talking about, the same destructive cycle. There's a list of options. I've never once started a patient on naltrexone, acamprosate, disulfiram, gabapentin, topiramate, all agents that you talk about in the guideline. Should acute providers in emergency settings, urgent cares, wherever it is, should we be offering those medications, and what dent do you think you would have?
Reuben Strayer: Right. So the answer to your question is, yes, we absolutely should be doing this. And what you're referring to are anti-craving medications, and this is an aspect of treatment of AUD that has been totally overlooked in acute care settings until now. The anti-craving drugs, most easily and notably naltrexone, oral naltrexone or its long acting intramuscular equivalent (trade name Vivitrol), are modestly effective agents to curb cravings and allow motivated patients to reduce or eliminate their alcohol use.
So they're not a magic bullet in the same way that buprenorphine is, but especially when combined with some of the other aspects of care, like withdrawal management, so giving people who are motivated to reduce their drinking medical options, medications to treat their withdrawal that they will experience as soon as they walk out of the emergency department and go to the bar and get another drink immediately, if you offer them an alternative to that using medications like gabapentin or chlordiazepoxide, and you can combine that with anti-craving medications like naltrexone, you can absolutely transition a person who has been using heavy quantities of alcohol daily to someone who either uses much less alcohol, which is an enormous win, or is able to abstain entirely.
This is well within the purview of emergency medicine and acute care and primary care. These medications are not hard to prescribe. They're relatively inexpensive, and it's something we should be doing. And we hope that with documents like the one that we produced and encouragement from professional organizations, this is something we'll see more and more of over the coming years.
Jeremy Faust: There are guidelines for so many things that are far less deadly than this. And what I mean by guidelines is government guidelines. There are things that we're supposed to do to show that we're treating our patients with the best available evidence in the highest levels of care. What's it going to take for this idea to become mainstream? It took a lot of effort for even the idea of medication-assisted therapy to be accepted by our field even in the face of a lot of evidence, and I would say that we still have a ways to go. What's it going to take to get people to have the same level of motivation?
My residents, they meet a patient who has opioid use disorder, they're more excited about helping that patient than I was coming up trying to save some guy by intubating in critical care. They are so focused on these patients, which is great, but we actually ignore these alcohol use patients in the same way. What's it going to take to put the light on, other than putting a guideline? Do we need the higher-ups on this? What's the approach?
Reuben Strayer: We hope that we're going to see a concerted PR campaign coming from a number of different angles in the same way that we saw this with the treatment of OUD. Again, alcoholism and alcohol use disorder has been a simmering crisis for decades and decades. And not to say that it hasn't crested in the pandemic. It's gotten much worse. The harms have gotten much more severe. We saw a 20% spike in mortality in 2020 and 2021. So it's another epidemic along with the viral pandemic and the epidemic of opioid addiction and overdose that we've been seeing. My hope is that, similar to the use of buprenorphine and the destigmatization of opioid use disorder in the emergency departments, that across the country we'll see a relatively robust uptake among a set of really motivated clinicians. For example, you in your department, it just takes one doc to start prescribing to get other people excited.
The fact is that many of the patients that are picked up intoxicated by paramedics on the street and delivered to the emergency department who come in day after day, we try to ignore them in many ways. We don't feel as though we have a lot to offer them. And I think that there is an appetite for emergency clinicians to try to meaningfully intervene on what we see year after year, the slow decline of these patients, and ultimately many times their demise. There's an opportunity to do better. And I think that we've learned with the way we've been able to intervene on OUD, on opioid use disorder, that we can do better, and I'm optimistic that we're going to take that same energy and apply it to alcohol use disorder.
Jeremy Faust: Let me ask you a philosophical question. OUD is a substance that is not generally legal to use recreationally. It's not legal to use recreationally, and it's a controlled substance. Alcohol on the other hand is sort of the opposite. It's like everyone uses it. It's totally legal. And so in a way, you don't have the stigma on alcohol as you do with opioids, and I can almost see it flipping over onto itself where people don't take it seriously because it's so commonplace, because they know someone who drinks a little too much, but it hasn't caused some of the problems that we're highlighting. Do you think that the different places where these two compounds started will have an impact on how we make progress in alcohol?
Reuben Strayer: Yeah, for sure. So it cuts both ways. The alcohol addiction epidemic, if you will, it's a crisis hidden in plain view. Again, it's everywhere. And we don't think even that much of on the sidewalk, stepping over someone who's passed out, obviously intoxicated with alcohol. Alcohol use is not only legal, it's celebrated in our society. It's encouraged. Of course there's huge commercial interests in making people feel that alcohol is a good thing for them to be using to have a good time. On one hand, this conceals the harms, because we're so used to being around heavy drinkers who we all have experience with, a coworker who occasionally shows up to work maybe with some alcohol on their breath, and we're like, "Oh Bob, he just tied one on last night. He does this occasionally." And we tend to make excuses for people who have evidence of struggling with alcohol addiction.
But at the same time, because there isn't the same stigma around alcohol use that there is around opioid use and opioid addiction where we use terms like junkies and really ascribe their struggles to bad choices or moral failing, because that same stigma doesn't exist with alcoholism, I'm optimistic that we'll be able to make an impact more quickly, because especially on the patient side, there isn't the same stigmatization, there isn't the same feeling of guilt. People are much more open to talking about their struggles with alcohol, because everyone knows an alcoholic. It's so prevalent.
Jeremy Faust: Another question in the document is about discharging patients with intoxication who are now sober. And I'll read it. It says, what are the key considerations when discharging a patient who presented with alcohol intoxication? And I was particularly drawn in by this discussion of what's humane, because very frequently there's this witching hour of 2:00 or 3:00 in the morning, it's like if I don't get them out, they're going to sleep there until the morning. And part of me is thinking with the hat of the ED, the emergency department is not a safe place for people to use as a hotel. It's not a safe place to be. Bad things happen. There's all kinds of risks.
You can get the wrong medication. And crowding, we need the resources, the nurses, and everyone else we work with needs to be able to focus on the patients who need them. On the other hand, 2:00 in the morning, 3:00 in the morning, and it's freezing outside and they're sober enough to go, is that the wrong thing to do? When you think about embracing the role of the emergency department as a safety net for society's ills, how do you approach that problem?
Reuben Strayer: Well, that's a hard problem. And we in emergency medicine exist in a broader context of public health and a social safety net that's provided by us, but by many other services, and especially the sickest patients with alcohol use disorder often have many walls of what I call the house of health. Many of those walls have fallen down, the house of health having at least four walls, medical, social, substance and psychiatric. And many of the sickest AUD patients, the ones who present frequently to emergency departments, often have multiple, if not all four walls of their house of health have fallen down. And yes, if they're sober enough to go at 2:00 AM, you can medical legally ask them to leave, and that's a very common practice, but you haven't done anything to improve their situation. You haven't done anything really to help them. And that's not to say that every patient with AUD wants help, and you're not going to be able to solve a problem that often developed over decades of slow deterioration.
You're often not going to be able to solve that instantly, but the goal here is to balance your need to manage the department for everyone else, to keep those beds available, to keep the flow moving in the department, to balance those needs with the needs of the patient in front of you. And the largest goal of the guideline that we just published is to get emergency clinicians to consider the person with AUD, or at high risk for AUD in front of them, and ask the question, a simple question, how can I help them, what can I do to improve their [inaudible 00:20:21], in the same way that we do for every other patient that comes through our doors.
Jeremy Faust: Some of these treatment options that we discussed, I have no experience with them. And I have some experience now, thankfully with opioid use, giving patients, inducing them on buprenorphine, or getting them to the bridge clinic which will do that, or having them walk out the door with naloxone, nasal NARCAN. That, I get. I know how that goes. And there's some patients who are really grateful, and there's some who aren't so interested, but I'm sure they're grateful for the effort. What's your experience been on trying some of these anti-craving medications, initiating them in the emergency department?
Reuben Strayer: So it's mixed, just like every other public health intervention, every other treatment that we offer. So the first step is just to engage the patient and just let the patient know that you care, that you're interested in helping them. That first step goes a long way. And then you can offer them medications to manage their withdrawal symptoms and their cravings. Many patients aren't even aware of these medications. Many are not going to be interested right now. That's okay. If they're not ready for treatment right now, you say, okay, that sounds good. We're here 24 hours a day, seven days a week. Come back when you're interested, and we'll get you going.
Many patients who are more motivated are thrilled at the prospect of being able to manage withdrawal and manage their cravings medically, using medications. And the idea of taking a medication every day that would cause them to not want to drink is really appealing to a lot of folks who want to reduce their alcohol use. And because so many of them only use the emergency department to access care, it turns out that we're the ones that need to be doing this.
Jeremy Faust: Well, when I read your guideline, I just had this immediate sort of “A-ha!” moment. I couldn't even believe that I hadn't thought about this in the same way. So I think you've already accomplished it for one doc. So thanks for the work and for highlighting it, and for joining us and sharing those views on MedPage Today.
Reuben Strayer: Well, thank you, Jeremy. And I hope that other emergency clinicians have a similar reaction, and that we can bend the curve on alcohol use disorder.
Voices: Dr. Reuben Strayer on a paradigm shift for treating alcohol use disorder patients in ERs.