September 16, 2025 • 24 mins
Subscribe to UnitedHealthcare's Community & State newsletter.
Health Affairs' Rob Lott interviews Aimee Moulin of the University of California Davis about her recent paper exploring a model for low-barrier treatment of opioid use disorder that could increase emergency department patient navigation and Buprenorphine use.
Order the September 2025 issue of Health Affairs.
Currently, more than 70 percent of our content is freely available - and we'd like to keep it that way. With your support, we can continue to keep our digital publication Forefront and podcast
Subscribe to UnitedHealthcare's Community & State newsletter.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rob Lott (00:00):
Hello, and welcome to A Health Podicy. I'm your host,
(00:04):
Rob Lott. As health affairsreaders know, September marks
the release of our theme issueall about the opioid crisis.
Many of the articles examine thepowerful benefits of medication
assisted treatment foraddiction, treatments such as
(00:26):
buprenorphine. One persistentchallenge in this space has been
getting more of the people whocould benefit from that
treatment to actually commencethe therapy and stick with it.
It's a challenge that is madeall the more difficult by the
complex fragmented nature of ourhealth system. Of course, this
(00:47):
reality has policymakers andclinicians asking if it's
possible to reduce barriers toaccess. It's a tough question,
and it's the subject of today'shealth odyssey. I'm here with
Doctor. Amy Muhlen, a professorin emergency medicine at UC
Davis Medical Center and chiefof the division of Addiction
(01:09):
Medicine there.
She is also a founder andprincipal investigator of an
organization called BRIDGE,which has supported the
implementation of low thresholdemergency department initiated
medications for opioid usedisorder, and they're bundled
with harm reduction efforts andpatient navigation. Doctor.
(01:31):
Mullen is also the co author ofan article in the September
issue describing that very modeland evaluating its impact. I
can't wait to, look under thehood of this model, learn more
about it, and about itspotential, for scale. Doctor Amy
Mullen, thanks for joining thepodcast.
Aimee Moulin (01:52):
Thank you for having me. Appreciate the
opportunity to talk about this.
Rob Lott (01:56):
Absolutely. So before we learn a little more about the
model, I thought maybe you couldgive us some context. Can you
describe the sort of typicalexperience for a patient with
opioid use disorder in theemergency department prior to
the implementation of a programlike Bridge? How likely were
they to be started onmedication? Why wasn't
(02:19):
initiation more common at thattime?
Aimee Moulin (02:23):
Yeah. I think, medication initiation for opioid
use disorder in emergencydepartments prior to the program
was exceedingly rare. I thinkvery few emergency physicians
were prescribing buprenorphine.I think I probably knew
everybody who did personally.That's that's how rare I think
(02:43):
it was.
If you think back to 2016 atthat time, remember
buprenorphine was considereddangerous. You had to have a
special license. You had to havean X waiver. And treatment for
opioid use disorder, substanceuse disorders was considered a
very specific specialty, problemand definitely not something
(03:08):
that the emergency departmentfelt like was something that was
within their purview. So I thinkwhen we started, the typical
treatment for someone who evenoverdosed and tried to die in
emergency department was to letthem walk out without any
treatment.
Rob Lott (03:26):
Wow. Okay. So, maybe you can tell us a little bit
about your experience in thattime. What were you doing? Tell
us a little bit about how youcame to found, the Bridge
program.
Aimee Moulin (03:39):
Yes. I had an infant Bridge program at UC
Davis. We had hired, probablyone of the original substance
use navigators, Tommy Trevino.He was a drug and alcohol
counselor, had been working inour ED for several years, and
his main role was as someonewith lived experience, he did a
(04:01):
lot of motivationalinterviewing, coaching with
patients in the ED, and helps tolink them to outpatient
treatment. So I was fortunate inthat I saw this differently
because I could see the impactthat we had in the emergency
department because we hadsomeone who was working on this
problem.
So I was in that uniqueexperience of being able to see
(04:23):
the difference that the ED couldmake and start to understand the
need that was out there. I wasalso really lucky. You know,
health policy is sort of thecombination of the possible and
some of its timing.
Rob Lott (04:37):
Mhmm.
Aimee Moulin (04:38):
At that time, I was the president of our local
emergency department, ourCalifornia emergency physicians.
There was a budget surplus inCalifornia. And so we went out
on a leap and tried to fund EDnavigators in every emergency
department because that was mygoal for my, my policy goal for
(04:59):
emergency physician. That was myten year goal. We were vetoed
the first year, but I think thatstarted a conversation at the
state level, maybe catalyzedthis idea in California that
this was something that waspossible, and it sort of grew
from there.
Rob Lott (05:16):
Wow. Okay. So, before we go any further, let's learn a
little more about the modelitself. Can you describe it and
maybe how it represents a shiftfrom the sort of earlier
scenario described where no onewas getting any treatment?
Aimee Moulin (05:32):
Yeah. I think the main piece, the main shift that
we tried to make for emergencydepartments was that substance
use disorders, opioid usedisorder is an emergency. It's a
life threatening illness, we allknow that, the risk of death is
high, with an effective timesensitive intervention. This
(05:56):
becomes something that emergencydepartments are really good at.
And so shifting the thoughtprocess, that mental model from
this is an outpatient problem tothis is an emergency where
there's time sensitiveinterventions, I think was the
main shift that we tried to makefor the EDs.
So the model is really aboutmedications first. Someone,
(06:20):
everybody is universally offeredaccess to medications for opioid
use disorder. Incorporation ofharm reduction, individuals with
lived experience, that's thenavigator to provide that stigma
free care. And then, you know,the holy grail, which is the
connection to outpatienttreatment.
Rob Lott (06:41):
Got it. And just a few, points of clarification.
When you say the treatment istime sensitive, you mean that
the sooner the better or
Aimee Moulin (06:49):
Yeah. Okay. Right. Right. We know that so for
example, like someone who we seewith a non fatal overdose in the
ED has a pretty high rate of afatal overdose within the next,
you know, forty eight hours, onemonth to one year.
So the sooner that you canmitigate that risk of overdose
(07:10):
death with your treatmentoptions, we know that
buprenorphine reduces the riskof death, So there's a time
sensitivity to that interventionwhere you can mitigate harms.
And, you know, one of the mostimportant harms is death. And so
this is this is something wherethere's a huge opportunity for
emergency departments to engage.
Rob Lott (07:30):
Gotcha. And then tell us a little bit about sort of
the balance of the populationthat are, that is sort of
receiving this support. Is thisalmost entirely folks who arrive
at the ED for an overdose? Orare there people who arrive with
the flu or, you know, gastritisor something like that? And in
(07:50):
the course of treatment, itcomes up that they could also
benefit from buprenorphine.
What are you seeing mostcommonly?
Aimee Moulin (07:59):
Most commonly, not overdoses. Most commonly, we're
accessing people in the ED forother reasons or people who now
come into the emergencydepartment because they want
help. So we've been able tochange the narrative in in a
number of locations where peoplewill come in and say, hey. I
need help, and I don't knowwhere else to go. One of our
(08:22):
tenants was universally offeringhelp, so posting signs and
universally offering like, Hey,if you wanted to start
buprenorphine, we have thatopportunity here.
We did not screen patients andso I think that that's important
to say when we look in thecontext of the study is that we
did not screen everybody foropioid use disorder, so we
(08:45):
actually are probably not evenreaching all of the people who
should or could be eligible forbuprenorphine treatment in the
ED.
Rob Lott (08:52):
Interesting. Alright. Good question for follow-up
study. And that's perhaps a goodsegue for you to tell us about
this study. The paper in theSeptember issue of Health
Affairs, tell us a little bitabout it.
What exactly did you study? Whatoutcomes did you measure?
Aimee Moulin (09:10):
We were looking at essentially implementation of
this model in California EDs. Wehad a pretty rapid ramp up where
we tried to reach all of theemergency departments across the
state of California. And thispaper looked pretty much at how
well we were able to do. So wemeasured a couple things. One
(09:31):
were encounters with navigators.
So the number of people who hadan encounter with a navigator
for any reason could be alcoholuse disorder, stimulant use
disorder, or opioids. The numberof buprenorphine treatment
options that happened inemergency departments, so
buprenorphine was eitheradministered or prescribed in
(09:53):
the ED, those two outcomes wemeasured from grant reporting.
So that is data that the EDsreported to Bridge as a part of
the grant process. The other onewas we looked at buprenorphine
prescriptions by Californiaemergency physicians using our
(10:14):
prescription drug monitoringprogram in the state. So we were
able to identify emergencyphysicians based on sort of
episodic prescribing patternsand look at the number of
prescriptions in that databasethat were written by ED
physicians, and then we're ableto kind of track that and see
(10:35):
what percentage of people wereable to get a second
prescription kind of as a markerof follow-up that they stayed in
care.
Rob Lott (10:42):
Got it. Okay. And then tell us what you found. What
were, some of your top linefindings?
Aimee Moulin (10:48):
Yeah. I personally think the most important piece
of this is the volume, is ahundred and sixty five thousand
navigator encounters,encounters, almost forty five
thousand people treated withbuprenorphine, and then of the
people who got a prescription inthe ED, about thirty six percent
(11:10):
received a second prescription.I think the key part here,
though, is is the volume, thatemergency departments in a
relatively short period of timeare able to reach a high volume
of high need patients. So Ithink that is, I think, the key
takeaway. I think the otherpiece of that is to remember we
(11:35):
didn't screen.
So to think that this is aboutthe unmet need for substance use
treatment in our communities,because we were able to reach
that many people just by sayingto a handful of them, Hey, did
you want help? Imagine if wescreened or if there was broader
(11:57):
efforts to reach the need in ourpopulations.
Rob Lott (12:00):
Great. Well, I want to learn a little more about, sort
of your reaction or yourresponse to those findings. But
first, let's take a quick break.And we're back. I'm here with
(13:06):
Doctor.
Amy Muhlen, who's describing herpaper in the September issue of
Health Affairs. So just a momentago, you highlighted some of the
findings, including just thesheer volume as well as the fact
that this is in the contextwithout screening. There might
be a lot more people who couldbenefit down the road.
(13:29):
Obviously, as someone sointimately involved in this
program and who's been such abig part of its implementation,
I'm sure you had someexpectations going into this
research study, and I'm curiousif the study confirmed your
suspicions or if there were anysurprises, when the initial
(13:49):
results came back.
Aimee Moulin (13:50):
Yeah. I you know, as you mentioned, I was really a
part of the implementation, so Iknew that we were reaching a lot
of people. What I was surprisedat was the second prescription,
because the people that we arestarting on buprenorphine, I
mean, is not a population thatone would think out of the gate
has high rates of follow-up.There's high rates of the
(14:11):
primarily Medicaid population. Alot of people are experiencing
homelessness.
These are folks who did notpreviously have access to care.
The ED was their primary placeof care. So at the face of it,
this is not a population thatyou would think would would be
able to be engaged in care. Andso I was actually really
(14:34):
surprised that thirty sixpercent of the people got that
second prescription.
Rob Lott (14:39):
That's great. Let me I'm gonna be, take a cynical
viewpoint just for Mhmm. Amoment. And, as thirty six got
the second prescription, thatmeans, what, sixty four percent
did not. And I guess one way,again, cynical way of looking at
it is that like, maybe it's notworth all those sort of false
(15:03):
starts, if you will, that likelot, there's a lot of sort of
foregone treatment.
Is that something you'rethinking about? What's the sort
of response? Is it sort ofbetter to get 36% than 0%? Or
how are you approaching thatquestion?
Aimee Moulin (15:22):
I think you bring up a good point, right? There's
sixty four percent out therethat did not get that second
percent prescription, so there'sroom for improvement, right?
There's a huge population outthere that we could better
design our connections tooutpatient treatment, they're
imperfect, and there's a lot ofimprovements that we could make
in that outpatient treatmentsetting to make it more
(15:43):
accessible and friendly to movethe needle on that number. So I
think you're absolutely right topoint that out as to say like,
hey. There's a large percentageof people out there that we
could be doing a better job ofreaching to make sure that
they're able to stay in care.
And I think that's also anotherarea where further research,
like, how can we do a better jobof making connections between
(16:04):
the ED and outpatient care. Butthen also to remember, you know,
substance use disorder, relapseis common. There's a lot of
false starts, and that is justsort of part of the disease
trajectory. And so, you know,every we always say in my
hospital, like, a day withoutfentanyl is a day without
fentanyl. So even if there's oneday when someone is able to kind
(16:28):
of start that journey towardsrecovery, that's a good day.
Rob Lott (16:32):
That's a great way to look at it. In recent years,
maybe the last year or so, theoverall, the national numbers
are that we're actually seeing abit of a decline in, opioid
overdose mortality. And I'mwondering if you have a sense of
how programs like this may becontributing to that decline.
Aimee Moulin (16:56):
I would love to think that we're reaching people
at a scale that we're decreasingmortality, But I just I mean, I
don't think that we're thereyet.
Rob Lott (17:07):
Mhmm.
Aimee Moulin (17:07):
I I think that, though, to to some extent, we've
been following the highmortality numbers and absolutely
right. Right? Because people aredying at a completely
unacceptable rate and continueto even though they've flattened
out a little bit. But thosenumbers are so high because
fentanyl is so lethal. And thatis not even a a sum total of the
(17:32):
population we need to reach.
Right? We need to reach thepeople who are struggling with
substance use disorders,fentanyl, alcohol, stimulant use
disorder, and that marker isbecause fentanyl is so lethal,
but it is not at all a sum totalof the people who we need to
reach. So I I think we are along way from providing
(17:55):
treatment at scale to reallyaddress the problem.
Rob Lott (17:59):
Well, you just mentioned scale. That's a great
segue. Thank you. I know themodel you said ramped up pretty
quickly in California. Can youtalk a little bit about the
challenges behind thatexpansion, perhaps some of the
barriers to scale, and what wemight expect to see, as that
(18:20):
scaling takes place beyondCalifornia across the country?
Aimee Moulin (18:25):
Yeah. I think two things. One, I think a huge
obstacle for ED implementationis two. One, the it's not my
problem, viewpoint that wetalked about at the very
beginning of this is asubspecialty problem, and I
can't have any impact as anemergency physician. I think
we've pretty much, looking atoutcomes, beat that one to
(18:47):
death.
So I I think that we've shownthat that one's not true. The
other one that I hear a lot iswe don't see those patients
here. So I think there's stigma,we don't see those patients
here, but also there's sort ofthat you don't see what you
don't see. So if you don't wantto see this problem in your
(19:11):
patient population, you want toignore it, you don't want to
address it, you won't see it. Sothat I think is a common
refrain.
We don't see those patientshere. And, you know, once you
kind of get someone to start tolook, it's just not true. I
mean, it's it's an emergencydepartment. Right? You you see
these patients.
They're everywhere. And theother part is there's that
(19:34):
othering of those patients arenot my patients. Yeah. So stigma
is a big barrier toimplementation, and I think a
big barrier to treatment.
Rob Lott (19:44):
Do you have a sense that programs like this might
help begin to eat away at thatstigma or address it?
Aimee Moulin (19:52):
Yeah. You know, I you know, as as much as I'm sort
of talking down about emergencydepartments, we have to
recognize, like, they switchedreally fast. I mean, the
practice change that occurred inemergency departments in
California is prettyunprecedented. To have this
broad of implementation changein this short period of time, I
(20:13):
think, was really impressive.And, so I have to say once we
were able to start to addresssome of those issues, my
colleagues in emergency medicinedid have an open mind and
changed longstanding beliefspretty quickly.
I credit the sort ofimplementation technique of the
navigators. So we put someone inthere who was focused on this
(20:36):
who sort of modeled thatdestigmatized behavior. And then
because the patients had suchgood results, I think that
changed the hearts and minds ofa lot of my colleagues.
Rob Lott (20:49):
Well, yeah, nothing better than positive results to
make someone reevaluate theirpriors.
Aimee Moulin (20:56):
Try to combine, you know, data with stories.
That's that's really how youchange belief.
Rob Lott (21:02):
I bet. I I can imagine also that, in a way, the
navigator is sort of helping theemergency medicine clinician
sort of lightening their load alittle bit, whereas you're sort
of almost asking rather thanasking them to do more, you're
offering them a a way to do morewith less, if you will.
Aimee Moulin (21:26):
I yes. A 100%. I think the other policy change is
funding streams to supportnavigators, people with lived
experience in emergencydepartments. Because at the face
of it, right, this is a terribleplace to engage in substance use
treatment. It's busy, it'schaotic, there's no privacy,
(21:47):
everybody's in and out.
So having the navigator reallyfixes that gap. You have someone
who's there with livedexperience who can meet the
patient where they are, havethat conversation with them, be
a patient advocate. So it it,one, helps the patient, but
also, as ED physicians are busyand the ability to sit down and
(22:09):
talk to someone, I think issomething, one, we're not
trained in very well and two,because of the time sensitive
nature of other patients comingin, it can be very stressful for
the ED physician. They're notvery good at it. Navigators are
really fantastic and make a hugedifference.
Rob Lott (22:29):
Wow. What do you see as the most potentially fruitful
policy changes that could takeplace or be implemented over the
next few years that might leadto further expansion of the
Bridge program and programs likeit?
Aimee Moulin (22:47):
I think it's really funding models to support
ED navigators. Bringing peoplewith lived experience into
emergency departments is gamechanging revolutionary. Bringing
people in who focused on thatlinkage, as you mentioned,
there's the 64%, so paying a lotof attention to providing that
(23:08):
linkage to care, overcoming alot of the, as you mentioned,
that fragmented system inaddition to a lot of the social
barriers around transportation,communication, having someone
who can focus on that andaddress it for a patient
population, but that, of course,needs to be supported and funded
by our healthcare system. Andthen, you know, taking a step
(23:31):
back to think about why do wehave a system that is so hard
for people to access care? Like,the payment structures that we
have, particularly around whatis considered a specialty
service, really makes itimpossible for people to access
care.
I'm sometimes surprised thatanyone is able to make it
(23:54):
through all the hoops that weput in front of them. As a as a
health care system, like, theway we've designed care is
really almost to keep peopleout. And if you look at our
outcomes, we're we're we're wehave the system we have
designed.
Rob Lott (24:11):
Fair enough. Well, that's a a great, prescription,
if you will, for the future inareas for, for future study as
well. Doctor Amy Mullen, thanksso much for joining us here
today. I had a great timechatting with you.
Aimee Moulin (24:25):
Thank you. Appreciate it.
Rob Lott (24:27):
To our listeners, thanks for tuning in. If you
enjoyed this episode, pleaseleave a review, share it with a
friend, subscribe, and tune innext week. Thanks, everyone.
Thanks for listening. If youenjoyed today's episode, I hope
you'll tell a friend about ahealth policy.
Hello, and welcome to A Health Podicy. I'm your host,
(00:04):
Rob Lott. As health affairsreaders know, September marks
the release of our theme issueall about the opioid crisis.
Many of the articles examine thepowerful benefits of medication
assisted treatment foraddiction, treatments such as
(00:26):
buprenorphine. One persistentchallenge in this space has been
getting more of the people whocould benefit from that
treatment to actually commencethe therapy and stick with it.
It's a challenge that is madeall the more difficult by the
complex fragmented nature of ourhealth system. Of course, this
(00:47):
reality has policymakers andclinicians asking if it's
possible to reduce barriers toaccess. It's a tough question,
and it's the subject of today'shealth odyssey. I'm here with
Doctor. Amy Muhlen, a professorin emergency medicine at UC
Davis Medical Center and chiefof the division of Addiction
(01:09):
Medicine there.
She is also a founder andprincipal investigator of an
organization called BRIDGE,which has supported the
implementation of low thresholdemergency department initiated
medications for opioid usedisorder, and they're bundled
with harm reduction efforts andpatient navigation. Doctor.
(01:31):
Mullen is also the co author ofan article in the September
issue describing that very modeland evaluating its impact. I
can't wait to, look under thehood of this model, learn more
about it, and about itspotential, for scale. Doctor Amy
Mullen, thanks for joining thepodcast.
Aimee Moulin (01:52):
Thank you for having me. Appreciate the
opportunity to talk about this.
Rob Lott (01:56):
Absolutely. So before we learn a little more about the
model, I thought maybe you couldgive us some context. Can you
describe the sort of typicalexperience for a patient with
opioid use disorder in theemergency department prior to
the implementation of a programlike Bridge? How likely were
they to be started onmedication? Why wasn't
(02:19):
initiation more common at thattime?
Aimee Moulin (02:23):
Yeah. I think, medication initiation for opioid
use disorder in emergencydepartments prior to the program
was exceedingly rare. I thinkvery few emergency physicians
were prescribing buprenorphine.I think I probably knew
everybody who did personally.That's that's how rare I think
(02:43):
it was.
If you think back to 2016 atthat time, remember
buprenorphine was considereddangerous. You had to have a
special license. You had to havean X waiver. And treatment for
opioid use disorder, substanceuse disorders was considered a
very specific specialty, problemand definitely not something
(03:08):
that the emergency departmentfelt like was something that was
within their purview. So I thinkwhen we started, the typical
treatment for someone who evenoverdosed and tried to die in
emergency department was to letthem walk out without any
treatment.
Rob Lott (03:26):
Wow. Okay. So, maybe you can tell us a little bit
about your experience in thattime. What were you doing? Tell
us a little bit about how youcame to found, the Bridge
program.
Aimee Moulin (03:39):
Yes. I had an infant Bridge program at UC
Davis. We had hired, probablyone of the original substance
use navigators, Tommy Trevino.He was a drug and alcohol
counselor, had been working inour ED for several years, and
his main role was as someonewith lived experience, he did a
(04:01):
lot of motivationalinterviewing, coaching with
patients in the ED, and helps tolink them to outpatient
treatment. So I was fortunate inthat I saw this differently
because I could see the impactthat we had in the emergency
department because we hadsomeone who was working on this
problem.
So I was in that uniqueexperience of being able to see
(04:23):
the difference that the ED couldmake and start to understand the
need that was out there. I wasalso really lucky. You know,
health policy is sort of thecombination of the possible and
some of its timing.
Rob Lott (04:37):
Mhmm.
Aimee Moulin (04:38):
At that time, I was the president of our local
emergency department, ourCalifornia emergency physicians.
There was a budget surplus inCalifornia. And so we went out
on a leap and tried to fund EDnavigators in every emergency
department because that was mygoal for my, my policy goal for
(04:59):
emergency physician. That was myten year goal. We were vetoed
the first year, but I think thatstarted a conversation at the
state level, maybe catalyzedthis idea in California that
this was something that waspossible, and it sort of grew
from there.
Rob Lott (05:16):
Wow. Okay. So, before we go any further, let's learn a
little more about the modelitself. Can you describe it and
maybe how it represents a shiftfrom the sort of earlier
scenario described where no onewas getting any treatment?
Aimee Moulin (05:32):
Yeah. I think the main piece, the main shift that
we tried to make for emergencydepartments was that substance
use disorders, opioid usedisorder is an emergency. It's a
life threatening illness, we allknow that, the risk of death is
high, with an effective timesensitive intervention. This
(05:56):
becomes something that emergencydepartments are really good at.
And so shifting the thoughtprocess, that mental model from
this is an outpatient problem tothis is an emergency where
there's time sensitiveinterventions, I think was the
main shift that we tried to makefor the EDs.
So the model is really aboutmedications first. Someone,
(06:20):
everybody is universally offeredaccess to medications for opioid
use disorder. Incorporation ofharm reduction, individuals with
lived experience, that's thenavigator to provide that stigma
free care. And then, you know,the holy grail, which is the
connection to outpatienttreatment.
Rob Lott (06:41):
Got it. And just a few, points of clarification.
When you say the treatment istime sensitive, you mean that
the sooner the better or
Aimee Moulin (06:49):
Yeah. Okay. Right. Right. We know that so for
example, like someone who we seewith a non fatal overdose in the
ED has a pretty high rate of afatal overdose within the next,
you know, forty eight hours, onemonth to one year.
So the sooner that you canmitigate that risk of overdose
(07:10):
death with your treatmentoptions, we know that
buprenorphine reduces the riskof death, So there's a time
sensitivity to that interventionwhere you can mitigate harms.
And, you know, one of the mostimportant harms is death. And so
this is this is something wherethere's a huge opportunity for
emergency departments to engage.
Rob Lott (07:30):
Gotcha. And then tell us a little bit about sort of
the balance of the populationthat are, that is sort of
receiving this support. Is thisalmost entirely folks who arrive
at the ED for an overdose? Orare there people who arrive with
the flu or, you know, gastritisor something like that? And in
(07:50):
the course of treatment, itcomes up that they could also
benefit from buprenorphine.
What are you seeing mostcommonly?
Aimee Moulin (07:59):
Most commonly, not overdoses. Most commonly, we're
accessing people in the ED forother reasons or people who now
come into the emergencydepartment because they want
help. So we've been able tochange the narrative in in a
number of locations where peoplewill come in and say, hey. I
need help, and I don't knowwhere else to go. One of our
(08:22):
tenants was universally offeringhelp, so posting signs and
universally offering like, Hey,if you wanted to start
buprenorphine, we have thatopportunity here.
We did not screen patients andso I think that that's important
to say when we look in thecontext of the study is that we
did not screen everybody foropioid use disorder, so we
(08:45):
actually are probably not evenreaching all of the people who
should or could be eligible forbuprenorphine treatment in the
ED.
Rob Lott (08:52):
Interesting. Alright. Good question for follow-up
study. And that's perhaps a goodsegue for you to tell us about
this study. The paper in theSeptember issue of Health
Affairs, tell us a little bitabout it.
What exactly did you study? Whatoutcomes did you measure?
Aimee Moulin (09:10):
We were looking at essentially implementation of
this model in California EDs. Wehad a pretty rapid ramp up where
we tried to reach all of theemergency departments across the
state of California. And thispaper looked pretty much at how
well we were able to do. So wemeasured a couple things. One
(09:31):
were encounters with navigators.
So the number of people who hadan encounter with a navigator
for any reason could be alcoholuse disorder, stimulant use
disorder, or opioids. The numberof buprenorphine treatment
options that happened inemergency departments, so
buprenorphine was eitheradministered or prescribed in
(09:53):
the ED, those two outcomes wemeasured from grant reporting.
So that is data that the EDsreported to Bridge as a part of
the grant process. The other onewas we looked at buprenorphine
prescriptions by Californiaemergency physicians using our
(10:14):
prescription drug monitoringprogram in the state. So we were
able to identify emergencyphysicians based on sort of
episodic prescribing patternsand look at the number of
prescriptions in that databasethat were written by ED
physicians, and then we're ableto kind of track that and see
(10:35):
what percentage of people wereable to get a second
prescription kind of as a markerof follow-up that they stayed in
care.
Rob Lott (10:42):
Got it. Okay. And then tell us what you found. What
were, some of your top linefindings?
Aimee Moulin (10:48):
Yeah. I personally think the most important piece
of this is the volume, is ahundred and sixty five thousand
navigator encounters,encounters, almost forty five
thousand people treated withbuprenorphine, and then of the
people who got a prescription inthe ED, about thirty six percent
(11:10):
received a second prescription.I think the key part here,
though, is is the volume, thatemergency departments in a
relatively short period of timeare able to reach a high volume
of high need patients. So Ithink that is, I think, the key
takeaway. I think the otherpiece of that is to remember we
(11:35):
didn't screen.
So to think that this is aboutthe unmet need for substance use
treatment in our communities,because we were able to reach
that many people just by sayingto a handful of them, Hey, did
you want help? Imagine if wescreened or if there was broader
(11:57):
efforts to reach the need in ourpopulations.
Rob Lott (12:00):
Great. Well, I want to learn a little more about, sort
of your reaction or yourresponse to those findings. But
first, let's take a quick break.And we're back. I'm here with
(13:06):
Doctor.
Amy Muhlen, who's describing herpaper in the September issue of
Health Affairs. So just a momentago, you highlighted some of the
findings, including just thesheer volume as well as the fact
that this is in the contextwithout screening. There might
be a lot more people who couldbenefit down the road.
(13:29):
Obviously, as someone sointimately involved in this
program and who's been such abig part of its implementation,
I'm sure you had someexpectations going into this
research study, and I'm curiousif the study confirmed your
suspicions or if there were anysurprises, when the initial
(13:49):
results came back.
Aimee Moulin (13:50):
Yeah. I you know, as you mentioned, I was really a
part of the implementation, so Iknew that we were reaching a lot
of people. What I was surprisedat was the second prescription,
because the people that we arestarting on buprenorphine, I
mean, is not a population thatone would think out of the gate
has high rates of follow-up.There's high rates of the
(14:11):
primarily Medicaid population. Alot of people are experiencing
homelessness.
These are folks who did notpreviously have access to care.
The ED was their primary placeof care. So at the face of it,
this is not a population thatyou would think would would be
able to be engaged in care. Andso I was actually really
(14:34):
surprised that thirty sixpercent of the people got that
second prescription.
Rob Lott (14:39):
That's great. Let me I'm gonna be, take a cynical
viewpoint just for Mhmm. Amoment. And, as thirty six got
the second prescription, thatmeans, what, sixty four percent
did not. And I guess one way,again, cynical way of looking at
it is that like, maybe it's notworth all those sort of false
(15:03):
starts, if you will, that likelot, there's a lot of sort of
foregone treatment.
Is that something you'rethinking about? What's the sort
of response? Is it sort ofbetter to get 36% than 0%? Or
how are you approaching thatquestion?
Aimee Moulin (15:22):
I think you bring up a good point, right? There's
sixty four percent out therethat did not get that second
percent prescription, so there'sroom for improvement, right?
There's a huge population outthere that we could better
design our connections tooutpatient treatment, they're
imperfect, and there's a lot ofimprovements that we could make
in that outpatient treatmentsetting to make it more
(15:43):
accessible and friendly to movethe needle on that number. So I
think you're absolutely right topoint that out as to say like,
hey. There's a large percentageof people out there that we
could be doing a better job ofreaching to make sure that
they're able to stay in care.
And I think that's also anotherarea where further research,
like, how can we do a better jobof making connections between
(16:04):
the ED and outpatient care. Butthen also to remember, you know,
substance use disorder, relapseis common. There's a lot of
false starts, and that is justsort of part of the disease
trajectory. And so, you know,every we always say in my
hospital, like, a day withoutfentanyl is a day without
fentanyl. So even if there's oneday when someone is able to kind
(16:28):
of start that journey towardsrecovery, that's a good day.
Rob Lott (16:32):
That's a great way to look at it. In recent years,
maybe the last year or so, theoverall, the national numbers
are that we're actually seeing abit of a decline in, opioid
overdose mortality. And I'mwondering if you have a sense of
how programs like this may becontributing to that decline.
Aimee Moulin (16:56):
I would love to think that we're reaching people
at a scale that we're decreasingmortality, But I just I mean, I
don't think that we're thereyet.
Rob Lott (17:07):
Mhmm.
Aimee Moulin (17:07):
I I think that, though, to to some extent, we've
been following the highmortality numbers and absolutely
right. Right? Because people aredying at a completely
unacceptable rate and continueto even though they've flattened
out a little bit. But thosenumbers are so high because
fentanyl is so lethal. And thatis not even a a sum total of the
(17:32):
population we need to reach.
Right? We need to reach thepeople who are struggling with
substance use disorders,fentanyl, alcohol, stimulant use
disorder, and that marker isbecause fentanyl is so lethal,
but it is not at all a sum totalof the people who we need to
reach. So I I think we are along way from providing
(17:55):
treatment at scale to reallyaddress the problem.
Rob Lott (17:59):
Well, you just mentioned scale. That's a great
segue. Thank you. I know themodel you said ramped up pretty
quickly in California. Can youtalk a little bit about the
challenges behind thatexpansion, perhaps some of the
barriers to scale, and what wemight expect to see, as that
(18:20):
scaling takes place beyondCalifornia across the country?
Aimee Moulin (18:25):
Yeah. I think two things. One, I think a huge
obstacle for ED implementationis two. One, the it's not my
problem, viewpoint that wetalked about at the very
beginning of this is asubspecialty problem, and I
can't have any impact as anemergency physician. I think
we've pretty much, looking atoutcomes, beat that one to
(18:47):
death.
So I I think that we've shownthat that one's not true. The
other one that I hear a lot iswe don't see those patients
here. So I think there's stigma,we don't see those patients
here, but also there's sort ofthat you don't see what you
don't see. So if you don't wantto see this problem in your
(19:11):
patient population, you want toignore it, you don't want to
address it, you won't see it. Sothat I think is a common
refrain.
We don't see those patientshere. And, you know, once you
kind of get someone to start tolook, it's just not true. I
mean, it's it's an emergencydepartment. Right? You you see
these patients.
They're everywhere. And theother part is there's that
(19:34):
othering of those patients arenot my patients. Yeah. So stigma
is a big barrier toimplementation, and I think a
big barrier to treatment.
Rob Lott (19:44):
Do you have a sense that programs like this might
help begin to eat away at thatstigma or address it?
Aimee Moulin (19:52):
Yeah. You know, I you know, as as much as I'm sort
of talking down about emergencydepartments, we have to
recognize, like, they switchedreally fast. I mean, the
practice change that occurred inemergency departments in
California is prettyunprecedented. To have this
broad of implementation changein this short period of time, I
(20:13):
think, was really impressive.And, so I have to say once we
were able to start to addresssome of those issues, my
colleagues in emergency medicinedid have an open mind and
changed longstanding beliefspretty quickly.
I credit the sort ofimplementation technique of the
navigators. So we put someone inthere who was focused on this
(20:36):
who sort of modeled thatdestigmatized behavior. And then
because the patients had suchgood results, I think that
changed the hearts and minds ofa lot of my colleagues.
Rob Lott (20:49):
Well, yeah, nothing better than positive results to
make someone reevaluate theirpriors.
Aimee Moulin (20:56):
Try to combine, you know, data with stories.
That's that's really how youchange belief.
Rob Lott (21:02):
I bet. I I can imagine also that, in a way, the
navigator is sort of helping theemergency medicine clinician
sort of lightening their load alittle bit, whereas you're sort
of almost asking rather thanasking them to do more, you're
offering them a a way to do morewith less, if you will.
Aimee Moulin (21:26):
I yes. A 100%. I think the other policy change is
funding streams to supportnavigators, people with lived
experience in emergencydepartments. Because at the face
of it, right, this is a terribleplace to engage in substance use
treatment. It's busy, it'schaotic, there's no privacy,
(21:47):
everybody's in and out.
So having the navigator reallyfixes that gap. You have someone
who's there with livedexperience who can meet the
patient where they are, havethat conversation with them, be
a patient advocate. So it it,one, helps the patient, but
also, as ED physicians are busyand the ability to sit down and
(22:09):
talk to someone, I think issomething, one, we're not
trained in very well and two,because of the time sensitive
nature of other patients comingin, it can be very stressful for
the ED physician. They're notvery good at it. Navigators are
really fantastic and make a hugedifference.
Rob Lott (22:29):
Wow. What do you see as the most potentially fruitful
policy changes that could takeplace or be implemented over the
next few years that might leadto further expansion of the
Bridge program and programs likeit?
Aimee Moulin (22:47):
I think it's really funding models to support
ED navigators. Bringing peoplewith lived experience into
emergency departments is gamechanging revolutionary. Bringing
people in who focused on thatlinkage, as you mentioned,
there's the 64%, so paying a lotof attention to providing that
(23:08):
linkage to care, overcoming alot of the, as you mentioned,
that fragmented system inaddition to a lot of the social
barriers around transportation,communication, having someone
who can focus on that andaddress it for a patient
population, but that, of course,needs to be supported and funded
by our healthcare system. Andthen, you know, taking a step
(23:31):
back to think about why do wehave a system that is so hard
for people to access care? Like,the payment structures that we
have, particularly around whatis considered a specialty
service, really makes itimpossible for people to access
care.
I'm sometimes surprised thatanyone is able to make it
(23:54):
through all the hoops that weput in front of them. As a as a
health care system, like, theway we've designed care is
really almost to keep peopleout. And if you look at our
outcomes, we're we're we're wehave the system we have
designed.
Rob Lott (24:11):
Fair enough. Well, that's a a great, prescription,
if you will, for the future inareas for, for future study as
well. Doctor Amy Mullen, thanksso much for joining us here
today. I had a great timechatting with you.
Aimee Moulin (24:25):
Thank you. Appreciate it.
Rob Lott (24:27):
To our listeners, thanks for tuning in. If you
enjoyed this episode, pleaseleave a review, share it with a
friend, subscribe, and tune innext week. Thanks, everyone.
Thanks for listening. If youenjoyed today's episode, I hope
you'll tell a friend about ahealth policy.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
The Joe Rogan Experience
The official podcast of comedian Joe Rogan.