There has been no let-up. A recent study of ICUs in 44 states conducted by academic medicine researchers documented a substantial increase in the incidence and mortality of patients from opioid overdoses between 2009 and 2015. Numbers from the National Institutes of Health (NIH) echo similar bad news: More than 2.5 million Americans have opioid use disorders and the numbers are continuing to grow.
Less obvious, however, is that the opioid epidemic has had “a disproportionate impact on AAMC members,” according to Tannaz Rasouli, the AAMC senior director of public policy and strategic outreach. “Our hospitals represent two-thirds of hospitalizations associated with substance use despite representing only 5% of all hospitals.”
“Our hospitals represent two-thirds of hospitalizations associated with substance use despite representing only 5% of all hospitals.”
Tannaz Rasouli
AAMC
In a recent Capitol Hill briefing about how medical schools and teaching hospitals are reaching underserved communities, Michael Lyons, MD, associate professor of emergency medicine and director of the early intervention program at the University of Cincinnati College of Medicine, talked about the unique role medical schools can play in coordinating care not only in a university setting but also in the community.
“Most notably, our medical school dean [William Ball, MD] has convened a university-wide task force on opioids, which illustrates how medical schools are the logical leaders for coordinating the overall university response to health threats,” said Lyons. “Medical schools and academic medical centers don’t have to live within their four walls. A multidisciplinary effort that coordinates with the community at large is what is required to tackle a problem as big as this epidemic.”
To create an organized response, medical schools and teaching hospitals are partnering with public health and law enforcement agencies, as well as with local health care providers to address the clinical, social, and rehabilitative challenges, said John Prescott, MD, AAMC chief academic officer.
Medication-assisted treatment (MAT), for example, is an accepted evidence-based standard for treating opioid disorders that isn’t being used widely by clinicians despite literature pointing to its effectiveness. Why? Physicians aren’t getting the certification they need to provide this course of treatment. The U.S. Drug Enforcement Administration requires physicians have eight hours of training, become certified, and obtain a waiver to prescribe synthetic opioids used in MAT.
West Virginia University (WVU) School of Medicine is among the teaching hospitals taking steps to facilitate greater access to MAT. In 2016, WVU began offering one-day training at the medical school to help physicians qualify for waivers to prescribe MAT drugs. Once they’ve obtained waivers, physicians in rural areas are supported by WVU biweekly teleconferences to help them review cases and get follow-up psychological care for patients.
Other obstacles in accessing MAT—primarily methadone, buprenorphine, and naltrexone— are starting to come down as well. More states are receiving funding through the federal MAT Prescription Drug and Opioid Addiction Grant Program. In addition, the Substance Abuse and Mental Health Services Administration is raising the cap on the number of patients for whom doctors can prescribe MAT drugs.
At the same time, teaching hospitals have been integrating MAT into their treatment regimens as the NIH and Centers for Disease Control and Prevention recommend. At Yale New Haven Hospital, emergency department (ED) physicians begin treatment with buprenorphine and arrange “a warm handoff” to office-based medical providers or opioid treatment programs.
“Opioid agonist medications, such as methadone and buprenorphine and naltrexone are essential for treatment and saving lives,” said Gail D’Onofrio, MD, MS, professor and chair of emergency medicine at Yale University School of Medicine.
Treatment challenges
Teaching hospitals, which shoulder the majority of opioid overdose patients, are trying to develop more effective, comprehensive treatment approaches to save lives and help patients break the addiction cycle.
The Food and Drug Administration (FDA) approved buprenorphine for opioid dependency in 2002. Buprenorphine, an opioid agonist and the primary synthetic opioid used in MAT, works by strongly binding to receptors in the brain and activating them partially to suppress withdrawal and cravings, but without the same euphoria as opioids like heroin.
“Abstinence-only treatment doesn’t work ... Attempts to resist drug cravings are like trying to stop your car from hitting a child, only to discover your brakes don’t work.”
Gail D’Onofrio, MD, MS
Yale University School of Medicine
MAT “is not sufficient in itself to put people back on track,” stressed Camila Arnaudo, MD, lecturer in clinical psychiatry at Indiana University School of Medicine. “Typically patients [with opioid addiction] also have one or two general psychiatric diagnoses like depression or PTSD. Many use cocaine or methamphetamines, or they may be taking Valium or Ativan in addition to an opioid pill, and this can be a lethal combination.” MAT should be complemented with either individual or group therapy or both, she stressed.
Initially, treatment for opioid abuse often begins with naloxone (Narcan) administered by police or EMTs for overdoses. EDs treating overdose patients make referrals for further medical management and ongoing mental health treatment once a life is saved. Withdrawal typically follows emergency treatment, “preferably in an observed setting” because of the intense symptoms, noted Janis Orlowski, MD, chief health care officer at the AAMC.
One reason why overdose deaths have increased over the last two decades, though, is that patients may not follow through on the ongoing medication and counseling recommended by their physician after they leave the ED.
“Abstinence-only treatment doesn’t work because chronic use of opioids alters brain functioning, making it impossible for patients to stop using no matter what the consequences,” said D’Onofrio. “Attempts to resist drug cravings are like trying to stop your car from hitting a child, only to discover your brakes don’t work.”
The scarcity of providers trained in addiction disorders is another challenge. “People are very good at hiding their addictions,” said Orlowski, who noted that many physicians who are not specialists in this area have difficulty assessing patients’ addiction risk. In addition, she said that psychological resources and financial support are lacking for opioid abuse treatment in many communities.
“Patients are so horrendously underserved,” Arnaudo agreed. “We have very few addiction psychiatrists in Indiana, and it takes a team of people to help.” she said. Add to that the problem that some primary care physicians are reluctant to treat patients with opioid dependency.
AAMC’s Prescott is seeing signs of progress, though. “Medical education is constantly changing to incorporate groundbreaking research into treatments for chronic pain and substance abuse disorders,” he observed.
The work of treating people with addiction disorders is rewarding despite the challenges, Arnaudo added. “Patients who get appropriate care can get better.”