Teaching Hospitals, Communities are Working to Get to the Root of Substance Use Disorders

While America’s teaching hospitals only represent 5% of all hospitals, according to an AAMC analysis of data from the Agency for Healthcare Research and Quality, approximately 61% of emergency department discharges for substance-related disorders in 2014 were from these institutions. Even more staggering, in 2015, more than 22 million people needed treatment for substance use disorders (SUDs), but less than 11% of those received it.

In light of this data, and as part of their missions of caring for their communities, medical schools and teaching hospitals are working to stem the tide of the opioid epidemic and provide treatment options for patients dealing with addiction or substance use disorders. An October 2017 congressional briefing, hosted by the AAMC and the Congressional Academic Medicine Caucus, highlighted examples of innovative care models in some of the hardest hit areas of the nation. Speakers included Clay Marsh, MD, vice president and executive dean for health sciences at West Virginia University (WVU); Michael Lyons, MD, associate professor in the department of medicine at the University of Cincinnati (UC) College of Medicine; and Jeanette M. Tetrault, MD, associate professor of medicine and program director, Addiction Medicine Fellowship at the Yale University School of Medicine.

Delivering Acute Care

As a method to prevent overdose deaths, the Centers for Disease Control and Prevention (CDC), among other agencies, promote the expansion of access to and use of naloxone, a safe antidote to reverse opioid overdose. Many academic medical centers across the nation have partnered with local law enforcement, first responders, and others to expand access to naloxone.

UC College of Medicine has partnered with the Hamilton County Public Health Department in Ohio, BrightView Health, Interact for Health, and Adapt Pharma—the maker of a Narcan, a nasal spray version of naloxone—to increase distribution of the spray by 400% across the county.

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The AAMC and Congressional Academic Medicine Caucus hosted an October 17 congressional briefing on how teaching hospitals are treating patients with substance use disorders in light of the opioid epidemic. Credit: Joseph Banez.

“There is no guarantee that someone will be present at the time of overdose and have naloxone in hand,” Lyons said at the October briefing. “But, what if it was everywhere? We’d have to show not just examples of where it saved someone, but also regional impact on overall mortality. It won’t solve the opioid epidemic, but if it’s seen by policy makers and practitioners as a way to buy time, then things might change.”

Due to the UC College of Medicine’s existing relationships and expertise—including already being engaged in naloxone distribution, and having existing collaborations with the health department and community-based organizations—Lyons and the program team were able to overcome funding and logistical hurdles that might have stopped a similar program at a different institution in its tracks.

Through the program, Narcan is being distributed to first-responders, area emergency departments, the local jail, and substance abuse treatment centers. The team is also examining the potential placement of “Nalox Boxes,” developed at the Warren Alpert School of Medicine at Brown University, to increase the availability of the drug. This would provide access to naloxone much like the automated external defibrillators seen at airports and other heavily populated locations.

Lyons and others at the UC College of Medicine have assisted with the program’s implementation, especially in health care settings. Next, Lyons will lead a team to analyze the program and determine its impact on overdose deaths in the county. 

Connecting Patients with Long-term Services

 While naloxone can reverse an acute case of overdose, medical schools and teaching hospitals are also working to provide avenues to care over the long-term for patients who have overdosed and those with SUDs

Yale New Haven Hospital has instituted a specialty clinic within its primary care clinic, staffed by a multi-disciplinary team, which connects patients to pharmacotherapy, counseling, and other services. Medical students, nursing students, and addiction medicine fellows serve as part of the care team, allowing the next generation of health care professionals to learn how to treat SUDs in a clinical setting. Patients can be referred to the clinic from the primary care clinic or from Yale New Haven’s emergency department.

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During the congressional briefing, Tetrault noted that the educational aspect of the clinic would “translate into lasting clinical care models in the community by training residents to do this on their own, and teaching them the skills necessary to deliver treatment within the primary care setting.”

Yale New Haven has also begun administering buprenorphine—a form of medication-assisted treatment (MAT)—within its HIV clinics and in the emergency department, followed by a referral to a primary care setting for the remainder of a patient’s treatment. Clinician researchers within the emergency department, led by Gail D’Onfrio, MD, MD, MS, professor and chair of emergency medicine at Yale University School of Medicine, have studied the impact of the emergency department intervention and found that nearly 80% of patients who were started on buprenorphine in the ER were in treatment 30 days later. This is compared to less than 50% of patients who were either given a referral to treatment or received an intervention of brief counseling followed by a referral to treatment.  

The number of clinicians who can provide buprenorphine has been cited as a limiting factor in providing treatment to patients dealing with SUDs. Physicians must obtain special certification to prescribe the drug, and once trained, they are limited in the number of prescriptions they can write, resulting in access issues for patients seeking this form of treatment. To overcome this hurdle and increase access to buprenorphine, Yale has begun training physicians at primary care sites across Connecticut to prescribe the drug. “We are providing educational initiatives that train champions and expand the reach of care,” Tetrault said.

West Virginia has recorded 41.5 of every 100,000 deaths being due to drug overdose in 2015, making the state the hardest hit by the epidemic, as estimated by the CDC. The state’s rural geography can make it harder to connect patients to long-term treatment. Clay Marsh, MD,  noted that the state has a population density of 77 people per square mile and that 56% of residents do not have broadband Internet, adding to the difficulty in connecting with patients. 

“We are providing educational initiatives that train champions and expand the reach of care.” 

Jeannette M. Tetrault, MD
Yale University School of Medicine

To combat this, WVU has been working to implement telemedicine and telecare as part of its Comprehensive Opioid Addiction Treatment (COAT) program, along with medication-assisted treatment, 12-step programs, and behavioral counseling. The university has also built upon the Project ECHO (Extension Community Health Outcomes) model, first developed in New Mexico, and has implemented tele-ECHO to extend treatment for SUDs and other related health issues, such as Hepatitis C, to rural underserved communities. 

Creating Comprehensive Approaches to Treatment

WVU is also working to develop a robust state-wide approach to combatting the epidemic. Efforts include partnerships with local communities, increased education for current clinicians and future health professionals, expanded wellness and behavioral health programs, and education and skills development programs for patients in treatment and recovery. The university is also partnering with the Departments of Defense and Veterans Affairs on innovative approaches to the treatment of chronic pain.

“It’s like pulling a weed,” Marsh said. “If you get rid of what’s above the ground, it’ll come back again. Then there’s the root.” Marsh and WVU’s approach is to respond to the patient’s medical needs while providing community building programs and job training for individuals. To accomplish this goal, the university has partnered with Coalfield Development, a non-profit aimed at formally unemployed West Virginians, especially coal miners, to provide paid work, mentorship, and education to patients with SUDs.

In addition to its Narcan distribution project, UC College of Medicine is also developing a comprehensive approach to delivering care to its affected community, including an ongoing needle exchange program, a Dean’s Task Force, increasing the availability of addiction services and consultations, and an early intervention program, led by Lyons. UC Health, the college’s clinical partner, is also a site for a study led by the National Institute on Drug Abuse on Yale’s emergency department buprenorphine intervention.

“It’s like pulling a weed. If you get rid of what’s above the ground, it’ll come back again. Then there’s the root.”

Clay Marsh, MD
West Virginia University

“That type of multi-venue, multi-disciplinary, and coordinated effort is the comprehensive approach we need to tackle a problem as big and complex as the opioid epidemic,” Lyons said.

Advancing Funding Efforts

When asked during a question and answer session at the briefing about what types of federal government actions would best aid their efforts, Marsh, Lyons, and Tetrault advocated for further funding into the causes of and potential treatments for SUDs from the National Institutes of Health, and incentives for educational programs through Titles VII and VIII of the Public Service Health Act. The panelists also mentioned the need for further funding for graduate medical education through Medicare to assist meeting the shortfall of physicians, both in terms of treating patients with SUDs and in general.