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Why Don’t ERs Offer Addiction Treatment?

“Research shows that people who have had an overdose are more likely to have another. Emergency department education and post-overdose protocols, including providing naloxone and linking people to treatment, are critical needs.” ~ Dr. Alana Vivolo-Kantor, Ph.D., Behavioral Scientist, National Center for Injury Prevention and Control In 2017, over 72,000 Americans died because of fatal drug overdoses. And for every death, there are estimated to be at least 30 overdoses where the victims survived.  Importantly, when you factor in other health problems such as infections, disease, injuries, and self-harm resulting from substance abuse, it adds up to almost five million drug-related ER visits every year.   It’s easy to understand the overwhelming challenges faced by many Emergency Rooms. Recovery from addiction is a process that requires a serious commitment of time, effort, and resources, so by its very nature, an Emergency Department is not the place to receive comprehensive substance abuse treatment. However, an ER setting is the proper setting to stress the dangers of alcohol and drug abuse. And if the information is presented properly, a “captive” patient still open after a serious health scare might be more receptive to the idea of rehab.  Professional intervention at this point can mean the difference between the patient actually receiving treatment for their problem and getting better and a continued and worsening addiction. But for a variety of reasons, most substance abusers who end up in the ER never receive more than the most rudimentary care for substance abuse. After their immediate presenting health concern is addressed, the availability of treatment programs might be mentioned in passing, if at all.  Too often, they are merely given a pamphlet, wished good luck, and left to their own devices. Here, we will take a look at why more addiction recovery services are not offered in an ER setting and how changing that might save thousands of lives.

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Emergency Rooms and Overdoses: The Statistics

Long before we receive data from death certificates, emergency department data can point to alarming increases in opioid overdoses…This fast-moving epidemic affects both men and women, and people of every age. It does not respect state or county lines and is still increasing in every region in the United States.” ~ Dr. Anne Schuchat, MD, Acting Director, Centers for Disease Control and Prevention According to the CDC, opioids such as prescription painkillers, heroin, and illicit synthetics like fentanyl continue to worsen the US drug crisis:

  • Between July 2016 and September 2017, ED visits for suspected opioid overdoses increased 30%.
  • Eight states report substantial increases of 25% or more in the rate of opioid overdose ER visits.
  • Significant increases in all Midwest states, including:
    • Wisconsin (+ 109%)
    • Illinois (+66%)
    • Indiana (+35%)
    • Ohio (+28%)
    • Missouri (+21%)
  • In the Northeast, the largest increases were seen in:
    • Delaware (+105%)
    • Pennsylvania (+81%)
    • Maine (+34%)
  • In the Southeast region, North Carolina reported a 31% increase.
  • Large metropolitan areas with populations over one million residents saw an increase of 54%.
  • 45% of ER visits involving drugs are for reasons of abuse, rather than adverse reactions.
  • 27% are for the nonmedical use of prescription pharmaceuticals.
  • 21% involve illicit drugs.
  • 14% are for alcohol in combination with another drug.

What Drugs are Filling ERs?

“We see some cardiac complications from using meth, because it’s like a stress test. But opioids suppress the respiratory system, which causes serious medical problems with permanent effects…(patients have) lost consciousness, stopped breathing, had a cardiac arrest or are to some extent brain damaged and are on a respirator… We don’t see these life-threatening overdoses (with other drugs) like we see with opioids, because of their ability to suppress breathing.” ~ Dr. Andrew Bernard, Chief of Trauma and Acute Surgery at the University of Kentucky Health Center And those statistics only take opioids into account. It is also important to remember that almost a third of overdose deaths involve benzodiazepine tranquilizers. Cocaine and methamphetamine production and availability are also at record levels, increasing the possibility of abuse and overdose. But there are three substances of abuse that send more people to the hospital than any other:

  • Alcohol -According to the World Health Organization, there are more than 200 diseases and chronic health conditions that are directly attributable to drinking.  In fact, alcohol kills 88,000 people per year.  Since 2007, the number of alcohol-related deaths in America has jumped by 35% 67%  among women and 27% among men.
  • Opioids -More people die because of opioids than any other class of drugs, and the number of overdose deaths continues to rise.  Ultra-powerful synthetics like fentanyl and its analogues have replaced heroin as the single largest drug threat in America. In 2017, the New York Times reported that fentanyl-related deaths had spiked by 540% within just three years.
  • Benzodiazepines -Typically prescribed for and insomnia for anxiety, tranquilizers such as Xanax, Klonopin, or Valium are extremely habit-forming.  In fact, even a person who is taking their medication precisely as directed can develop a severe dependence.  Between 1996 and 2016, the number of benzodiazepine-related overdose deaths quadrupled.

This is why Dr. Marcus Bachhuber, Assistant Professor of Medicine at Albert Einstein College of Medicine, says, “Benzodiazepine prescriptions are widespread, but their use may not be the smart choice for many patients.

Alcohol, Painkillers, and Tranquilizers: A Deadly Trio

“It is nothing short of a public health crisis when you see a substantial increase of avoidable overdose and death related to two widely-used drug classes being taken together.” ~ Dr. Robert Califf, Commissioner, Food and Drug Administration Of special relevance, these are all Central Nervous System depressants that slow the heart rate, reduce blood pressure, and suppress breathing.  And when they are used in combination, those effects are magnified to a dangerous degree. 75% of all drug overdoses—and 98% of fatal ones—involve multiple substances.

  • 80% of drug deaths involving heroin, buprenorphine, or methadone also involve “benzo” tranquilizers.
  • Between 2005 and 2011, there were almost 250,000 ER trips for painkiller/tranquilizer combinations.
  • There also an additional 164,000 ER trips for alcohol/tranquilizer interactions.
  • The use of all three substances resulted in over 43,000 ER visits.
  • Approximately 40% of the ER trips ended with a “serious outcome”—i.e. long-term hospitalization, disability, or death.

How Did the Opioid Crisis Get This Bad?

“Addiction is a problem. We now have an opioid stewardship committee, because we as an organization and profession have realized prescribing opioids is harmful to the greater good. Most patients get too much when they get (opioids), either too high a dose or (for) too long a duration…We’ve done that because we’ve realized we (physicians) are a major part of the problem. So many people who are heroin addicted, they didn’t hit heroin first. The first thing they did was take someone’s pain pill.” ~ Dr. Andrew Bernard The present opioid crisis started about a generation ago, when Big Pharma drug companies introduced powerful opioid painkillers such as Oxycontin to the market and then misrepresented the potential for abuse.  Doctors were also aggressively targeted by sales representatives to encourage to prescribe these “safe and effective” drugs. As a result, the pain was treated almost like another of the senses, and providers freely dispensed opioid painkillers as a first-line treatment option for both acute and chronic pain.  Terms like “doctor shopping” and “pill mills” entered the American vocabulary. By the time the truth came out about the abuse and overdose potential of pain-killing opioids, a market had already been firmly established.  And when the Federal government and the medical industry finally took steps to change prescribing practices, drug cartels and illicit manufacturers were there to continue to supply the overwhelming demand. This is why heroin has seen such a resurgence – because it is cheaper and easier to obtain than black market prescription painkillers.  While a single pill can cost up to $75.00 or more, a dose of heroin can be purchased for about the same price as a pack of cigarettes.  Significantly, 80% of heroin addicts started out by misusing prescription opioids.

The Rise of Synthetic Opioids

“In terms of danger level, opioids are bad, heroin is worse and fentanyl is the worst. When these pills hit the street and you as an addict think you`re taking Oxy, and you take 10 pills, it’s very likely they could contain fentanyl, and just one of those pills could kill you.” ~ Agent Tom Lenox, Drug Enforcement Administration This is also why powerful synthetic opioids are so popular.  Because there are completely manufactured in a laboratory that without the need for components from the opium poppy, many drug cartels have ramped up production.  For them, it is an economic business decision, because heroin costs three times as much to manufacture. And when it is mixed in or even substituting for other opioids –almost always without the user’s knowledge – the results can be deadly.  Because fentanyl is up to 100 times more potent than morphine, an addict taking their “normal” amount can quickly overdose.  A tiny amount the size of six grains of salt can kill a full-grown man. In fact, some analogues of fentanyl are 10,000 times stronger than morphine.  At that potency, a lethal dose is measured in micrograms.  Some synthetic opioids are so powerful that it takes multiple administrations of the lifesaving overdose reversal drug Narcan to revive them.

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Why Don’t ERs Provide Addiction Treatment?

This is a time when people are vulnerable, potentially frightened by this event that’s just occurred and amenable to advice, referral and treatment recommendations. It’s safe to characterize it as a missed opportunity for the health system to respond. ~ Dr. Julie Donohue, Associate Professor of Health Policy and Management, University of Pittsburgh It is important to keep in mind the role that Emergency Departments play in the American healthcare system. The goal of the ER is to provide lifesaving and stabilizing treatment and then afterward refer patients to the appropriate provider for any ongoing needs. This means that that ERs are simply not set up, equipped, or staffed to provide the long-term specialized care that addicts and alcoholics need to successfully and safely recover. That being said, it is still possible that with a few adjustments to policies, procedures, and practices that hospital emergency rooms can play a more direct part in the addiction recovery process. Let’s take a closer look at some of the challenges and concerns that currently complicate matters.

Poor Training is a Problem

“The professionals that are supposed to be able to refer and treat don’t have the training to know how and what to do.” ~ Dr. Corey Waller, Senior Medical Director, National Center for Complex Health and Social Needs Despite the fact that the crisis has been identified as a public health emergency, most doctors receive very little training on how to identify and interact with at-risk substance-abusing patients.  In fact, some residents get less than an hour of training in addiction treatment. That’s not entirely surprising, because even in the larger medical community outside of Emergency Rooms, there is a severe shortage of addiction specialists.  As of 2015, there were just over 3000 physicians who were board-certified in addiction medicine. That is not nearly enough to properly treat nearly 26 million Americans who meet the criteria for a Substance Use Disorder diagnosis.

Patients’ Rights are a Concern

I suspect the majority of them are discharged… They wake up and say, ‘I want to go home.’…If an adult patient is determined to have decision-making ability and is not suicidal, they have the authority to check themselves out.” ~ Dr. Andrew Bernard In America, patients who are mentally competent have the right to determine for themselves the medical treatment they accept.  This includes addiction recovery services. In other words, no matter how many times an ER staff sees the same patient for drug-related reasons, and no matter how obvious the addiction is, doctors have virtually no authority to compel or force a person into a rehab program or even keep them in the hospital. But this ignores the fact that addiction significantly changes people’s brains, in ways that keep them from making those logical decisions that are in their own best interests, such as seeking treatment after a drug overdose. Dr. Waller explains, saying, “They’re not putting a pro and cons list on the refrigerator. They’re just reacting to a situation that feels very much like survival.

The Logistics Logjam

The big thing about overdoses is it requires intervention and critical care, and is going to require more resources. They have to have one-on-one care, or one-on-two care…The longer they stay in the ED and require higher levels of care… we get bogged down.” ~ Dr. Charles Hobelmann, Emergency Department physician Emergency rooms are usually extremely busy, where doctors and nurses have to make quick decisions that can mean the difference between life and death.  The goal is to stabilize patients and then refer them to the appropriate provider for continued care and follow-up. Unfortunately, most patients seen for drug-related issues never take the next step in their care, i.e. getting professional help for their SUD. This is why some Emergency Departments will see the same patients for the same reasons again and again and again. There is no way to change the overall goal of an ER because immediate life-saving measures have to come first.  But there can be a more focused effort on connecting substance-abusing patients with local treatment programs and resources.

Inadequate Drug Screening

People are like walking drug stores now, there are so many drugs in their system. A lot of the treatment now is focused on opioids. The important thing for the medical and treatment community to know is they are using far more than opioids.” ~ Dr. Eric Wish, Ph.D., Director, Center for Substance Abuse Research (CESAR) Intake questionnaires are often perfunctory, with almost none of the follow-up questions that could provide critical information.  Drug screenings are not performed as a matter of course, and when they are, the tests are usually very basic panels that cannot detect many of the newer drugs.  Even more concerning, the existence of mislabeled or counterfeit drugs complicates both rescue and recovery efforts. Dr. Wish says, “It used to be [drug users] didn’t want to admit what they were taking. In this age they don’t know what they are taking.” This “checking-the-boxes” approach too often only focuses on treating the immediate problem of the overdose and nothing else. “But what that completely ignores are the psychological aspects of [addiction]…When you ignore that, you are fully ignoring the disease. And you’re looking at the patient like a toxicological problem and not a human,” says Dr. Waller.

Are Current Emergency Policies Enabling Addiction?

We hear from paramedics, ‘I went to the same house more than once in a single shift. You can’t really force a patient to go… and later in the day, they are using again.” ~ Dr. Andrew Bernard There is no doubt that emergency opioid overdose reversal medications like Narcan save lives.  Almost instantly after administration, the victim is revived and normal breathing is restored. But because they are aware of the safety net, some opioid addicts or being even less cautious than they were before.  They have less fear of a fatal overdose because they know that they can be brought back from the edge. This has caused a great deal of frustration among first responders.  Detective Lt. Patrick Glynn, of the Quincy Police Department in Massachusetts, says, “…a lot of people think that this is a fix-all for the heroin problem, which it’s not. I understand why some officers are getting frustrated with it. You can have the same officer that revived the same person two or three times… They’ll say, ‘We did this person again’ or ‘We did him before.’ I tell them that’s part of the process, the relapse…” Perhaps there is a better way to look at it.  Instead of viewing Narcan use as enabling, it should be looked at as simply helping a fellow human being survive until they are healthy. One thing is fairly certain, however.  Unless they receive further treatment, most addicts eventually go back to using. Mark Gimbel, who for 23 years served as the Director of Drug Policy for Baltimore County, Maryland, says,  “Narcan will stop an overdose, but long-term, what can it do? The only thing that will change the behavior of an addict is a long-term treatment.”

Stigma: The Biggest Barrier to Addiction Treatment

“While drug addiction and mental illness are both chronic, treatable health conditions, the American public is more likely to think of addiction as a moral failing than a medical condition.” ~ Dr. Colleen L. Barry, Ph.D., MPP, Associate Professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health Toxic shame and guilt keep many people with a SUD from getting the help that they need.  And while the general public can be partially excused for not being knowledgeable about the “addiction as a disease” concept, what is surprising is how much bias exists among physicians. A 2014 Dutch study found significant differences in how physicians may view addicted patients.  These attitudes largely depended on how much training and experience working with substance abusers the doctor had.  Of special relevance, physician bias can negatively affect treatment outcomes. The research suggests that doctors trained as general practitioners typically have the lowest level of regard for people with SUD. Psychiatrists who were not additionally trained as addiction specialists have an intermediate level of regard for SUD patients, while medical professionals who received specific training on substance abuse matters have the highest opinion of affected patients. Negative attitudes may include:

  • Fear toward substance users
  • Anger toward substance users
  • A belief that substance users are “to blame”

These results clearly show how important it is to improve training among doctors.

Changing the Paradigm

“We’re working hard to not create a one-drug system of care. We’re trying to use the money and attention to the opioid epidemic to support our efforts to build a robust addiction treatment structure that is integrated with our health care system so that any person with addiction can get the care they need.” ~ Kelly Pfeifer, Director, High-Value Care Team, California Health Care Foundation Learning from past difficulties, there are Emergency Departments in California, Massachusetts, and some other states that are trying to improve the long-term outcomes for patients seen for drug-related issues. They are attempting to start treatment for SUD in the ER, similar to what is done for patients with other chronic ailments, such as diabetes or heart disease.  In those cases, the patient being seen it isn’t just stabilized, given a pamphlet with a few talking points. Instead, they are given medication that is specific to their illness and they typically meet with a highly-trained specialist to discuss their health needs. This approach has shown to be highly effective in helping patients with addictive disorders, as well. In 2015 a study conducted by researchers at the Yale School of Medicine looked at three interventions for opioid-addicted patients who sought emergency medical care. The first group was merely given a handout containing contact information for local addiction services. The second group received a short, 10- to 15-minute interview session with a researcher who provided information about local treatment options and who helped the patient connect with the program of their choice, even going so far as arranging for transportation. The third group got the same interview, an initial dose of the anti-craving medication buprenorphine, additional take-home doses, and an appointment – within 72 hours – with a primary care provider who could continue the buprenorphine treatment. This is known as a “warm handoff”, referring a patient while the needs and interest are still high. The study found that 78% of patients in the third group — the buprenorphine group — were still in treatment 30 days later, compared with just 45% in the group that was interviewed and 37% who were only given the handout.

The Gold Standard of Addiction Treatment

The majority of opioid users would not stop using opioids without medication-assisted treatment. Could people go cold turkey and stop? Maybe, but their long-term success is better with the medications. Medication-assisted treatment (MAT) helps people get through the cravings and withdrawal so they can manage some of the other things that are essential to recovery.” ~ Chrissy Smith, Human Service Center The use of FDA-approved drugs to reduce cravings and alleviate withdrawal symptoms is known as Medication-Assisted Treatment.  The combination of medication and other evidence-based treatment strategies such as behavioral counseling and group therapy is highly effective and is considered to be the “gold standard” of addiction treatment. Up to 70% of patients receiving MAT are able to remain substance-free for a year or more. In addition, MAT patients are more likely to:

  • Stay in treatment longer.
  • Complete treatment.
  • Refrain from drug or alcohol use throughout treatment.
  • Remain substance-free at follow-up assessments: three months, six months, and one-year.
  • Reduce criminal behavior.
  • Have better employment rates.
  • Remain married.

Currently, there are almost three dozen approved medications that can support a successful recovery from addiction. Specifically for opioid addicts, methadone and medications containing buprenorphine are the most common pharmacological options. But because it has several advantages over methadone, buprenorphine is becoming more widely used. Methadone’s effects increase with dosage, but buprenorphine’s level off at a plateau, due to a “ceiling effect” that does not increase, even when more is taken. This means a patient receiving buprenorphine cannot get high from ANY opioid. This is crucial when it comes to preventing fatal opioid overdoses. Because of the ceiling effect, the danger of respiratory depression is much less than it is from methadone. Buprenorphine SAVES lives. In France, buprenorphine use reduced heroin mortality by 50%.  And in Baltimore, there was a 37% heroin mortality decrease.

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What Are Some Possible Solutions?

Everything we’re talking about is what we do for every other health condition. This is really just bringing addiction treatment into the medical mainstream.” ~ Dr. Sarah Wakeman, Medical Director, Massachusetts General Hospital Substance Use Disorder Initiative There is no one single solution that is going to completely curb the opioid epidemic or the drug crisis that the fuels.  But each small step, when used in combination with the others, adds up and makes a difference. To sum up, some possible solutions include:

  • Better substance abuse training for doctors, nurses, and first responders
  • Implementation of policies that make it easier for ER doctors to hold overdose patients longer
  • Improved drug screening
  • On-staff addiction specialists who can meet with every substance-abusing patient
  • Sensitivity training to avoid bias and stigma
  • MAT
  • Appointment to see an addiction specialist scheduled within 72 hours of discharge
  • Improved follow-up calls and apartments

The biggest takeaway from all of this is that the drug crisis in America requires a change in the way we think and act about addiction.  Initiating treatment during an ER visit is a powerful tool that has the potential to save tens of thousands of lives every year. As Dr. Gail D’Onofrio, the Chair at Yale Medicine, says, “They are already in your ED because they’re there with withdrawal or other complications. … In fact, you got a good chance you’re going to reduce your ED visits once you get them into treatment.