New Haven, Conn. – A new clinical study is one way Connecticut is getting to the bottom of a serious problem that crosses all economic, social and racial boundaries – opiate addiction. Prescription drugs like oxycontin, percocet and lortab issued for acute pain such as an injury and chronic pain associated with a debilitating disease are more and more developing into addictions for the patients they are given to. What’s worse – after the well of painkillers runs out for the addicted, a common alternative is the cheaper and more accessible heroin. One doctor we talked to at Yale University has dedicated much time and effort in finding a solution to the epidemic.
“I think the most important question we had is how we can get more people into treatment,” says Dr. Gail D’Onofrio, Professor of Emergency Medicine and Chair of the Yale University Department of Medicine. “Because we know that opioid addiction is an escalating problem in the U.S..”
Dr. D’Onofrio teamed up with other doctors to conduct a study on medically assisted addiction treatment. Since those patients are often seen in emergency departments, the team looked at 3 different methods of getting patients the treatment they need.
The first was the referral method. From the emergency room, the doctors would refer them to treatment. Based on the patient’s insurance and wishes they gave them potential places for them to go and access to a phone call. The second was a brief intervention and facilitated referral to community-based treatment services. Based on their insurance and preferences they would facilitate direct linkage to the treatment center, eliminating barriers such as obtaining insurance clearance and arranging transportation to the treatment center. The 3rd group received the brief intervention, ED-initiated treatment with buprenorphine/naloxone and a referral to primary care within 72 hours for medical management and continued buprenorphine treatment for 10 weeks.
While it was hypothesized that the 3rd group would be more likely to remain in treatment 30 days post that initial visit, the results were astounding. The 3rd group was twice as likely to remain in treatment than the other two groups combined. Around 38% of the first group was in treatment 30 days later, followed by 47% in the second group, and 78% in the third.
“We interviewed patients at 30 days regarding their past 7-day illicit opioid use,” says Dr. D’Onofrio. “And found that people that were in the buprenorphine group were less likely to use an illicit opioid. Less than once a week versus 2 or more times in the other groups.”
The doctors found little difference in HIV risk scores or urine samples (opioids stay in the system up to 3 days and therefore one does not know the intensity of use – the patient may have used once in that timeframe or 20 times). With each use there are potentially harmful events such as overdose, HIV transmission, etc. Dr. D’Onofrio believes it’s a new paradigm in intervening. Doctors could start treatment for this chronic disease of opioid addiction and refer for continued care, similar to what they do with other chronic diseases such as hypertension and diabetes.
“Buprenorphine is by definition a partial agonist,” says Dr. D’Onofrio. “That decreases craving and withdrawal symptoms. It is a medication with less side effects than methadone.”
While there may be some diversion on the streets, persons with opioid addictions are using this drug to feel less dope sick, not for a “high”.
“All addiction is a chronic, relapsing disease,” says Dr. D’Onofrio. “When someone is a diabetic, they might binge for example on a birthday cake and their blood sugars may be elevated, but we get them back on track without the stigma that is associated with a relapse in patients with drug addictions.”
The doctor’s theory is that recovery depends on a lot of factors. The patient’s motivation to change, their ability to remove themselves from friends and environments where drugs are used, accessing treatment for underlying mental health issues, etc. These issues are important, as is the administering of medication therapies such as buprenorphine.
Dr. D’Onofrio says in addition to Connecticut’s battle with opioid abuse, the emergency department sees lots of other drug use such as cocaine, stating that about 50% of the patients who needed treatment for opioid abuse also used cocaine. Alcohol, however, is still the number one drug that we see the negative consequences of every day in every emergency room.
Opioid abuse in Connecticut, like other states, knows no economic or social boundaries. It is mostly in Whites but occurs in every education level and financial status. Most patients start with prescription drugs and found they couldn’t support their habit – which can cost hundreds of dollars a day. They then switch to the cheaper and more accessible heroin.
While the buprenorphine assisted treatment proved to be successful, Dr. D’Onofrio says there are still a lot of barriers. Doctors have to take a course and achieve a special waiver to prescribe the drug, yet physicians can prescribe thousands of oxycodone pills without taking any additional courses other than their medical school training.
Dr. D’Onofrio says buprenorphine should be a part of any doctor’s training. Doctors should be educated about medication therapies for drug dependence in the same manner that they are educated for all types of drug therapy. “The amount of barriers we put in place for people battling addiction is enormous and we need to find innovative ways to narrow the gap between treatment need and service.” says Dr. D’Onofrio. Right now physicians with special waivers have restrictions on the number of patients they can treat at one time. We need to address this.
There are a number of reasons that a person can become dependent on opioids. Perhaps they had surgery or broke their arm and are given 100 oxycodone tablets, find they have a problem stopping then and then start doctor shopping. With the prescription monitoring programs that all states now have but one, we are better able to prevent multiple doctors prescribing multiple prescriptions. However, the most important thing is for doctors to screen their patients for opioid problems and dependence, and to start the conversation with them to engage in treatment in needed, and not just try to push the problem down the road.
Legislation is being sought as well. New Haven home to one of the first needle exchange programs, is working on a Good Samaritan Law to make Naloxone (a known antidote for opiate overdose) more accessible. The drug is already available for all first responders, emergency medical services and fire personnel and can be obtained from pharmacies without a prescription.
“The last shift that I worked, I had to pronounce a young man who died of an overdose,” says Dr. D’Onofrio. We need to have naloxone available to friends and family members and as many first responders as possible.
Education is key for providers, Dr. D’Onofrio goes on to say, for not prescribing large amounts of short acting opioids.
“When someone gets their wisdom teeth taken out, they may not need 20 pills of oxycodone,” says Dr. D’Onofrio. “A patient may not need a month’s worth of opioids for an injury. We need to make sure that we only give out what we have to for acute short-term pain.”
For chronic diseases, Dr. D’Onofrio says we need to come up with alternative medicines and innovative therapies for treating chronic pain like stimulators, massages therapy etc. She says we need to stop jumping to opioids when patients are complaining of pain. More physician education and access to treatment services are needed.
Dr. Gail D’Onofrio is Professor of Emergency Medicine and Chair of the Department of Emergency Medicine at Yale University School of Medicine. Her research interests include the screening, treatment and referral of ED patients with alcohol and other drug problems. She is internationally known for her work in developing the Brief Negotiation Interview, and testing models of care for ED patients with alcohol and drug problems throughout the spectrum of severity. Her research has been funded by NIAAA and NIDA. She is also dedicated to training physicians and other health professionals in screening, intervention and referral for substance abuse and she is funded by a SAMSHA training grant. In addition she has a K12 from NIDA, “Drug Abuse, Addiction, and HIV Research Scholars (DAHRS)” to prepare investigators for careers focusing on drug abuse, addiction and HIV in general medical settings.
She received her M.S. from Boston University in 1975 and her M.D. from Boston University School of Medicine in 1987. She completed her Emergency Medicine residency at Boston City Hospital in1991and a SAMSHA faculty development fellowship in1997.