As an emergency medicine physician at the University of Maryland Medical Center, Dr. Gentry Wilkerson has seen more and more overdose patients in recent months. The facility averaged about 0.5 per day in 2015, but jumped to 1.2 per day in 2016.
Besides witnessing life-threatening crises, Wilkerson is also seeing patients with significant health complications from opioid abuse. The cases range from an abscess formed at an injection site all the way up to endocarditis, an infection of the heart valves that can lead to open heart surgery.
“We realize that you want to treat the opioid epidemic in a multi-pronged fashion, and part of that is trying to get people into recovery, but also recognizing that some people are not going to recovery [in that moment] so you want to mitigate their potential for harm,” Wilkerson said. “Part of that is by getting them access and training to the antidote naloxone.”
Minnesota reported 336 deaths in 2015 linked to excessive or abusive use of prescription opioids or illicit versions of the drug, such as heroin. That death count is six times the number of cases in 2000. Minnesota Attorney General Lori Swanson is promoting the “Dose of Reality” media campaign to warn people of the dangers of misusing or overusing opioid painkillers.
The opioid epidemic is also scarring lawmakers and judges across the country, with the increasing caseload the drugs themselves bring and the attendant problems that follow.
The state now offers an adult drug court, a juvenile drug court, and a family dependency treatment court, along with other treatment courts that seek to address the addiction not just the crime or child neglect that ensues.
The Minnesota Legislature is considering five bills this session dealing with opioid addiction, including the accessibility of naloxone. House File 770/Senate File 563 allows pharmacies to be paid directly by the MA program for nonscheduled injectable drugs used to treat substance abuse that are administered in an outpatient setting. It is sitting with the House Health and Human Services Finance Committee but has not been referred to the Senate.
House File 1134/Senate File 752 would amend Minn. Stat sec. 152.11 by limiting the time for filling or refilling a prescription for an opioid to 30 days after a prescription is issued or was first dispensed. It is in the House Health and Human Services Reform Committee and the Senate Health and Human Services Finance and Policy Committee.
House File 1135/Senate File 751 requires disclosures about addiction and other information to the patients or the patient’s caregiver. It is before the House Health and Human Services Reform Committee and the Senate Finance Committee.
The Prescription Monitoring Program would become mandatory under H.F. 1137/S.F. 753 Under current law, prescribers and dispensers are required to maintain a user account with the program, but are not required to access the prescription electronic reporting system when prescribing or dispensing an opioid or other controlled substance. It is before the Civil Law and Data Practices Policy Committee and the Senate Health and Human Services Finance and Policy Committee.
Pharmacists could prescribe opiate antagonists under H.F. 1140 and S.F. 1049, now before the House Health and Human Services Reform Committee and the Senate Health and Human Services Finance and Policy Committee.
In December, UMMC rolled out a new program where Wilkerson and three other staff members trained individuals who sought treatment for suspected overdoses in the emergency department on how to use naloxone. Each person received a certificate giving them a blanket prescription to purchase naloxone without a doctor’s signature. Friends and family of the individuals could also receive training during the individual’s treatment with the department. In early February, additional staff became proficient in providing training to patients and their loved ones.
“[We are] trying to capture them at a time when they are probably more likely to be receptive to these sorts of interventions,” Wilkerson said.
In the past few months, UMMC has begun another program aimed at helping individuals after an overdose. Emergency department patients who are interested may be given a dose of suboxone, a medication similar to methadone which curbs narcotic dependence. Patients are first assessed on the Clinical Opiate Withdrawal Scale (COWS) — an 11-point gauge used to understand each patient’s level of signs and symptoms of withdrawal.
“If [the patients] meet a certain number and are expressing a desire (to quit) and we are available to arrange rapid follow up, we will provide them with a dose of suboxone in the emergency department and a follow-up visit, ideally the next day,” Wilkerson said.
Across the country, other health care systems also are looking for ways to abate the opioid epidemic.
The Minnesota-based Winona Health stopped letting patients refill opioid prescriptions over the phone and now requires patients taking opioids to have face-to-face meetings with their doctors every three months. The health care system also opened the Conservative Management Clinic (CMC) in fall 2015 with goals of helping patients find safe and effective treatment methods to ease their pain levels yet also alerting them to risk of addiction with opioids.
In January 2016, St. Joseph’s Healthcare System in New Jersey launched the ALternatives To Opiates (ALTO) program. Instead of giving emergency room patients opioids to treat their pain, doctors are prescribing non-opioid medications, trigger point injections, nitrous oxide and ultrasound-guided nerve blocks to help them.
University of Kentucky Albert B. Chandler Hospital’s Chief Medical Officer and trauma surgeon Dr. Phillip Chang remembers the moment he realized doctors can play a role in stopping opioid addiction.
A man in his 20s was involved in a bad car crash, which resulted in staying several days at the facility. After discharge, he returned to the hospital several times saying he was in high levels of pain. “He continued to complain of pain to a degree that is out of proportion, if you will, from the injuries he has had,” Chang recalled. “He was a few weeks out. The amount of pain that he is describing is inconsistent with the healing part that he should have had. That is when we went ‘Hmmmm. Something is probably wrong.’”
Pulling reports from multiple doctors, Chang discovered the patient had received over 1,000 opioid pills in about a four to six week period from multiple physicians. He wasn’t a drug abuser before the crash, and physicians, individually, had only given him proper dosages. “That is when I realized that not only have we been part of the problem, but we can definitely be part of the solution,” Chang said.
Emergency department doctors now prescribe non-narcotics, particularly when a patient is switched from IV drip to pill form and only give narcotics as a last resort. The outcome thus far has been good, he said.
The hospital looked at 400 narcotic naive patients and compared the amount of narcotics patients were going home with before and after implementation. “The milligram equivalent of morphine almost got cut down by half,” he said. “We knew we were on to something.”
The numbers of patients being sent home without any narcotics also increased. “What was interesting with the study was that when we looked at patients that are already dependent or addicted to narcotics, we showed no effect,” Chang said. “This is a big problem and we recognize there is a multi-pronged approached. What we want to offer is the small piece of it which is the prevention part. We need to prevent patients from becoming addicted.”
Formal numbers could not be released because they are pending a study publication by the hospital.
Staff members are considering rolling out this protocol to a majority of the hospital, with the exception of cancer and hospice patients. When any doctor wants to prescribe narcotics, the internal medical system would ask them to consider giving non-narcotics instead.
“We are not inconsiderate of [patient] pain,” Chang said. “In fact, we are thinking about it so much that we want to come up with the right combination of non-narcotics and narcotics, if necessary, to help them with their pain.