As an emergency medicine physician at the University of Maryland Medical Center, Dr. Gentry Wilkerson is seeing more and more overdose patients. 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.
He and his colleagues are trying to do something about it.
In December, the medical center rolled out a new program through which 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. 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 sort of interventions,” Wilkerson said.
In the past few months, UMMC has begun another program aimed at helping individuals after an overdose. Emergency department patients that are interested may be given a dose of suboxone, a medication similar to methadone that curbs narcotic dependence. Patients are first assessed on the Clinical Opiate Withdrawal Scale, or COWS – an 11-point gauge used to measure signs and symptoms of withdrawal in a patient.
“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.
The efforts in Maryland match efforts by health care systems across the U.S. as they try to blunt the opioid epidemic.
In Central Pennsylvania, Lancaster General Health/Penn Medicine is focused on improving how it transfers overdose patients from the emergency room physician to a treatment provider, a process known as a warm handoff.
LG Health is developing the handoff process in collaboration with Harrisburg-based Rase Project, a nonprofit committed to helping people find treatment and recovery. The new process may eventually be replicated in other local hospitals.
In the old handoff, overdose patients were discharged and handed a brochure with information about detox, treatment and recovery programs.
Under the new process, a certified recovery specialist from Rase Project, which has a location near the hospital in Lancaster, will visit the hospital within an hour of the patient’s arrival – if the patient agrees.
The recovery specialist will then chat with the patient about options, and see if he or she is willing to get help. Patients who are not interested or are unwilling can keep in touch with the recovery specialist and hopefully decide later to get help, said Alice Yoder, director of community health at LG Health.
LG Health is also working on emergency protocols with paramedics, so that when a patient receives naloxone, the hospital is notified so a recovery specialist can be there when the patient arrives.
From problems to solutions
Dr. Phillip Chang, chief medical officer and trauma surgeon at the University of Kentucky Albert B. Chandler Hospital, remembers the moment he realized doctors can play a role in stopping opioid addiction.
A 20-something man was involved in a bad car crash that resulted in a several-day stay 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 ‘Hmm. 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 given him only 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 they were going home with before and after implementation of their new protocol. “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.”
Staff are considering rolling out the protocol to most of the hospital, with the exception of cancer and hospice patients. When doctors want 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.”