Facing the Opioid Emergency
Highland Hospital ER is seizing the moment with opioid addiction treatment.
A homeless man estranged from his family and infant son. A well-groomed middle-aged businessman. A young woman and her partner. A man in his 20s, also homeless. And all addicted to opioids, either prescription medications such as oxycodone (OxyContin), hydrocodone (Vicodin), and fentanyl, or street drugs like heroin.
The face of opioid addiction is remarkably complex, explained Dr. Andrew Herring, an emergency medicine specialist at Highland Hospital. “We see patients with opioid-use disorder aged 16 to 74—men, women, homeless, working.”
Often there is a history of chronic pain from an injury or surgery. The patient gets a medical prescription for opioids for the pain and that leads to addiction. When the prescription runs out, he moves on to illicit pills or heroin. Addiction often stems from the recreational use of pills, heroin, and smoking opium as well.
Herring is finding that the emergency department is the perfect place to approach patients about addiction treatment. As he describes it, it’s like seizing the moment. “People coming in with opioid addiction often want a change and are willing to participate in their treatment. They just don’t know how to get help. There can be this moment in the emergency room, when the patient is in withdrawal and in pain, when we can connect.”
Because the emergency department is open 24/7, routinely manages crisis, and accepts walk-ins, patients don’t face the barriers to treatment that are present in the outpatient setting, like needing an appointment, he added.
In February, Herring launched a program in the emergency department at Highland Hospital to identify patients addicted to opioids and transition them into addiction treatment. “It’s been an incredible success,” said Herring. In July, the program had 12 patients referred from the ER who were in active treatment for their addiction, and he estimated that the program had worked with more than 50 others.
Herring has trained all of the ER staff to be alert for patients who might be dealing with opioid addiction and to look for signs of withdrawal like severe abdominal pain, shivers, watery eyes, aches, and pains. If a patient experiences moderate to severe withdrawal, he may recommend treatment with Suboxone or buprenorphine, medications that suppress withdrawal symptoms and decrease cravings associated with opioid addiction. Herring and his team are also employing alternatives to opioid prescriptions for pain treatment, like regional anesthesia, acupuncture, and non-opioid meds like lidocaine, gabapentin, ketamine, and magnesium.
“People have to be ready for recovery. It often takes more than one ER visit and multiple points of engagement,” said Christian Hailozian, a key member of Herring’s team.
When an ER physician identifies a patient who is opioid dependent and may be willing to seek treatment, Hailozian gets paged. His job is to bridge the patient to care for their addiction. Hailozian presents the options: Highland’s outpatient treatment center where the patients can get psychosocial support, possibly more Suboxone to help them through withdrawal, and access to support groups meetings.
But not all patients cross the bridge. Hailozian described a man he worked with a few months earlier. “He was in his 40s and had been struggling with opioid addiction since his 20s. When he arrived at the ER, he was heavy in withdrawal. He listened to the treatment options outlined, but said, ‘I’m not ready.’”
Drug overdose is the single largest cause of accidental death in the United States today, and opioids are driving the epidemic. In 2015 (the most recent year for which statistics are available), 2 million Americans were struggling with prescription pain medication addiction and 591,000 were addicted to heroin. Together prescription opioids and heroin led to over 33,000 overdose deaths that year. “It’s a huge public health issue right now,” said Herring. “It affects urban, suburban, and rural communities. It’s everywhere.”
And Oakland and its neighbors are not immune. In the same year, there were 165 emergency department visits and 63 deaths due to opioid overdose in Alameda County.
Savannah O’Neill, project coordinator for the Overdose Prevention Education and Naloxone Distribution Program in Alameda County, said looking at overdoses and deaths underestimates the problem. (Naloxone, sometimes called the “rescue shot,” blocks the effects of opioids and can bring someone back from an overdose.) “It’s difficult to get a complete picture, because the data are hard to collect and there are huge numbers not in treatment,” said O’Neill. But from her experience, she believes that, like the rest of the country, opioid abuse has been growing in Alameda County since 2012. And, the number of prescriptions written contributes greatly to the current opioid epidemic. In Alameda County, opioid prescriptions were written at a rate of 536.3 prescriptions per 1,000 residents in 2015, roughly equal to one prescription for every two residents of the county.
There’s a large economic cost of the pain and withdrawal cycle of opioid addiction, too, said Herring. Patients will come to the ER and feign illness to get pain medication relief. Clinicians in turn run blood tests and scans trying to identify the cause of the pain, all unnecessary, resulting in a huge waste of money and time. Herring’s goal is to bring opioid addiction “into the light,” to de-stigmatize it. “I want our patients to know it’s OK to talk about their addiction and to be able to say, ‘I’m in trouble and want help.’”
That is what happened with the patient Hailozian had worked with months previously but had refused treatment: The patient came back to Highland’s ER. Hailozian got paged. “He said he wanted treatment, and today he’s meeting with Dr. Herring. We always engage with these patients and encourage them to come back to the ER. We let them know the door to treatment is always open.”