In this exclusive interview with a highly acclaimed emergency physician, learn how one hospital emergency department has been impacted by the opioid epidemic, effective solutions they’ve developed to help their community, and steps you can take to protect you and your family from becoming victims.
The statistics are sobering:
• Of the 20.5 million Americans 12 or older that had a substance abuse disorder in 2015, 2 million involved prescription pain relievers.
• Drug overdose is the leading cause of accidental death in the U.S., with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers.
• In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills.
• 4 in 5 new heroin users started out misusing prescription painkillers.
• Between 1994 to 2007, the prescribing rates for prescription opioids among adolescents and young adults nearly doubled.
• Most adolescents who misuse prescription pain relievers are given them for free by a friend or relative.1
In light of these startling facts, on August 10, 2017, President Trump declared the opioid crisis a “national emergency,” which enables the executive branch to direct funds toward expanding treatment facilities and arming police officers with naloxone, an anti-overdose medicine.
No area of our healthcare system has remained untouched, including emergency departments, which treat more than 1,000 people a day for misusing prescription opioids.2 Mark Rosenberg, DO, Chairman of Emergency Medicine for St. Joseph's Healthcare System in Paterson, New Jersey, and a member of the board of directors for the American College of Emergency Physicians, has seen his fair share of opioid abuse.
Here is an excerpt of my interview with Dr. Rosenberg:
What initially prompted your interest in this area?
Pain—whether it be from a terminal illness, a fall, a fracture—is one of the number one complaints for people coming into the emergency department (ED), yet emergency medicine as a specialty hasn’t done a great job managing pain historically. We arbitrarily use different drugs for treatment, and we don’t typically track results after people leave the ED. Over the past several years, I've had a front-row seat to the effects of the rise of the opioid crisis—its move from urban outlying neighborhoods into main street suburbia. I work with a nurse who had to resuscitate her teenage son three times due to heroin overdose. I've never seen anything like this and felt compelled to do something about it. I decided my goal was to create THE best pain management program in emergency medicine—to come as close to creating an “opioid-free” ED as possible.
This seems like a daunting task. Where did you begin?
We implemented two major initiatives at St. Joe’s—the first was to aggressively manage pain using alternatives to opioids whenever possible. The second was to start medical assisted treatment on people who present to the ED with dependency or an overdose. To attack the first step, we initiated a pain management fellowship. Our initial fellow and I conducted an exhaustive review of the literature of all pain articles worldwide. We looked for the most common complaints in the ED as well as best practices for non-opioid treatment. From this, we formalized non-opioid treatment protocols for the top five most common diagnoses. The program, which we named ALTO (alternatives to opioids), was a huge success. In its first year, we reduced the number of opioid prescriptions within our ED by 57 percent. We have shared ALTO with other EDs across the country, and it has garnered significant interest by local, state and federal politicians.
You mentioned the second step was to help those who already presented with dependency. How did you go about doing that?
We had a large number of patients presenting to the ED who were already addicted to opioids or heroin, so we put them on an aggressive medical assisted treatment program that included counseling with former heroin addicts who are in recovery. This program was also successful, realizing a 50 percent recovery rate for those who came into the ED to rid themselves of dependency.
What is the connection between opioid abuse and heroin?
Studies show that four out of five heroin addicts started as opioid abusers. Once addicted to pain killers, it’s often difficult to get ongoing prescriptions, and opioids can be expensive to buy illegally. For example, on the streets of Paterson, New Jersey, a dose of Oxycodone costs about $30, whereas heroin costs roughly $2. It’s easy to see how people can change their habit based on economics. If we can reduce the dependency on opioids, we can reduce the number of people who transition to heroin.
What do you think people would find surprising about opioid addicts?
I think most people have a certain impression of addicts, but the reality is that opioid addicts come from all walks of life. It’s the 17-year-old high school football player that lives next door to you. It’s the 40-year-old housewife you go to church with. It’s your co-worker. One alarming trend is that we see many people with very physical jobs—professional athletes, construction workers, acrobats, dancers—become addicted because they are prescribed opioids for work-related injuries. It impacts everyone.
What factors do you think contributed to this epidemic?
There are so many, and it’s very complex. Years ago an article came out that stated opioids were non-addictive, safe to use for acute pain and should not be withheld from patients in pain. So we went down this prescribing path that we believed was benign and patient-friendly. Additionally, federal agencies and patient satisfaction surveys asked patients to rate their physician on how well they managed their pain. In my pain management “tool box,” I have Tylenol, Motrin, some other minor medications, and then Percocet. I have one chance to make you feel better, so I’m going to go for the strongest medicine that I know will take care of the pain. Doctors were incentivized for zero pain—prescribing opioids was the solution. ALTO puts more tools in our tool box—it gives patients more options.
So it requires a change in thinking, does it not? For both physicians as well as patients.
Exactly. It’s a different set of expectations. The goal isn’t necessarily total elimination of pain—it should be on function. What can we do to help you better function with the pain you have. We still aggressively address pain, but we look at alternative approaches and a different pain goal, not necessarily zero pain. It takes much more time on the physician's part. It only takes me 30 seconds to write a prescription for a pain med; it takes me 20 minutes to go down an alternative route and explain to a patient why this is the best option. And if I do determine that I need to prescribe an opioid, I have a very in-depth conversation explaining the appropriate way to take the medication to avoid the risk of addiction.
Was there an impact on your patient satisfaction scores after implemented ALTO? And were there any unintended outcomes?
Interestingly, patient satisfaction increased for our ALTO patients—those presenting with pain—despite the decline in prescribing. We spent more time talking with them, and we demonstrated that we cared about addressing their pain but didn’t want to risk addiction. As would be expected, we saw a decrease in the number of drug addicts who came to our ED for pain meds. However, we saw an increase in patients within certain demographic groups. For example, the number of pediatric patients increased, as parents wanted their children to go to a non-opioid ED. In our geriatric ED, we saw an increase in the number of people bringing in their parents and grandparents who also wanted opioid alternatives for their loved ones’ pain. And we saw an increase in people who formerly had addictions and didn’t want to risk addiction again.
Are there opportunities for ALTO beyond just the ED?
Absolutely. The largest number of initial opioid prescriptions come from the ED, but other specialties are responsible for most of the ongoing prescribing—primary care physicians, orthopedists, dentists—any specialty that tends to see a large number of patients in pain. ALTO should work with all situations of acute pain and, if opioids are needed, then the opioids can be combined with ALTO medications or protocols. Even patients who are currently on opioids for chronic pain can institute ALTO protocols to help decrease the opioid dose.
What advice do you have for individuals/consumers on how they can minimize the risk of opioid addiction for themselves or their family members?
1. If you need treatment for pain, talk to your doctor about alternatives to pain medications. Keep in mind that the goal isn’t necessarily to completely eliminate your pain—it’s to minimize it to the extent that you are functional.
2. If you both agree that an opioid is your best alternative, be sure you fully understand the risks. Talk to your doctor or pharmacist to make sure all your concerns are addressed.
3. Take the medication according to your physician’s directions, and stop taking it as soon as possible. Unlike antibiotics, you do not need to finish the prescription.
4. Make sure to get rid of any leftover medications appropriately. All states have different protocols for the elimination of opioids—review your state’s requirements and follow them accordingly.
5. Never take someone else’s medication for your own pain, and never give your medication to anyone else. While well-intended, there can be serious consequences for taking pain medications without physician guidance.
6. Consider natural alternatives—there are studies that have demonstrated significant pain improvement for chronic pain sufferers from activities like listening to music, acupuncture, yoga and meditation. These could be considered in addition to your doctor’s recommended therapy.
7. If you believe you or a loved one has become addicted to pain medications, seek help immediately. The sooner the addiction is addressed, the better the chance of overcoming it.
If you read articles on this topic, there are many opinions on who is to blame for the opioid crisis—the drug companies who make them, the physicians who prescribe them, the patients who abuse them, or the lawmakers who let it happen. We need to shift the discussion from one of blame to one of healing. Regardless of how we got here, all constituents need to work together to identify innovative and effective solutions to effectively manage pain in ways that reduce existing addictions and prevent future cases. Thank you to Dr. Rosenberg for sharing this success story.
By Tracy Young, Founder & CEO, TWYOUNG Consulting
1 American Society of Addiction Medicine, Opioid Addiction: 2016 Facts and Figures.
https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf
2 Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. The DAWN Report. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2013. http://www.samhsa.gov/data/2k13/DAWN127/sr127-DAWN-highlights.htm
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