To get a sense of how severe the opioid crisis is in the U.S., you can look at the number of fatal overdoses — more than 33,000 in 2015, according to the Centers for Disease Control and Prevention. That means, on average, 91 people are dying after overdosing on opioids each day. And for every fatal overdose, there are believed to be roughly 30 nonfatal overdoses.
Clinicians and researchers trying to get a handle on the epidemic look at those nonfatal experiences as opportunities to jump in and figure out whether there is overprescribing going on or whether the patient needs help getting treatment for an addiction. But a paper published Tuesday in the Journal of the American Medical Association, suggests such interventions don't happen often enough.
"This is a time when people are vulnerable, potentially frightened by this event that's just occurred and amenable to advice, referral and treatment recommendations," says Julie Donohue, associate professor of health policy and management at the University of Pittsburgh and senior author of the paper. "It's safe to characterize it as a missed opportunity for the health system to respond."
Using claims data from Medicaid patients in Pennsylvania from 2008 to 2013, Donohue and her colleagues looked at prescription opioid use and medication-assisted treatment rates before and after overdoses. Medication-assisted treatment numbers were based on documentation showing that a patient had been dispensed one of three drugs approved by the Food and Drug Administration to treat opioid addiction: buprenorphine, naltrexone or methadone.
While one might expect to see a big decrease in the filling of opioid prescriptions or a big increase in treatment rates among people who had experienced overdoses, this was not the case. The researchers found, for example, that among people who had overdosed on heroin, the filling of opioid prescriptions fell by 3.5 percent, while medication-assisted treatment increased by only 3.6 percent.
Even though medication-assisted treatment is considered the gold standard of treatment for opioid addiction, researchers found treatment rates to be low overall. Only 33 percent of heroin overdose survivors and 15 percent of prescription opioid overdose survivors had been dispensed buprenorphine, naltrexone or methadone within six months of an overdose.
Donohue says many hospital emergency departments are not adequately set up to serve or even screen patients with addiction. "They may not have strong connections to treatment providers. So they, at best, may leave patients with a list, but then there is no active follow-up," Donohue says. "People who are quite vulnerable and are at great risk for future overdoses are falling through the cracks."
Dr. Corey Waller, who trained in emergency medicine and is now senior medical director for the National Center for Complex Health and Social Needs, says medical teams often lack basic knowledge.
"The professionals that are supposed to be able to refer and treat don't have the training to know how and what to do," Waller says, pointing out that as a resident, he received less than one hour of instruction in addiction treatment.
Another problem, he says, is that emergency departments treat an opioid overdose as a toxicological problem, not unlike dealing with a patient who took too much Tylenol.
"But what that completely ignores are the psychological aspects of [addiction]," Waller says. "When you ignore that, you are fully ignoring the disease. And you're looking at the patient like a toxicological problem and not a human."
He says it's important to remember that opioid addiction changes people's brains in ways that keep them from making logical decisions, such as seeking out treatment after an overdose. "They're not putting a pros and cons list on the refrigerator," he says. "They're just reacting to a situation that feels very much like survival."
Dr. Yngvild Olsen, medical director for the Institutes for Behavior Resources/REACH Health Services in Baltimore, says the study confirms what many in the addiction medicine field have known for a long time: There's a need for interventions beyond what she calls the "usual standard of care, which has been to hand people a phone number or pamphlet and say 'Here. Good luck.' "
Olsen says such interventions are in the works. She points to a 2015 study by researchers at the Yale School of Medicine who tested three interventions for opioid-dependent patients who came to the emergency department for medical care.
The first group was given a handout with contact information for addiction services. The second group got a 10- to 15-minute interview session with a research associate who provided information about treatment options and helped the patient connect with a treatment provider, even arranging transportation. The third group got the same interview, plus a first dose of buprenorphine, additional doses to take home and a scheduled appointment with a primary care provider who could continue the buprenorphine treatment within 72 hours.
The study found that 78 percent of patients in the third group — the group that got a dose of buprenorphine in the hospital — were still in treatment 30 days later, compared with 45 percent in the group that only got the interview and 37 percent who only got the handout.
Based on the study, hospitals across the country are now discussing incorporating buprenorphine into emergency department care for patients who have overdosed, Olsen says. Several Baltimore hospitals have begun doing so. She is hopeful that such a system could provide new paths to treatment for people who need it, while not overburdening emergency department staff who are already stretched thin.
"Conceptually, it makes so much sense," Olsen says. "It is, in my mind, one of those landmark studies that really addresses how to take advantage of those missed opportunities that the JAMA research letter describes."
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