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The Opioid Crisis:

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Shara Martel

on 2 November 2018

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Transcript of The Opioid Crisis:

The Opioid Crisis

Emergency Physicians as Innovators, Policymakers & Heroes

Faces of Addiction


The 100 Years Leading to the Current Crisis
Robert Heimer PhD
Professor of Epidemiology & of Pharmacology
Director, CT Emerging Infections Program
20.1 million Americans > 12 years of age
have a substance use disorder

2.1 million have a opioid use disorder

3.3 million report non-medical use of
pain relievers in the past month
Overdose Death Rates
Special Populations
Start Young With Prevention
Addiction is a disease NOT

a Moral Failing
Anxiety Irritability Restlessness Insomnia Nausea Abdominal Cramps Aching bones Aching muscles Sweating
What does it feel like to have opioid use disorder?
From “Narcotic Blockade” by V.P. Dole, M.E. Nyswander and M.J. Krock, 1966, Archives of Internal Med

What does it feel like when taking
opioid agonist treatment?

Advantages of Opioid Agonist Treatment
Reduction in illicit substance use
Less viral hepatitis, HIV, & IV drug use complications
Reduction in risk of opioid overdose and death
Reduction in risky behaviors
Reduced risk of legal consequences
More time available to
-Have sustainable relationships
-Find gainful employment
-Deal with other medical problems
Endorsed By
"These medications ... are the current standards of care for reducing illicit opioid use, relapse risk and overdoses... However, limited access... can create barriers to treatment."
NEJM, June 2017
Because that's where the patients are!
Options for ED Providers
Initiation of
(FDA 2002 Specially trained MDs/Exemptions)

A Randomized Trial of ED-Initiated
Interventions for Opioid Dependence
JAMA, 2015
The Opioid Crisis From
Research to Practice
Jesse McCauley (24 years old)

Nov 6, 2015
One of 3 brothers to die of an overdose
Steven Cagno (17 years old)

Rockland, Massachusetts
Newton, New Jersey
Died on Aug 12, 2016 from an overdose on the floor of his sisters room. He had just started snorting fentanyl. His father passed away just 9 months later of cancer. Family of 5 is now a family of 3.
Max Slade, (25 years old)
Albuquerque, New Mexico
Died from a heroin overdose on June 7, 2014. Struggled with substance use for many years and turned to heroin 6 years prior to his death.
Antonio, Gibson (35 years old)
Akron, Ohio
Nick Tupper (27 years old)
He overdosed on July 10, 2012. He died when his girlfriend was 4 months pregnant with his daughter
Stuart, Florida
Died of an overdose of on March 21, 2017. Nicky loved his family, his dog and music
Gregory Zemp (48 years old)
Overdosed July 17, 2017 of a combination of oxy, morphine, fentanyl and ketamine.
Bothell, Washington
Laura Beth (21 years)
Freeman, Missouri
Died from a drug overdose on September 30, 2017. She loved all kinds of animals, travel and christmas lights.
Michelle Minard (65 years old)
Died of an overdose July 1, 2016 and struggled with drugs most of her life. She had 3 children and 6 grandchildren one of which she never had the chance to meet.
Los Angeles, California
Nicholas Lopez (Age 21)
An only child Nick died of a heroin overdose on March 12, 2017
Phoenix, Arizona
Safe Prescribing
Dec, 2017
Access to MAT
Reducing the stigma
Lauren Whiteside MD, MS
Harborview Hospital -
Seattle, Washington
Joan Papp MD
Metro Health
- Cleveland Ohio
Founder and Medical Director of Project DAWN (Deaths Avoided With Naloxone)
Michael Lyons MD
University of Cincinnati
Cincinnati, Ohio
Leads a naloxone access program that aims to include the distribution of naloxone by 400%
Elizabeth Samuels MD, MPH
Rhode Island Hospital - Providence, Rhode Island
Led the levels-of-care implementation for the Rhode Island Department of Health
Started PreventOverdoseRI.org

30% ED Visits for Opioid Overdose
July 2016 - September 2017
MMWR March 9, 2018
Jeanmarie Perrone MD
University of Pennsylvania,
Philadelphia, Pennsylvania
Eric Ketcham MD, MBA
San Juan Regional Medical Center -
Farmington, New Mexico
2016- Joint venture with closing methadone clinic and hospital and took over as clinic medical director
2nd largest ED referral source

Krista Brucker MD
Eskenazi Health -
Indianapolis, Indiana
Project POINT
(Planned Outreach, Intervention, Naloxone & Treatment)
The way we about addiction
The way we addiction
Opioid Overdose Deaths
Source: CDC National Vital Statistics System
Naltrexone (Vivitrol)
Super Heroes Are Here
EM Leaders Across the U.S.
Scott Weiner MD, MPH
Bringham and Womens Hospital
- Boston, Massachusetts
Director of B-CORE: The Brigham Comprehensive Opioid Approach and Education Program.
Ester Choo MD, MPH
Ryan McCormack, MD
Bellevue Hospital,
New York - New York
Rachel Haroz MD
Cooper University Health Care
Andrew Herring MD - HigHland hospital
And Lets Change
The way we about addiction
CDC National Syndromic Surveillance Program NSSP
Effects of Buprenorphine on m-Opioid Receptors
Greenwald MK. Neuropsychopharmacology (2003)
Drug Overdose Death Rates 1999-2016
Source: NCHS National Vital Statistics System, Mortality
Reduce OD Deaths
NSDUH, 2017
March 2018
-Bipartisan agreement-
Opioid allocation:
billion for efforts toward prevention, treatment and law enforcement initiatives.
What is NOT considered evidence based treatment?
Detoxification only
Abstinence-oriented therapy
Mutual support programs
Naloxone (Narcan)
Pure antagonist
Requires 7-10 day detoxification
Injectable or pill form
No potential for abuse or diversion
Has a higher cost than buprenorphine or methadone

Yale SBIRT website:

Yale DAHRS website:
Addiction Treatment

Effective Treatments for Opioid Use Disorders
Medication-Assisted Treatment (MAT)
The use of medication, combined with counseling and behavioral therapies to provide a whole patient approach to treatment of substance use disorders
Myth: Offering treatment will increase visits
Lee et al., Lancet 2017
What is the future?
July 2016 - September 2017
MMWR March 9, 2018
CDC National Syndromic Surveillance Program NSSP
Offering treatment will NOT increase visits
Visits for Opioid Overdose
Harm Reduction
Treatment Gap
So Why the ED?
Overdose deaths during expansion
of methadone and buprenorphine in France 1996-2003
Emmanueli, Addiction 2005
Drug users using medication treatment
Heroin OD deaths during expansion of methadone & buprenorphine in Baltimore 1995-2009
Schwartz, AJPH, 2013

MAT and Opioid Use Before and After Overdose in Pennsylvania Medicaid
Opioid prescribing and MAT changes from before to after overdose among medicaid enrollees who have a 3X higher risk of opioid overdose
Patients continued to have high prescription opioid use, with only slight increases in MAT engagement
Frazier W, JAMA 318.8 (2017): 750-752.
Access to Buprenorphine
Interactive-Web Portal
Reuben Strayer MD
Kate Hawk MD, MHS
Louis Nelson MD
Sergey Motov, MD
Alexis LaPietra DO
Jason Hoppe, DO
Gillian Beauchamp MD
Maryann Mazer PharmD, MD, MPH
R. Corey Waller, MD
Aimee Moulin, MD
Lynn Richardson, MD
Arjun Venkatesh MD, MBA, MHS
Research Into Practice
Bring Addiction Medicine into EM
Donald Stader, MD
only 1 in 5 get treatment
NSDUH, 2017
What Role can Emergency Physicians Play in this
Escalating Epidemic?
Joshua Elder MD, MPH, MHS
Tim Platts-Mills
James Galbraith MD
Erik Hess MD
photo credit: NIDA
The Science of Addiction
Reward Pathway
Drug Cues Stimulate Craving
Pictures of drugs and paraphernalia increases blood flow in the amygdala.
Disclosure Statement
Current grant funding:
Every day, more than 115 people in the U.S. die after overdosing on opioids.
CDC, 2016 Data

Provided funding for filming & production of
videos displayed on our interactive web portal
Virtually all corners of the U.S. impacted by drug overdose
Chronic Pain
Opioid Use Disorder
Combination of behavioral, environmental and
biological factors increase vulnerability
Genetic risk factors account for 50% of the
likelihood that an individual will develop addiction
Experimental Use
Methadone Buprenorphine Naltrexone
Nearly half of opioid related OD deaths involved fentanyl
31 trials (5430 participants)
Methadone and Buprenorphine are equally effective
Medications Addiction Treatment
Mattick et al., 2014
Amato et al, Cochrane Review 2011
What is NOT considered evidence based treatment?
Detoxification only
Abstinence-oriented therapy
Mutual support programs
Naloxone (Narcan)
Safe Prescribing
Harm Reduction
Joan Papp MD
Metro Health - Cleveland, Ohio
Founder and Medical Director of Project DAWN (Deaths Avoided With Naloxone)
Krista Brucker MD
Eskenazi Health - Indianapolis, Indiana
Project POINT
(Planned Outreach, Intervention, Naloxone & Treatment)
Overdose Education & Naloxone Distribution
Access to MAT
Shah A, MMWR, March 17, 2017
Past 7 Day illicit Opioid Use
Engaged in Treatment 30-Days
Cost-effective acceptability curve: base case analysis.
(a) Willingness-to-pay for a 1 percentage point
increase in the probability a patient is engaged
in treatment 30-days post-enrollment.
(b) Willingness-to-pay for 1 additional opioid-free
day in the past 7-days
Addiction, 2017
Project ASSERT
Health Promotion Advocates
University of Washington
Richard Rothman MD, PhD
Johns Hopkins
Lauren Whiteside MD, MS
Michael Lyons MD
University of Cincinnati
Lynn Richardson MD
Mt Sinai
STAT, Faces of Addiction, 2016 https://www.statnews.com/feature/opioid-epidemic/obituaries/
Kelly Doran MD
Jay Schuur, MD
Quality Improvement Measures
Opioid Initiative for dissemination
through a national quality network of EDs

Safe Prescribing
Ann Intern Med, 2018
Compton W - NIDA

Opioid-focused interventions,
best-practice toolkit
NIDA Clinical Trials Network: Opioid Use Disorder in the ED
Project ED Health
It is NOT simply replacing one drug for another
Ethan Cowan MD
Mt Sinai- Beth Isreal

Pragmatic trial to develop and test a user-centered clinical decision support to implement
ergency department-initiated
for opioid use
(at adequate dosing)
Opioid use
Retention in treatment
Only 72%

initiated XR-NXT
(204/283) vs
270/287 for BUP-NX p<0.0001
Relapse rates > XR-NTX
than BUP-NX (
65% vs


< 1/3 of Addiction Treatment Programs Use MAT
Clinical Trials Network: Initiating Extended Release Buprenoprphine for OUD in Low Resourced, High Intensity EDs
Ryan McCormack, MD
State Initiatives
Elizabeth Samuels MD, MPH
Change the trajectory of the opioid epidemic

Embrace science based treatments
Engage emergency physicians
Lead Investigator
Kate Hawk MD, MHS
Addiction is a chronic relapsing brain disease
It is NOT a moral failing
Reducing the stigma
The Other Medication for OUD

Once initiated both medications were equally safe and effective
Randy Knight, MD
1 Click!
Knudsen et al.,
J Addict Med
Adapted from “Narcotic Blockade” by V.P. Dole, M.E. Nyswander and M.J. Krock, 1966, Archives of Internal Med

Lancet, 2018
Randy Knight MD
Adapted from: National Council for Behavioral Health
CORE, 2016
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.).
Kerry Broderick, MD
Full transcript