Pubdate: Sun, 01 May 2016
Source: New Haven Register (CT)
Copyright: 2016 New Haven Register
Author: Esteban L. Hernandez


Dr. Leana Wen, a practicing emergency care physician and Baltimore's 
health commissioner, has seen what addiction does to patients.

Speaking to reporters this month in Baltimore, Wen recalled a 
patient, who developed an addiction and would lie about illnesses to 
ensure she had access to treatment, but then died of a heroin 
overdose after multiple attempts to get appropriate treatment.

"Our overall goal: We have to get people into treatment at the time 
that the need it," Wen said.

But the rate of fatal opioid overdoses has skyrocketed in the United 
States. Opioid-involved deaths more than tripled from 2000 to 2014, 
including an age-adjusted death rate increase of 210 percent from the 
same time span, according to Centers for Disease Control and 
Prevention. In 2014 alone, 28,000 people died of fatal opioid 
overdoses, according to the CDC.

Yet the medical community continues grappling with just how to offer 
treatment and care for the estimated 2 million people addicted to 
opioids, according to the National Survey of Drug Use and Health. 
There's at least 7.9 million Americans 12 and older who meet the 
criteria for an illicit drug use disorder, according to federal the 
Substance Abuse and Mental Health Service Administration.

Connecticut hasn't fared well in its fight to stop the spread of 
opioids, a drug class that includes illicit substances such as heroin 
and legal ones like oxycodone and morphine. The state's fatal death 
rate has mirrored the national trend, steadily increasing in the past 
five years: Connecticut has seen an increase of fatal overdoses 
involving opioids every year since 2012, when 195 people died from 
opioid substance use. Last year 444 people died of the same substance 
use, according to figures from the Chief Medical Examiner's Office. 
Overall, 723 people died of drug overdoses in 2015, up from 357 in 2012.

The state is taking more steps to stem the spread of opioid addiction 
and, by extension, perhaps curb the number of fatal overdoses, which 
have overtaken motor vehicle accidents as the leading cause of 
accidental deaths in Connecticut. The state's General Assembly passed 
laws expanding the availability of naloxone and provisions that spare 
first responders from liability and the House last week passed a bill 
that would limit the number of narcotics prescribed to patients.

The bill places a 7-day cap on opioid prescriptions in an effort to 
rein in what many called the "over-prescribing" of painkillers by 
doctors, reported. There is an exception clause 
included in the bill for those receiving long-term prescriptions from 
their doctors allowing them to exceed the 7-day cap.

Further, the U.S. Attorney's Office announced this month the 
launching of a coordinated, statewide initiative to provide a 
protocol for all municipal police departments to investigate fatal 
overdoses as crime scenes to help find the source of the drug. The 
state Department of Correction plans to expand methadone treatment 
for prisoners. Sen. Richard Blumenthal, D-Conn., released a 27-page 
set of recommendations, "Opioid Addiction: A Call for Action," April 
15 that offers suggestions on how states can address increases in 
substance use disorders related to opioids.

The scope and magnitude of the issue has reached the White House, as 
President Obama joined people in recovery and medical professionals 
during the National Rx Drug Abuse and Heroin Summit in March. 
Coincidently, he was joined by Wen during the discussion. Dr. Gail 
D'Onofrio, professor and chairwoman of emergency medicine at the Yale 
School of Medicine was there, too.

Obama's drug policy chief, White House's Director of National Drug 
Control Policy Michael Botticelli, also spoke to journalists in Baltimore.

Botticelli said the opioid epidemic came to the attention of medical 
professionals "in a dramatically different way."

"This was not a cartel from Mexico kind of pushing drugs in our 
community, this was basically, an epidemic generated by the 
over-prescribing of prescription medication within our medical 
community," Botticelli said.

According to the CDC, 249 million prescriptions were written in 2013 
in this country. The number of opioid prescription dispensed 
quadrupled since 1999, despite no change in the amount of pain 
Americans reported. Nearly 65 percent of people who use prescription 
painkillers acquire the drugs through friends or family, Botticelli said.

The proliferation of legal painkillers has a domino effect; the 
National Survey on Drug Use and Health found people addicted to 
prescription opioids were 40 times more likely to be addicted to 
heroin. Those who used cocaine were 15 times more likely to be 
addicted to heroin, while marijuana users were three times more likely.

But to prevent more fatal overdoses, it starts with addressing the 
disease - as soon as a doctor notices it.

Treatment options for opioid addiction

During the American Society of Addiction Medicine conference at which 
Wen spoke, the message repeated regarding treatment for opioid 
addiction was clear: There is no silver bullet for treating 
addiction. Most of the doctors and researchers who spoke specifically 
discussing opioid use disorders suggested an approach similar to the 
one Wen described as the most beneficial form of treatment.

Wen ascribes to American Society of Addiction Medicine's definition 
of addiction as a chronic disease of the brain, not necessarily a 
definition accepted by everyone.

"Treating addiction as a crime is inhumane, it's unscientific and 
it's ineffective," Wen said. "We know what works ... medication, 
counseling and wrap-around services."

Among initiatives in Baltimore spearheaded by Wen were creating 
"wrap-around" services that include informing patients of possible 
treatment when they're brought to the ER. It includes issuing a 
standing order for the city's 600,000-plus residents to have a 
prescription for naloxone, the anti-overdose drug, and creating a 
24/7 hotline operated by social workers and counselors familiar with 
mental health and addiction. They also created a public health 
campaign to teach people how to prevent overdoses and a mobile needle 
exchange program.

Could such a model work for some of the largest cities in 
Connecticut? In New Haven, the medical community is already on 
high-alert and has been developing treatment programs for several years.

"We are trying really hard to integrate our services," said D'Onofrio

This means providing a combination of medically-assisted treatment 
such as methadone and buprenorphine but supplementing this treatment 
with therapy, inpatient or outpatient care. Methadone and 
buprenorphine are among three FDA-approved medications used for 
treating opioid use disorders, the third one being naloxone, 
according to Allan Coukell, senior director for health programs at 
The Pew Charitable Trusts.

Dr. Patrick O'Connor, a professor of medicine and chief, general 
internal medicine at Yale School of Medicine, estimated there's 
probably about 350,000 people in this country undergoing methadone 
treatment and 600,000 medicating with buprenorphine. It's a fraction 
of the people in need of treatment.

"There should be more," O'Connor said. "We have these highly 
addictive treatment options for opioid dependency that work very well 
and we need to get these scientifically proven, effective treatment 
to patients."

D'Onofrio said Yale's medical school has been heavily involved in 
bringing addiction medication to the forefront, including developing 
a practice using buprenorphine.

"Addiction is like driving your car, and you see a kid in front of 
your car and you want to stop, but the brakes don't work," D'Onofrio 
said, repeating what she said is one of the best analogies she's 
heard to describe the disease.

Like Wen, D'Onofrio is an emergency care physician who has firsthand 
experience treating people with addiction in life-threatening 
situations. This background allowed D'Onofrio to contribute to a 2015 
Yale study for initiating buprenorphine treatment after an initial 
emergency care visit.

"We've done some very innovative work," D'Onofrio said. "What we 
found is that the people who received the buprenorphine were two 
times as likely to be engaged in a treatment at 30 days (after 
initial visit). They were less likely to use illicit opioids during that time."

The study is helping develop a protocol for YaleNew Haven Hospital. 
It includes discharging patients with opioid use disorders with a 
72-hour supply of buprenorphine and naloxone. D'Onofrio said the 
hospital has trained 15 emergency care doctors who can prescribe buprenorphine.

"What we are doing is trying to change this paradigm that when you 
have a chronic disease that is life-threatening, why aren't we 
initiating treatment in the emergency department right away and 
setting up an appropriate referral the same way if you came in with 
severe highblood pressure?" D'Onofrio said.

Discharging patients after they overdose without further treatment 
options means "What we are saying to someone is, 'See you later, go 
about your life, maybe you'll live,'" D'Onofrio said.

"We shouldn't be doing that. We should be trying to get them into treatment."

A patient must fit criteria before they're discharged with the 
buprenorphine supply. It's difficult to overdose on buprenorphine and 
it's generally considered safer than methadone.

Even as the medical community develops treatment options and 
lawmakers seek to limit prescription for opioids, access to treatment 
for addiction disorders itself remains limited. The statistical 
percentage of its availability is something Wen said still shocks her.

"Eleven percent of patients with addiction nationwide are able to get 
the treatment that they need," Wen said, noting a figure based on an 
ASAM study. "We would not find that acceptable for any other illness."

Children are also capable of developing addiction. A child and 
adolescent psychiatrist, Dr. Brian Keyes is the director of the 
Children's Center of Hamden, which provides inpatient and outpatient 
treatment programs for children with substance use disorders. Keyes 
also works at the University Of Connecticut School of Medicine and 
Yale Child Study Center.

Most of the youth here begin their addiction at alarmingly young 
ages: Some are as young as 6, and begin by experimenting with 
cannabis or drinking as well using other substances. They typically 
don't begin by using opioids. Most commonly, the children have family 
members who've also experienced substance use disorders. "

"This is a life-threatening disorder," Keyes said about addiction. 
"People see it happening to every racial, socialeconomic area ... it 
makes it more real that this happens to everyone."
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MAP posted-by: Jay Bergstrom