Opiate Crisis: From the 5th Vital Sign to the #1 Public Health ChallengeChristopher S. Goode, MD, FACEPChair, Department of Emergency MedicineWest Virginia University School of MedicineAssistant Vice President, Emergency MedicineWest Virginia University Health System

Disclosures

• I recently received $30,000 from DHHR to develop Medication Assisted Treatment in the Emergency Department training to educate all providers across WVU Medicine affiliated facilities

• I have faculty that have research funding from Gilead Pharmaceuticals via the FOCUS trial that is evaluating the prevalence of undiagnosed HIV and HEP C in West Virginia

• I am currently conducting research evaluating the availability of behavioral medicine services to emergency department across the state of WV

Objectives

• To define how the opiate crisis began• To discuss the mental and physical challenges• To define the public health challenge of opiates• To define current treatment options to date• To discuss future treatment options

How did we get here?

• In the 1990’s the development of new and safer pain outpatient patient control options were developed and studied, many of these studies were industry sponsored (Oxycontin came to market in 1995)

• 2001 the Joint Commission rolled out new standards that included “pain as the fifth vital sign”

• In the 2000’s we added “how well was your pain controlled?” to many patient satisfaction surveys• Unfortunately providers were also being paid based on patient satisfaction

leading to pressure to prescribe

Heroine Use in WV

• When the pills dried up, the patients looked for other ways to get their high

• In 2017 the number of narcotic prescriptions in WV fell by 31.3M doses (12% decrease over 2016), still enough for 65 doses for every man, woman, and child in the state for a year

• But yet overdose deaths continued to increase• Heroin is cheap, can be ingested a number of ways, and is not

“regulated” by the food and drug administration

What does is mean to be “addicted”?• Addiction is a primary, chronic disease of brain reward, motivation, memory and

related circuitry. It is characterized by one or more of the following (ABCDE): • Inability to consistently abstain• Impairment in behavioral control• Craving• Diminished recognition of problems• Dysfunctional emotional response

• Cycle of relapse and remission• This disease is often progressive and fatal• Manage vs. Cure• Two main goals:

• Keep alive• Increase quality of life

The Vicious Pathway

The Mindset to Recovery

• Relapse is a normal part of recovery• Most addicts will relapse 5+ times• If you are alive, it is worth trying to quit!

Public Enemy #1

Why West Virginia?

• Labor intensive economy leads to injury• Depressed economic climate leads to viscous cycle of despair• Limited access to non-opioid therapies, limited access to pay for

other therapy modalities

At What Cost?

• Deaths from drug overdose have risen steadily over the past two decades and have become the leading cause of injury death in the United States• ~64,000 OD deaths in 2016

• 21% increase from 2015• 25-34 y/o: 1 in 5 deaths

• West Virginia led the country in deaths due to drug overdose with ~52 per 100K deaths in 2016

• 2015 = 41/100k • Ohio 2nd = 38/100k

• 345% increase in opioid deaths from 2001-2016

National Institute on Drug Abuse

Comorbid Disease Processes

• HIV• Hep C• Endocarditis

Comorbid Disease

• 9% of new HIV cases in WV report being IVDA• Some studies show that 65% of IVDA have HepC• Endocarditis is killing young people

• Average costs for treatment is $50,000• 42% of those treated were on Medicaid or have no insurance

What Have We Done to Date?

• Limit the number of prescriptions written• Increase access to abstinence based treatment• Harm reduction strategies• Public Overdose Reversal• Improved recognition of the effect on the foster care system• Increased recognition of NAS

Current Treatment Options for Opiate Dependence

• Abstinence Based Treatment (Tough Love)• Medication Assisted Treatment• Faith/Community Based Recovery Programs• Sober Living Homes

Abstinence Based Approach

• Tough Love• ED Treatment of the side effects

• Clonidine• Zofran• Referral to outpatient treatment• Return to the “playground”

• How successful is this approach?

Abstinence/Prolonged Treatment

• Bed Availability• Costs

• Inpatient Detox is about $1500 per day. Then what do you do after the first 7 to 14 days of detox is over? Back to the playground?

• 30 day programs cost anywhere from $5000 to $50,000• 6 months programs (Passages Malibu) can cost up to $500,000• Sober Living Homes cost about $1500 per month (keeps you out of the

playground)

Medication Assisted Treatment

• Methadone• Vivatrol• Narcan• Buprenorphine (Suboxone)

Methadone

• Full agonist- binds to the same receptor as opiates• Has been used since the 1960’s• Decreases cravings and mitigates withdrawal• Can be titrated down over time• Can lead to recovery and increased functioning• Limited to use in non-residential outpatient clinics (i.e. Methadone

clinics)

Naltrexone (Narcan)

• Direct antagonist • Has been provided in the emergency departments and by EMS for

many years via IV/IM route• Recently extended to first responders, law enforcement via use of

intranasal devices• Now available by prescription, and over the counter, to be given by

family/bystanders• Initially was an IM auto injector, now available in prepackaged

intranasal kits• Generic Medication is about $20 to $30• Intranasal kits range from $130 to $140

IM Kit

Intranasal Kit

Vivatrol

• Once monthly (antagonist) narcan given to induce withdrawal upon use of opiates

• Requires the patient to be drug free for 7 to 14 days as not to induce acute withdrawal

Buprenorphine

• Mixed agonist/antagonist- drug activates some receptors and does not activate others

• Dual effect of detoxification and maintenance• Has been tightly managed by DEA and Boards of Pharmacy since

introduction in early 2000’s. • Increased utilization in last few years has drawn mixed emotions• Decreased utilization of methadone clinics• Still requires “special training” and use is limited• Available in sublingual tablet and film form

Best Description (courtesy of Dr. Jim Berry)

The Future

• MAT initiated out of the ED• Neuromodulation• Implantable Micropellets• “Organic” programs

• Faith Based Programs• Peer Recovery Programs

MAT in the ED

• Advantages• Decrease in Overdose Rates• Decrease in costs of care• Increase compliance• Utilizes the COWS (Clinical Opiate Withdrawal Scale)

• Disadvantages/Challenges• Requires “X” License• 3 day rule- allows for ED physicians to give daily dose for up to 72 hrs• Requires robust outpatient follow up system• No ED wants to become “MAT Center of Excellence”, will require

administrative safeguards

MAT as Outpatient

• COAT Clinic (Morgantown)• Group based therapy with medicated assistance• Require adherence to meetings, therapists, and group therapy• 50% dropout rate in first 90 days• 20% dropout rate if they make it sober for 90 days

Neuromodulation for Opiate Abuse

• Clinical trials currently ongoing in WV• Treatment of pain at the spinal cord level utilizing modulation of

the nerve root• Treatment of addiction by implanting devices into the areas of the

brain that drive addiction

Organic Programs

• Peer Recovery Coaches• Faith Based Programs• Traditional Programs

Closing Thoughts

• We have to fix this problem, it is killing over generations• We have to be open minded in our approach

• Statistics show what we have been doing is not working• Modern medicine created this problem, modern medicine needs

to help fix the problem

Credits

• Dr. James Berry• WVU Behavioral Medicine and Psychiatry

• Dr. Nicole Dorinzi• WVU Department of Emergency Medicine

• The many patients, and families, that I have interacted with over the past 16 years of practicing emergency medicine in WV that shared with me their pain and suffering brought on by this crisis

Questions?

• Correspondence• Christopher S. Goode, MD, FACEP• Email: cgoode@hsc.wvu.edu• Phone: 304.293.0295