Osteopathic physician Bradley Miller, DO '98, FAAFP, speaks on addiction in rural communities and an obligation to teach future physicians.
by Janice Fisher
Having spared no corner of the nation, no demographic category, the opioid epidemic has reshaped the interests and energies of practitioners and programs in every medical specialty. The faculty and alumni of 色中色 are no exception. Here, a dozen faculty members and alumni share their professional stories and personal viewpoints about dealing with what has been called the worst public health crisis in American history.
Richard Gold, DO 鈥91, who began his career in HIV medicine and then became interested in how HIV and addiction intersect, is medical director of Cornerstone Treatment Facilities Network. With two detox and rehab facilities, one in New York City in Queens and the other in Rhinebeck, New York, and a total of 265 detox and rehab beds, it is one of the largest such facilities in the state. A team of 24 physicians and nurse practitioners provides medically supervised inpatient withdrawal and stabilization and inpatient rehab.
鈥淧erhaps only 15 to 20 percent of our patients,鈥 says Dr. Gold, 鈥渁re using one substance鈥攋ust opiates, for example. Many people who turn to benzodiazepines鈥擷anax, Klonopin鈥攁re self medicating for anxiety. Benzos work well for the short-term treatment of anxiety, but people get on them for years. Young people who have no psychiatric diagnosis can be addicted to benzos, which they buy on the street. Some take a huge amount鈥攊f I took that many, I鈥檇 probably stop breathing.
鈥淔entanyl is a super-powerful opiate. But some people don鈥檛 even realize they鈥檙e using it. They鈥檙e buying counterfeit Xanax that鈥檚 actually fentanyl. They take what they think is one Xanax, and they die of a fentanyl overdose.
鈥淲e see people using a large quantity of pills. They are prescribed strong narcotics for pain, but then the doctor cuts them off. They wind up turning to heroin, which is much cheaper than buying narcotic pills on the street.鈥
A 2017 New York law guarantees all patients up to 14 days of addiction treatment, with no insurance authorization required. 鈥淚n terms of detox,鈥 which typically lasts five days, says Dr. Gold, 鈥渢hat鈥檚 great, because we used to have to call the insurance company and wait hours for them to call us back. And now we don鈥檛 need authorization for detox, and the patient does not have to wait for treatment, or possibly be denied. Prior to 2017, when we鈥檇 have to get authorization, a lot of people wouldn鈥檛 get any rehab services.
鈥淏ut rehab is intended to be a 28-day program. And now, insurance companies generally don鈥檛 allow us to extend it much beyond 14 days.鈥 Cornerstone鈥檚 average length of stay for rehab decreased from 13.5 days in 2016 to 10.5 days after the new state law took effect. (The numbers include patients who left against medical advice or whose stays were shortened for any other reason.) 鈥淯nfortunately,鈥 says Dr. Gold, 鈥渆ven 14 days isn鈥檛 very long to teach somebody new behaviors.鈥
鈥淲e see people using a large quantity of pills. They are prescribed strong narcotics for pain, but then the doctor cuts them off. They wind up turning to heroin, which is much cheaper than buying narcotic pills on the street.鈥
Another unintended consequence can be seen with Suboxone. 鈥淧robably 20 percent of our patients,鈥 says Dr. Gold, 鈥渢est positive for Suboxone, but they haven鈥檛 been prescribed it. Doctors are prescribing it for other patients, but some of those patients are selling it to buy illicit drugs.
鈥淥n the other hand, a lot of doctors just don鈥檛 want to deal with Suboxone patients. In New York State, some certified Suboxone prescribers have zero patients. In rural areas, patients may have no options for obtaining Suboxone. Even upstate in Rhinebeck, there are many fewer options than in New York City.鈥
Dr. Gold maintains, 鈥淵ou have to be a certain kind of person, have the right mindset, to want to do this work. Somebody who comes in and is withdrawing isn鈥檛 in their best state of mind, and you have to be able to let their behavior go. The reason I went to medical school was to help others. It is very rewarding to be able to save a life and help some people get their lives back.鈥
When David Festinger, PhD, professor of psychology and director of substance abuse research and education, PCOM, started publishing in the early 1990s, use of crack cocaine was epidemic. 鈥淚 thought it was the most insidious addiction imaginable,鈥 he says. Now he studies opioids. 鈥淚f you had to set this up as a behavioral experiment, you couldn鈥檛 create a more efficient substance to facilitate and sustain an addictive disorder.鈥
Dr. Festinger, past president of the American Psychological Association鈥檚 Division of Psycho-pharmacology and Substance Abuse, explains that 鈥渙pioids stimulate the reward centers in our brain very effectively. They mimic very closely the natural endorphins in our body that dull pain and encourage our engagement in behaviors that are essential for survival. When ingested, opioids compete powerfully with and eventually diminish the availability and impact of those natural endorphins. That鈥檚 why opioids have a very high addiction potential. For some people, a chronic compulsion develops鈥攁n inability to stop using even when it鈥檚 causing harm, destroying their lives. A person has to use increasingly larger doses of the drug to get the same high.鈥
After tolerance, individuals who chronically use opioids typically develop physical dependence. 鈥淭he body enters withdrawal when the individual stops taking the drug, so now it鈥檚 a negative reinforcer,鈥 Dr. Festinger explains. 鈥淵ou鈥檙e taking the drug to avoid being punished by the withdrawal symptoms.鈥
Dr. Festinger鈥檚 current research evaluates medication-assisted treatment (MAT) in drug courts, a setting he has been studying for more than 15 years. 鈥淥nly recently,鈥 he says, 鈥渉ave drug courts begun to evaluate the use of medication in helping individuals graduate from drug courts sooner, maintain abstinence and demonstrate reduced criminal recidivism. Methadone has shown a lot of efficacy, mostly as a replacement substance and as a way of reducing criminality and the spread of infectious diseases.鈥 More recently, the full antagonist naltrexone, which completely blocks opioid receptors, has become available in a longer acting form, Vivitrol. 鈥淎n intramuscular injection completely blocks opioid receptors for 30 days. That means the user can鈥檛 overdose, can鈥檛 get high. The hope is that after a long enough time, they鈥檒l learn it鈥檚 not working.
鈥淎mong incarcerated individuals who are addicted to opioids, researchers have begun to examine administering the first dose of naltrexone before they leave prison. But the best behavioral approaches,鈥 according to Dr. Festinger, 鈥渉aven鈥檛 been tested yet. For example, individuals could be released earlier or receive reduced sentences on the condition that they continue to obtain and take their monthly doses of naltrexone. That鈥檚 where we run into ethical stickiness. Could you give a person a fair option to choose鈥攖o say, 鈥極K, I know this is a condition of my release, just like paying fines, getting a job, not breaking parole鈥?
鈥淭he criminal justice system is almost entirely opposed to using anything but the full antagonist naltrexone in MAT. There鈥檚 a stigma associated with medications that have a potential euphoric effect. But that鈥檚 a very black and white way of thinking.鈥 A very few courts, and some parole and probation officers, are starting to look at Suboxone, the partial agonist whose active ingredients are buprenorphine and naloxone. 鈥淎s more and more research shows that Suboxone may be an effective strategy,鈥 says Dr. Festinger, 鈥渋t鈥檚 going to be important to educate the criminal justice stakeholders about the utility of this method.
鈥淣altrexone and Suboxone are really our first-line treatments now, but there鈥檚 no shortage of need for psychology in this arena,鈥 he says. 鈥淐ognitive behavioral therapy, contingency management, and other evidence-based behavioral strategies that we are so strongly aligned with here in our department of psychology can be very useful not only on their own but also as a way to increase compliance and adherence with the medications.
鈥淭here鈥檚 not a student that goes through our doctoral program who鈥檚 not going to come up against this in their future clinical work.鈥
In North Carolina, where Stephen D. DeMeo, DO 鈥08, MEd, is a neonatologist at WakeMed Health & Hospitals in Raleigh, the number of infants hospitalized for opioid withdrawal at birth, or neonatal abstinence syndrome (NAS), is up almost 900 percent since 2005. That increase, he says, correlates directly with the numbers of child-bearing-age women who are addicted to or abusing opioids in the state. 鈥淲e鈥檙e the downstream effect of the problem.鈥
There are 48 neonatal beds at WakeMed, with five or six infants being treated for NAS at any given time. 鈥淭he average length of hospital stay for those babies is 20 days, compared to two to four days for a normal baby,鈥 says Dr. DeMeo.
鈥淎s with everything else in health care, we tend to focus on the crisis moment, when a baby is admitted to the NICU,鈥 Dr. DeMeo says. 鈥淏ut hospitals are having more success when they partner with treatment programs in the prenatal period. Our best bet is to identify at-risk women as early as we can, and partner with their obstetricians, psychologists, and treatment programs, and in this way become a part of their lives.
鈥淚 have an appreciation,鈥 says Dr. DeMeo, 鈥渇or all the non-pharmacologic things we do鈥攖hinking about external stimuli, swaddling, infant positioning and feeding. We鈥檝e learned that non-separation of infant and mother is really important; those babies get out of the hospital faster. And you can encourage moms to continue breastfeeding, which has been shown to decrease length of stay. Part of the osteopathic orientation is toward care of the whole patient, and in pediatrics that sphere is a little wider鈥攜ou really have to take care of the whole family.
鈥淎bout 60 to 70 percent of the moms we care for are in a supervised treatment program. Others are women who don鈥檛 realize the impact of having taken narcotics or prescription drugs off the street. I have to build trust, so I鈥檒l say, 鈥楲ook, I鈥檓 here to take care of everybody. It鈥檚 in the best interests of your baby to have a good understanding of what鈥檚 been in your body for the last couple of months.鈥 We are very much against states鈥 decisions for punitive action against mothers who are abusing opioids, because all that does is drive mothers away from care.
鈥淲e need to be asking,鈥 says Dr. DeMeo, 鈥渨hether the NICU is the best place to take care of babies that are withdrawing. I would love to have a dedicated care area where we could have access to the developmental team, our pediatric pharmacist, our social workers, to give moms and babies their own space. But that obviously runs into lots of capacity issues.
鈥淩ight now, babies have to get off methadone before they are discharged, and there鈥檚 a multitude of reasons for that. But some hospital systems have gotten grants for home visitation of nurses to evaluate how an infant is doing. We could still take care of this infant鈥攎aybe under the supervision of a neonatologist, but out of the NICU itself鈥攁nd then, once the infant is controlled on medicine, create a transition to home that鈥檚 safe, where you decrease time in the hospital but you still provide moms and dads with what they need.鈥
As an attending emergency room physician for 12 years, Rachel Mallalieu, DO 鈥02, has seen 鈥渁 lot of families that were not whole.鈥 She and her husband, Jared Mallalieu, DO 鈥03, already the parents of four sons, became licensed foster parents in the fall of 2015, taking care of children who have suffered from neonatal abuse syndrome.
They adopted a daughter from foster care, Mila, in 2017. 鈥淚 have a good relationship with Mila鈥檚 mom,鈥 Dr. Mallalieu says. 鈥淪he was a foster child herself and never had any resources.鈥
Earlier in her career, says Dr. Mallalieu, who currently works two nights a week, she rarely saw deaths result from opioid abuse. But at Baltimore Washington Medical Center鈥揋len Burnie, Maryland鈥檚 second busiest ER, 鈥渋n my first two shifts in 2014, I had two heroin overdoses, and both patients ultimately died. A 21 year-old man, released that day from prison, shot up, was administered Narcan, and his heart started beating again. But he was declared brain dead the next day. A few days later, a 55-year-old man died of a heroin overdose; I had to break the news to his adult daughter. Now people dying is a fairly regular occurrence for me. In the last four years, so many have died that I can鈥檛 remember.鈥
Dr. Mallalieu has seen that 鈥渢he common denominator among so many foster placements is a parent with a drug addiction. This problem took years to create, and it will take years to fix. But through foster care, I can affect one child at a time, one family, and that鈥檚 what gives me hope. I鈥檝e brought along at least three families to also be foster parents鈥攕ometimes until the child鈥檚 parents can take them back鈥攐r to adopt. The hope is that the child can break the cycle and learn a different way of living. If illness is dormant in them, they鈥檒l have tools to handle it.鈥
鈥淚n the pain world,鈥 says Ron Paolini, DO 鈥85, an addiction psychiatrist and addiction medicine and brain injury specialist at Eisenhower Army Medical Center, Neuroscience and Rehabilitation Center, Fort Gordon, Georgia, 鈥渃hronic pain and acute injury are like apples and oranges. With acute injury, opioids are effective. But we know that chronic pain is not a clear indication for the use of opioids.
鈥淲hat helps,鈥 Dr. Paolini says, 鈥渋s what DOs are really good at鈥攖reating the whole person. The Army uses acupuncture, including 鈥榖attlefield acupuncture,鈥 in the management of pain. They use restorative exercise, which teaches you how to exercise and keep moving without further injury. They use regenerative medicine to work on joints; they use yoga. It鈥檚 a comprehensive approach, along with cognitive behavioral therapy.
鈥淚n Eisenhower鈥檚 Interdisciplinary Pain Management Center [IPMC],鈥 Dr. Paolini continues, 鈥渨e have a chiropractor, acupuncturist, occupational therapist and social worker, as well as a physician assistant and nurses, neurologist, and physical medicine and rehabilitation specialists. Everyone works together in the management of the patient. The providers offer radiofrequency ablation, nerve block, spinal cord stimulators, lumbar discography, and injections. And the Traumatic Brain Injury [TBI] clinic draws on brain injury specialists in physical medicine and rehabilitation medicine, and psychiatry, along with neurology, neuropsychology, clinical psychology, clinical social work, psychometry, physical therapy, speech language pathology/cognitive therapy, occupational therapy, recreational therapy and case management.鈥
Both the IPMC and the TBI clinic offer intensive, three-week outpatient programs utilizing group integrative therapies. Both are designed to focus on functional recovery for service members, with the IPMC鈥檚 Intensive Outpatient Program (IOP) more specific for motivated service members wanting to overcome chronic pain to return to full physical readiness for duty, and the TBI Functional Recovery Program (FRP) more specific for cognitive and behavioral health consequences of injuries but mindful of pain issues and effects as well.
The IOP comprehensive program aims to reduce and eliminate the use of opioids. Treatment includes restorative physical training and aquatic therapy along with integrative modalities such as chiropractic care, acupuncture, massage therapy and yoga, and cognitive behavioral therapy. The FRP utilizes a modified physical training approach, adding more extensive spiritual recovery through chaplaincy interventions coupled with a family program to involve spouses. Working in harmony along with the comprehensive services and support of Eisenhower Army Medical Center, Dr. Paolini says, 鈥淭hese programs make a difference. It鈥檚 amazing to hear people describe how these programs have changed their lives.鈥
Donald Lewis, DO 鈥00, is chief psychiatrist for the Federal Bureau of Prisons, overseeing the mental illness and substance abuse treatment of approximately 183,000 inmates in the nation鈥檚 122 federal prisons. Approximately 40 percent of the inmates have a substance abuse disorder, many involving opiates.
Like his colleagues in other settings, Dr. Lewis, who has served in his role since 2009, sees an increase in the acuity of substance abuse鈥搑elated problems as well as increased polypharmacy among inmates. Resources are spread thin, he says.
Yet here is the irony: Substance abuse treatment is better in prison than what inmates would receive in the community. 鈥淢any of our patients don鈥檛 want to leave to go back to a community that doesn鈥檛 support them and where their only avenue is selling and using drugs,鈥 says Dr. Lewis. Because prison is such a highly controlled environment, no one can hide their drug use, as they can in the community.
鈥淚 love taking care of these guys,鈥 says Dr. Lewis. 鈥淭hey are generally getting regular psychiatric care for the first time in their lives, and 95 percent are extremely appreciative. And I love to see them change. In the community, regardless of what I recommend, I have zero control. Here I know they are compliant. We can sometimes clear up four or five concomitant psychiatric diagnoses. We don鈥檛 have to worry about insurance; there are no reimbursement issues. We are available same day for emergencies and have nationwide access to charts, psychiatric records, and lab work.
鈥淢ost of the time I have no idea what their crimes are; that doesn鈥檛 affect management. You just treat them.鈥
The small fishing town of Lubec, in Washington County, Maine, is where Bethany Pinkham Day, MS/PA-C 鈥12, spent five years in her first job as a physician assistant at Regional Medical Center, a federally qualified health center.
The closest hospital was about 45 minutes away; specialists, two and a half hours.
鈥淪o you got really good at handling complicated patients,鈥 says Ms. Day.
Tourists arrived in the summer, with split knees or twisted ankles, and there were retirees鈥斺減eople from away鈥濃攁ttracted by Lubec鈥檚 11 miles of coastline. But commercial fishing is Lubec鈥檚 business鈥攁nd fishing, says Ms. Day, 鈥渋s a pretty grueling job physically; it takes its toll on backs and knees. Fishermen who were suffering from joint issues were used to getting their pain pills. All of a sudden there was a clampdown on the prescription of opiates, with strict law in place by July 2017. Then we started seeing an influx of heroin.鈥
A fisherman told Ms. Day that he鈥檇 go down to the boats in the morning and see people 鈥渟hooting up heroin in their trucks, because it gave them the energy to get through the day.鈥 When they were paid at the end of the day, they purchased more heroin. It often came from out of state鈥擭ew York, Philadelphia, New Jersey. 鈥淵ou had a lot of people with easy cash. Smart businessmen from away recognized that there was a growing opiate problem and then started flooding the area.鈥
Those seeking medication-assisted treatment could turn to a methadone clinic in Calais, 45 miles from Lubec, or to a handful of providers within the county who prescribe Suboxone. But detox centers were hundreds of miles away. Those seeking a quick detox had few choices; some went to the ER or the jail. The police, says Ms. Day, 鈥渟truggled with funding and having resources to deal with the problem. There was a lot of demand, and not a lot of supply.鈥
Up to 80 percent of the opioid abusers Ms. Day saw came from a residential treatment program staffed by volunteers鈥攕ome formerly addicted themselves鈥攊n Machias, the next closest town. Ms. Day had to deem these patients 鈥渕edically appropriate鈥攚ithout any benzo use or multiple substances, without heavy drinking.鈥
The Clinical Opiate Withdrawal Scale is typically used to categorize mild, moderate, or severe withdrawal. Depending on where a detox patient fell, says Ms. Day, 鈥測ou could sometimes get away with just doing symptomatic treatment鈥攕omething like clonidine to help with the agitation and the heart rate issues, and trazodone to help with sleeplessness. If people needed a little bit more, you could give them Bentyl [dicyclomine] for the abdominal cramping. Sometimes all people needed was a little bit of Benadryl. Typically, depending on what was in their system, they could be feeling a little better in 48 to 72 hours.鈥
The residential program鈥檚 founder was from Camden, New Jersey, and many people in the program were from New Jersey and Philadelphia. 鈥淭hey would bring people up to this program to get them out of their environment, and vice-versa; they took people from Maine down there,鈥 says Ms. Day. 鈥淪wapping the environments helps at least initially, but the difficult thing is when people return.鈥
Ms. Day lived in downtown Lubec鈥斺渕ore of a main street area, right on the border of Canada.鈥 The hours were long, with a lot weekend and afterhours care. 鈥淚 didn鈥檛 have any friends or family within a three- or four-hour drive,鈥 she says, 鈥渁nd it was hard getting away because the demand was so high. But my work gave me purpose.鈥
Shari Allen, PharmD, BCPP, assistant professor, pharmacy practice, GA鈥揚COM, regularly faces concerned veterans in her work at the Atlanta Veterans Affairs Medical Center in Decatur, Georgia. 鈥淭hey say to me, 鈥業鈥檝e been on these meds for so long鈥欌攐pioids, benzodiazepines鈥攁nd my doc wants to take me off them, out of nowhere.鈥 They don鈥檛 see that they shouldn鈥檛 have been on those meds long-term to begin with.鈥
Dr. Allen tells them, 鈥淭hey鈥檙e taking you off benzos, but then you鈥檙e going to be put on a medication such as an anti-depressant, which is the recommended way to treat anxiety. The honest truth is that anti-depressants do not work overnight. Here鈥檚 what鈥檚 you can expect.鈥
As a community pharmacist, Dr. Allen must make constant judgments when presented with a prescription for opioids or other controlled substances. 鈥淒o they need that drug? Why is the script from another state?鈥 She can check the Georgia Prescription Drug Monitoring Program, an electronic database, to see whether someone appears to have been 鈥渟hopping鈥 for the drug at other pharmacies. 鈥淚 might tell them, 鈥業 can鈥檛 fill this today unless I can talk to your doctor.鈥 Some will say, 鈥楴ever mind.鈥欌夆
Dr. Allen, who is also a preceptor for PCOM School of Pharmacy students, teaches a third-year substance abuse elective. Last year, every week the class reviewed 鈥渁 new substance鈥攚hat it looks like, what addiction to it looks like. We had guest speakers, including a pharmacist who had become addicted to opioids. We had someone come in from the Drug Enforcement Administration. I made students go to a Narcotics Anonymous meeting just to open their eyes to what they鈥檙e going to see as pharmacists.鈥
鈥淵ou can鈥檛 overestimate the power of human touch,鈥 says Walter Ehrenfeuchter, DO 鈥79, FAAO, professor and director of neuromusculoskeletal medicine and osteopathic manipulative medicine, GA鈥揚COM. 鈥淭he professional touch involved in manipulative treatment tends to break down communication barriers between physician and patient. So patients end up telling me things on the treatment table that they won鈥檛 tell their own psychologist or psychiatrist on the couch.鈥
Dr. Ehrenfeuchter describes the multistep process of using OMM to treat an opioid-dependent patient: 鈥淭he first thing we do is to find out why they are on the opiate to begin with. Most of the people we see are in pain, but pain is not a diagnosis. The next step is to see if somatic dysfunction is present. Then manipulative treatment does a number of things. First, it removes somatic dysfunction and reduces pain levels almost regardless of the cause. Second, it demonstrates to patients that they can move. So many have been told to rest, to avoid this or that activity. That sets up a vicious cycle鈥攎ore atrophy, more pain. Once we demonstrate that they can move without dying, the next step is to start to reintroduce exercise into their lives, perhaps just moving their own body against gravity. Sometimes there is a co-diagnosis鈥攚hether it鈥檚 degenerative disc disease, osteoarthritis, muscle tears and sprains that didn鈥檛 heal well and the exercise has to progress really slowly or they fail. And the one thing you don鈥檛 want them to do psychologically is to fail.
鈥淕enerally, as you get the pain under better control, patients often taper or discontinue pain medicines on their own. Most people don鈥檛 want to be on them.鈥
Samvid Dwivedi, DO 鈥09 (GA鈥揚COM), an interventional pain physician and anesthesiologist at Henry Ford Health System in Detroit, works to manage the pain of 鈥減eople who otherwise have a long healthy life ahead of them, and that鈥檚 where using opioids becomes a problem.鈥
In the pain clinic, Dr. Dwivedi deals with 鈥渁 lot of post-surgical pain as well as chronic pain from non-surgical sources鈥攍ike chronic arthritic knee pain, back pain, neck pain, pain from cancer. People have neuropathies from poorly controlled diabetes or chemotherapy, fibromyalgia, complex regional pain syndrome, chronic headaches and facial pain.
鈥淲e shoot for a multimodal approach to pain management,鈥 Dr. Dwivedi says. 鈥淲e typically don鈥檛 even approach the opioid option until there鈥檚 no other option left. We use a mix of medication鈥攎uscle-relaxing medication, nerve pain medication, anti-inflammatories, various intravenous infusions; we do a lot of spine, joint, and other nerve injections under X-ray and ultrasound guidance to see if we can calm down the source of pain. We work closely with PT to improve patients鈥 range of motion, flexibility, muscle strength, and conditioning, and employ behavioral health specialists to address the depression and frustration that is comorbid with chronic pain.
鈥淎s this opioid epidemic continues to unwind,鈥 Dr. Dwivedi says, 鈥渨e have to make sure that the pendulum doesn鈥檛 swing too far. There鈥檒l always be patients who do benefit from opioid management. Everyone is trying to tout various other modalities as opioid-free ways of pain control: stem-cell therapy, implantable devices, TENS units, peripheral nerve stimulators, various creams and lotions. We want to make sure we don鈥檛 send patients down the wrong path where they could truly get hurt from treatments not backed by good evidence.鈥
Dr. Dwivedi points out that in other specialties, 鈥測ou can do objective tests and tell what someone鈥檚 heart function is or what their gut function is. With pain, that鈥檚 difficult to do. We try to be as objective as we can in treating a very subjective problem.
鈥淎nd I think that was part of what became the opiate problem: physicians always wanting to help people, and if someone comes in and they鈥檙e suffering, our first instinct is to try to do what we can as quickly as we can. Unfortunately, I think we lost control of that train when it left the station.鈥
George K. Avetian, DO 鈥80, FCPP, a family practitioner in Upper Darby, Pennsylvania, is president-elect of the Delaware County Medical Society, as well as co chairman of the Delaware County Health Advisory Board and chairman of the Medical Subcommittee of the Delaware County Heroin Task Force. In these roles and others, he welcomes the opportunity as a PCP to have both a voice in and impact on the opioid crisis, an epidemic that he stresses 鈥渉as no boundaries or borders.鈥
The Medical Society鈥檚 activities include educating physicians on proper opioid prescribing, providing information about programs for patients who may require rehabilitation; updates on the governor鈥檚 declaration of emergency regarding the opioid crisis; and instructing on how to dispose of unneeded and unused pharmaceutical products.
"The medical community wasn鈥檛 always aware that drug-seeking was driven by our giving the drugs in massive quantities."
Dr. Avetian is proud that Delaware County was the first entity worldwide after FDA approval to purchase Narcan Nasal Spray, which reverses heroin and prescription painkiller overdoses, for use by police officers who suspect an overdose. 鈥淲e have instructed every officer in use of the product,鈥 says Dr. Avetian. The district attorney recruited police chiefs, he says, who 鈥渞ealized the problem wouldn鈥檛 be solved through the legal system. All counties in Pennsylvania now participate.鈥 Delaware County has also hired certified recovery specialists, who are another resource at every ER to counsel patients and their families about resources. A local drug collection van and drug drop boxes are available鈥斺漬o questions asked, we just collect and dispose.鈥
James F. Baird, IV, DO 鈥09, an attending emergency physician and assistant medical director of the Emergency Department, Jefferson Washington Township Hospital, Turnersville, New Jersey, was honored by the Philadelphia Business Journal as a 2017 Extraordinary Doctor for launching a tracking program at Kennedy鈥檚 emergency departments that he hopes could lead to the creation of a national database of opioid-seeking patients. 鈥淚n the emergency department,鈥 Dr. Baird says, 鈥減atients come through very fast. They may have been in other EDs in other systems, but we don鈥檛 have that data. Health information exchanges are a bit archaic. If we could log in patient information and keep track of people who OD or exhibit signs of drug abuse behavior, we could get people more help.
鈥淩ight now, we rely on the Prescription Drug Monitoring Program, which lets us see whether people have been prescribed controlled substances. But if someone ODs and gets reversal agents, we don鈥檛 have access to that information unless they鈥檝e been in our healthcare system.鈥 Dr. Baird is frustrated that in 2018, 鈥渨e still can鈥檛 get electronic health records to share data. I can get records from another system, but by faxing. I know patients are going 20 minutes to another ED, and then 30 miles north鈥攇oing all around South Jersey. A regional databank is my long-term dream.
鈥淚f a patient is exhibiting drug-seeking behavior, the old way was to say 鈥榥o, get out.鈥欌夆 Dr. Baird knows from his senior colleagues 鈥渢hat the medical community wasn鈥檛 always aware that drug-seeking was driven by our giving the drugs in massive quantities. Our mindset must change from cynicism to empathy. I try, both within and outside the hospital, to teach people to look past how someone may be acting in the volatile ER. It鈥檚 a real opportunity to talk with this individual, and then you have an opportunity for intervention.
鈥淓very day, 175 people die from a drug overdose in America. I think that number is way under-reported, and about 60 percent of it is from opioids. The numbers are always behind the trends we see firsthand.
鈥淪o the database is important, but we鈥檙e trying to educate the public on the epidemic through town halls, high school meetings, partnering with law enforcement. We are showing the community that we鈥檙e here to help with your addiction.
鈥淚t begins with a conversation, and the conversation is being had. If you bring people to the table, someone will have an idea.鈥
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