- Between January and July 2016, Connecticut saw more than 600 deaths due to opioid overdose —more than for all of 2015.
- Since 1999, Yale Medicine’s Project ASSERT has seen more than 50,000 patients and placed about 85 percent of them into treatment programs.
- At Project ASSERT, a team of advocates helps patients locate treatment, negotiate health insurance and find transportation from the hospital.
- Recovering opioid addicts often have other chronic health conditions, such as mental health conditions or Hepatitis C. Local treatment programs treat these other issues concurrently.
- Yale Medicine is a hub for clinical research around opioid addiction, including research about risk factors behind opioid overdose.
Opioid addiction has become a public health emergency in the United States. Each day, 120 people die of an opioid overdose–43,000 people died in 2015.
In response to the crisis, Yale Medicine is changing the treatment paradigm with its team-based approach to breaking patients from the grips of addiction. Each professional has a distinct and vital role in shepherding people with addiction from the verge of death to the physical and emotional healing that’s possible with treatment. Here, four such team members describe their part in the process.
The emergency room doctor
“Here at Yale New Haven Hospital, we have seen an uptick of opioid overdoses this past year, with more than 10 or 15 patients presenting on a daily basis,” Dr. D’Onofrio says.
Though many patients are white males, the epidemic does not discriminate based on class, education level, sex or race. Opioid addiction includes dependence on naturally occurring substances such as heroin and related synthetic drugs such as Percocet and Oxycontin.
The effects of the drugs directly lead to acute medical problems. “Opioids attack the brain in certain areas, which reduces the body’s drive to breathe,” Dr. D’Onofrio says. She and other emergency department personnel are experts at reviving patients who have overdosed. Patients are often immediately given Narcan (also called naloxone), an antidote that “bumps the opioid off the opioid receptors in the brain, allowing the person to start breathing again,” she says.
Once patients’ lives are saved by Narcan, the next step is to find out whether patients are aware of any treatment resources and to provide any counseling or information that will help the patient get help for his or her substance use. Many patients come to the emergency department because they need help accessing treatment for opioid dependence.
If they’re in withdrawal, Dr. D’Onofrio can begin to manage those symptoms: “The most evidence-based treatment for opioid addiction is a medication-assisted therapy such as buprenorphine,” she says. Buprenorphine (often known as Suboxone) is safer than methadone, in terms of respiratory suppression, but similarly blocks the euphoric effects of opioids and decreases cravings.
An initial dose of buprenorphine, though, will not prevent a patient from going right back into the cycle of addiction. That’s why Yale Medicine takes advantage of the critical window of time when a patient is in the emergency department in order to get them into longer-term treatment.
Dr. D’Onofrio likens opioid addiction to other medical conditions. “If someone almost died of a cardiac arrest, you wouldn’t then say: ‘Here’s a pamphlet. Good luck to you. Hope you find a cardiologist!’” Dr. D’Onofrio says.
That’s where Project ASSERT comes in. It's a collaborative effort between Yale New Haven Hospital and the Section of Emergency Medicine, Yale University School of Medicine. The program acts as an active liaison between patients receiving emergency care and outside treatment centers and services. “Without Project ASSERT, it’s a revolving door, and these patients are going to die,” Dr. D’Onofrio says.
Gregory Johnson, health promotion advocate for Project ASSERT at Yale New Haven Hospital’s emergency department
Johnson is one of four health promotion advocates for Project ASSERT. He speaks directly with patients who have been revived at their bedsides. “At first, people are often very hesitant and underreport their drug use,” he says. Using a Dr. D’Onofrio—developed tool called the Brief Negotiated Interview (BNI), Johnson asks patients who are initially reluctant to seek out treatment what it is about their condition that they like. “How does taking drugs benefit you, and what are the consequences?” he might ask.
That sort of nonjudgmental probing can help patients look clearly at the effect of their addiction. “Because we catch a person in crisis, we’re able to use that situation to get them to see that they do have a problem and do need help,” Johnson says. “The key is to try to get the person to be willing to help themselves.”
Once patients decide that they need and want help, Johnson undertakes all the logistics involved in moving them from the emergency department into a treatment program. “Instead of just giving someone information, I can make all the arrangements,” he says. That includes assessing the patient’s insurance plan (if there is one) and seeing what’s covered, communicating with centers to find an opening, and even providing transportation from the hospital.
“A lot of times, the patients have burned bridges,” Johnson says. “They don’t have any resources, and they might not have insurance or any type of support system. If they don’t have insurance, we work diligently to find places where they can go.”
“I’m from a community that was drug infested,” Johnson says. “Now it seems the whole country is drug infested. I’ve talked to everyone from CEOs to homeless people. When I come to the emergency room, I can make a positive difference. I see a person in crisis, and through my intervention, I’m able to place that person directly on the path to treatment.”
The treatment specialist
Jeanette Tetrault, MD, director of the Addiction Medicine Fellowship Training Program at Yale Medicine and staff physician at the APT Foundation, an addiction treatment center in New Haven
“The ongoing management of substance use disorders is what we call maintenance treatment,” Dr. Tetrault says. “And it’s similar to how you would treat a patient with any chronic disease. Oftentimes with opioids, maintenance is in the form of medications such as buprenorphine.” Unfortunately, she says, there is a lot of stigma associated with using medications. But without it, it’s too easy for a patient to fall back into the cycle of drug use.
Medication to curb cravings is just one piece of the puzzle, though. “Patients with addictions often have other chronic health conditions, such as mental health conditions or Hepatitis C,” Dr. Tetrault says. “We provide treatment for these other issues concurrently.”
Setting specific goals, learning how to avoid triggers, and figuring out how to build new social relationships through individual or group therapy sessions are also key components of treatment. “There are lots of triggers and social cues that may cause a patient in treatment to relapse to drug use,” Dr. Tetrault says, “Patients may seek drugs as a solution to problems and a quick fix for whatever social or physical ailments they may be experiencing.”
“If a patient comes to me and says, ‘My life’s falling apart, I lost my job, I lost my family,’ then those are the things I really want to work on with them,” Dr. Tetrault says. “I want them to get those back.”
As with any chronic disease, relapse is part of the disease. When patients find themselves in crisis again, Dr. Tetrault says, it’s important to analyze which aspects of treatment worked for them in the past in order to improve their individualized treatment plans.
“The best part of my job is seeing patients who’ve struggled with a disease that’s highly stigmatized actually do well and get their lives back,” she says. “To be on that journey with a patient, and help them through that is very rewarding.”
Kathryn Hawk, MD, clinical instructor in emergency medicine at Yale Medicine and NIDA K12 Drug Abuse, Addiction and HIV Scholar
Dr. Hawk works as a physician in the emergency department and is also a recipient of a NIDA (National Institute on Drug Abuse) career development award, which allows her to spend 75 percent of her time doing research and policy work to improve care for patients with opioid use disorder and those at risk.
A researcher’s job may be to assess and investigate what works and doesn’t work in order to decrease the death rate of opioid-using patients at every stage: in the community, it the emergency room and while engaged in treatment.
Risk factors for opioid overdose is one area of Dr. Hawk’s investigations. For example, those who take chronic pain medication or who have an underlying respiratory illness are at greater risk of overdose when taking opioids. Coming out of inpatient treatment also puts people at a higher risk, because if they do use medication again their tolerance will be much lower than it was. “We want to educate people and make sure they recognize that engaging in specific behaviors puts them at increased risk of overdose,” Dr. Hawk says.
She’s currently using questionnaires to identify knowledge gaps in people who have overdosed, with the aim of improving emergency department based interventions such as those carried out by Project ASSERT. “Mandated treatment does not work,” Dr. Hawk says. “A guided conversation that gets patients to decide to participate is more effective.”
As for the root causes of addiction, Dr. Hawk acknowledges that it’s complicated. She has provided care for people who were prescribed Percocet or another pain reliever for an injury and ended up addicted. Then, because those pills are expensive, they transition to using heroin, which is much cheaper and readily available. Sometimes people jump straight to heroin, or use opioids in combination with alcohol or other illicit drugs.
“Sometimes people are self-medicating undiagnosed or undertreated mental illness,” she says. “I’ve heard of heartbreaking stories of how people ended up on the path to addiction. A lot of times people started out trying to deal with anxiety, PTSD (post-traumatic stress disorder) or other trauma, and somewhere down the line, they developed a substance use disorder.”
“The epidemic is so complicated,” Dr. Hawk says. “The three legs of the stool we are looking into are prevention, harm reduction, and access to treatment–specifically medication-assisted therapy. It’s going to take time to mitigate the problem. It’s really about education, reducing stigma and being willing to talk about addiction as a medical disease.”