Michigan finds some success fighting opiate crisis on front line: emergency rooms

Detroit Receiving Hospital Dr. Andrew King said intervention with opiate addicts is effective when they are in the emergency room. “We decided to catch these patients at their most vulnerable.” (Bridge photo by Ted Roelofs)

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DETROIT — A couple of months ago, Detroit resident Juanita Gross was desperate to turn her life around.

She had a $200 a day opioid habit. She had already overdosed three times – and feared the next one might be her last.

So she had her two adult children drive her to the Detroit Medical Center Sinai-Grace Hospital emergency room, still in withdrawal from a mix of cocaine and the opioid oxycodone. Doctors there stabilized her and contacted Team Wellness Center Detroit, a mental health and substance abuse treatment agency.

“One of the social workers there came right to my bedside and took me right in for treatment,” Gross recalled.

A day later, Gross was given an addiction medication that contained buprenorphine, considered by experts a potential life-saving treatment for opioid addiction when linked to comprehensive therapy.

Gross now makes her way to Team Wellness for regular group therapy sessions and for her medication, part of a collaborative treatment program that includes Sinai-Grace and two other DMC hospitals, Detroit Receiving Hospital and Harper University Hospital.

“Without this, I would be still using or dead or OD’d. It definitely saved my life,” Gross said.

Detroit resident Juanita Gross said outreach treatment saved her life. “Without this, I’d be using, OD’d or dead.”  (Bridge photo by Ted Roelofs)

The effort is part of a broader movement in Michigan and nationally to attack the opiate crisis on its frontline: the emergency room. The effort comes as opiate-related deaths reached a record high of 2,033 in Michigan in 2017, the last year of available data.

 “We decided to catch these patients when they are at their most vulnerable. We want to break down barriers and find them immediate help,” said Andrew King, an emergency room physician at Detroit Receiving Hospital.

Previously, opioid overdose patients or those in withdrawal typically were stabilized in the emergency room and then discharged, perhaps with a list of treatment agencies to call. Too often, King said, they would cycle back to the ER or worse.

“These patients are at high risk of overdose, unchecked addiction and ultimately, death,” King said.

For the past year, ER physicians at the three DMC hospitals have also administered buprenorphine to dozens of opioid abuse patients and connected them to Team Wellness for treatment. Of approximately 45 ER physicians at the three hospitals, King said, about 10 are certified to prescribe and administer the medication.

They do more than that. Doctors or social workers reach out to patients to ask if they want help. Those who do, like Gross, sign a form and are referred for immediate treatment at Team Wellness.

 

In many cases, drivers for Team Wellness come within minutes to the hospital to pick up these patients.

Preliminary findings at six months indicate this collaboration is paying off.

Of 44 patients with opiate use disorder referred to Team Wellness from November 2018 to April 2019, 24 were given buprenorphine either in the ER or at Team Wellness. Of those, 22 were still in treatment for the duration of the six-month study period.

King estimated that upwards of 130 opioid ER patients connected to Team Wellness for treatment in the past year.

“Those results are encouraging,” he said.

And while that’s welcome news, Michigan’s overall hospital network still lags other states in the extent of ER addiction treatment:

  • The first California hospital adopted buprenorphine treatment in 2016, followed by eight more in 2017. Boosted by $8 million in federal funds, more than 30 rural hospitals were expected to add buprenorphine ER treatment this year.
  • In Maryland, nearly a dozen hospitals now offer buprenorphine treatment for ER patients, with similar services planned for 18 more.
  • In March 2018, Massachusetts General Hospital in Boston became the first hospital in that state to offer buprenorphine to ER patients. In August 2018, Massachusetts Gov.  Charlie Baker signed legislation that mandates that all state ERs implement medication assisted treatment programs, including buprenorphine.

A public-private funding initiative announced in June promises to bring Michigan further down that treatment path, with $5 million in state and foundation funds aimed at boosting opioid treatment in hospitals and jails.

In part, the money will to go establish ER opioid treatment programs at Beaumont Hospital in southeast Michigan, Munson Medical Center in northern Lower Michigan and in county jails.

In November, Gov. Gretchen Whitmer announced plans to cut opioid deaths in half in five years, with measures that include removing prior authorization requirements for opioid-treatment medicines in the Medicaid program and spending $1 million on advertising to reduce the stigma around addiction. 

The move comes as opioid-related deaths in Michigan quadrupled over 10 years, from 506 in 2007. At 21.2 deaths per 100,000 people in 2017, Michigan’s opioid overdose death rate was the 13th highest in the nation, which averaged 4.6 deaths per 100,000 people.

The spike is largely the result of street versions of the synthetic opioid fentanyl, which is 50 times more potent than heroin and sought by addicts as a cheaper alternatives to prescription opioids. Deaths linked to synthetic opioids, principally fentanyl, soared from 72 in Michigan in 2012 to 1,368 in 2017.

State Sen. Curt VanderWall, R-Ludington, chairman of the Health Policy and Human Services Committee, said both the state and medical community need to do more to confront the crisis.

“We have made some inroads, but we’ve got a long way to go,” he told Bridge Magazine.

He said he would be “willing to look at” legislation similar to that of Massachusetts mandating medication assisted treatment at all emergency rooms.

Carrie Rheingans of the University of Michigan’s Center for Health and Research Transformation said the failure to link ER overdose patients with outside treatment remains an issue at many hospitals.

 “The biggest challenge that ER docs have is that if somebody is ready for treatment, there’s not a place for them to go. Treatment can be different things for different people,” Rheingans said.

“Michigan is not at the bottom for this, but we are not at the top, either.”

 Michigan Sen. Curt VanderWall, R-Ludington, chairman of the Health Policy and Human Services Committee, applauded recent efforts to help opiate addicts but noted that Michigan has “a long way to go.” (Courtesy photo)

Since 2002, a growing number of treatment experts have turned to buprenorphine, itself an opioid, as a life-saving alternative to dangerous opioids. 

Buprenorphine produces a less euphoric high than other opioids and one that tapers at higher doses. It also curbs the thirst for other opioids and when combined with naloxone – a combination sold as Suboxone – blocks the effects of opioids like heroin.

A groundbreaking 2015 Connecticut study found that administering buprenorphine in the ER combined with follow-up care can be an additional way to break the cycle of addiction to opioids like heroin or fentanyl.

The results, published in the Journal of the American Medical Association, found that 78 percent of those screened for opioid addiction and given buprenorphine remained in treatment after 30 days, compared to 37 percent screened and referred to community-based treatment.

Gail D’Onofrio, lead author of the Connecticut study and chair of the Department of Emergency Medicine at Yale New Haven Hospital, told Bridge in 2018 the study confirms the vital role ER’s can play in the opioid crisis.

“That was actually pretty surprising to us, that it was so effective,” she said.

Beyond a void of hospitals with buprenorphine ER treatment, Michigan also lags much of the nation in the overall share of physicians, nurse practitioners and physician assistants certified to prescribe buprenorphine.

According to a 2018 analysis by Avalere Health, a Washington, D.C., health care consulting firm, Michigan ranked in the bottom 10 states in the ratio of certified providers compared to opiate deaths.

Meanwhile, in Detroit, there’s a fair chance that overdose patients will be met at the hospital by Jewel Walton, 44, a certified peer support specialist who works for Team Wellness. Walton said she’s transported dozens of ER overdose patients from area hospitals to Team Wellness.

“I tell them, ‘If I can make it, so can you,’” Walton said.

That’s because Walton’s been down a similar road. She said she ran away from her Detroit home at age 13, winding up homeless and “hanging out with the wrong crowd” as she progressed from marijuana to crack cocaine to heroin.

“The lowest point was when my addiction was so bad I had nobody in the world. I was living on the streets, wherever I could put down,” Walton said. “I knew I had to turn my life around.”

Walton said she completed a drug treatment program at 19, earned her high school diploma and has since earned an associate's degree. She’s worked for Team Wellness since 2014.

Walton uses that trip from the hospital to Team Wellness as an opportunity to open a door of hope for her passengers.

“Some of them are crying,” Walton said. Some of them are overwhelmed by their addiction. I keep on sharing how I overcame my addiction. Some people want to open up, but they don’t know how.”

Elizabeth Cichon, special projects director for Team Wellness, said patients referred there typically remain for 24 to 48 hours, where they are assessed, administered buprenorphine if needed and set up for longer-term treatment.

Some, if they qualify, are referred to 30-day residential treatment. Many are set up with an outpatient treatment plan that includes ongoing individual or group therapy. Cichon said these patients are a combination of the homeless and working poor, most of whom are on Medicaid, the federal insurance program for low-income residents.

“We have seen some people who say they have been using for 50 years. We have seen some people in pretty bad shape. We’ve seen some people a few times. But the fact that they are coming back is a good sign,” Cichon said.

Cichon said she believes its direct link to the hospital emergency rooms is vital.

“That’s the key – that one-hour window where they say they want help. I have had people say I will come tomorrow and they don’t come tomorrow.”

At Henry Ford Hospital in Detroit and Henry Ford Wyandotte Hospital, ER physicians are preparing to launch a similar program early next year.

Jacob Manteuffel, an ER physician at Henry Ford Hospital, said the collaboration is tapping into a $150,000 grant from the U.S. Centers for Disease Control and Prevention to hire four peer recovery coaches to work with overdose patients after their discharge from the hospital.

Manteuffel said officials are still working to establish links with treatment agencies that will take these ER patients.

“We want to be a source of recovery. Addiction is a disease. Buprenorphine is a medication to treat that disease. We want to change the mindset around the stigma of addiction.”

At St. Joseph Mercy Ann Arbor, ER physician Hadar Tucker said ER physicians there have treated about a dozen patients with buprenorphine over the past year and referred them to two area clinics for follow-up treatment.

In January, he expects to tap into a $175,000 grant from the state opioid collaborative to train paramedics to see overdose patients at home after discharge and assess their readiness to take buprenorphine.

Patients overdosed on heroin typically need eight to 12 hours to detoxify – after which they exhibit withdrawal symptoms - to be able to safely take buprenorphine. If given too soon, buprenorphine can cause what’s known as precipitated withdrawal, sudden, intense withdrawal that can include excessive vomiting and diarrhea, intense sweating, and other severe side effects.

Once they clear a patient for treatment, paramedics will then contact an ER physician for a prescription for buprenorphine, and in some cases, pick up and deliver the prescription, Tucker said.

“We are trying to come up with a way to get to them while they are still in withdrawal,” he said.

Sitting in a small office at Team Wellness in Detroit, Juanita Gross reflected on her past overdose trips to the ER.

“They get you together and then they send you home. What do you do?”

Gross said her craving for drugs was too strong. Within days, she was back on opioids.

“You just nearly died. You say, ‘I ain’t never going to do it again,’ and then you go right back to it.”

But Gross said she’s determined to make it this time. She goes to group therapy twice a week. She said she volunteers 50 hours a week at a soup kitchen for the homeless.

“This has given me hope,” she said.

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Comments

DivineJules
Wed, 11/20/2019 - 11:08pm

Do you treat your patients who come into your ER in severe pain with the same courtesy, care, and aggressive management of their symptoms as you do those coming in with symptoms of addiction disorders? Are they treated with respect and dignity, and under the assumption that, indeed, they are in pain and worthy of the same degree of attention as those with addiction disorders? Does someone rush to their side to aid them, support them, and assure that they leave your emergency departments with their pain in good control? Do you make sure that they are referred to a good doctor who can help them manage their pain symptoms long term? Feel free to respond to those questions, but direct your answers to the C-50 Pain Patient Advocacy group or the Don't Punish Pain Rally group in your state. They will be awaiting your quick response!

Deb
Thu, 11/21/2019 - 9:31am

Thank you DivineJules . Well said !

DivineJules
Thu, 11/21/2019 - 5:07pm

Loved your comment! And the answer is NO, we don't and won't get this kind of respect and compassion. Instead MI wants to open 'safe shooting sites' so the junkies, who CHOOSE to use, can come and shoot up their illegal drugs!! What in the world is going on in this country? And you will not get a response at all.

Bones
Fri, 11/22/2019 - 10:36am

When the Conservative ghoul complaining about drug users forgets to switch to her sock-puppet account...

Deb
Thu, 11/21/2019 - 9:29am

That’s great . Now treat the chronic pain patient that is being denied their lifesaving pain meds with as much care as you are the addict .

Kathleen
Thu, 11/21/2019 - 5:03pm

I have to say that a chronic pain patient coming to the ER with intractable pain who has had their meds taken does and will not be treated with such compassion and care. The way cpp are treated when this opioid problem is an illegal drug peoblem is discraceful. Instead Rx medications that treat chronic pain have been the target. Sure there are those that abuse Rx meds, but on the whole this is an illegal drug problem that this country refuses to fight. How can they when the US has had troops guarding the poppy fields in Afghanistan for 10+ years!!!! Chronic pain patients (cpp) have had their legally prescribed meds taken without warning, or lowered to a level that is not theraputic. We have/are being treated like garbage and our doctors have fired us as patients with NO warning and told ‘Sorry, I don't prescribe anymore.’ Where is the compassion for those with chronic pain they never asked to have? Addicts choose to use the drug each and every time. The cpp did not choose the illnesses that cause unrelenting pain. Now there is talk of opening ‘safe shooting sites’ for the addicts. Are you kidding me? And I have had the medications, opioids, taken from me when they allowed me to have a good quality of life, raise 3 boys, work full time and buy a home.... Now in my retirement I am denied proper pain control. Doctors are being threatened by the DEA and LARA to stop prescribing or lose their licenses and practices. This whole opioid crisis is not due to the cpp community. When we go to the ER because the pain has become too much to bare we are turned away, treated like drug seekers. Red flagged forever on MAPS. And why is an addict immediately given another drug to be addicted to instead of the illegal drug? The cpp drugs are taken away and we have been forced into withdrawl and the medical profession does not care. The care and compassion is for the addict, the junkie who chooses to use the deadly drugs. Why are cpp made to suffer? Some to the point of suicide!!! We need to be cared for and shown compassion too. Someone needs to tell the truth.

Bones
Fri, 11/22/2019 - 10:38am

It's super cool that we've got the same user pretending to be two different people (DivineJules and Katherine) to push a false narrative about opiod treatment and pain management. Who are you astroturfing for? Purdue pharma?

middle of the mit
Sun, 11/24/2019 - 12:22am

Bones, You are one of the people on this site that I have seen push back on conservatives ill gotten ideologies. On this one though, you aren't in chronic pain are you?

Trust me friend, there are people who used those medicines responsibly and then had them taken away, only to be offered time release versions that no insurance would cover, and instead of $44 per month the cost was $350 per month, and if you add in the side effect medicine? Another $289 per month. That's over $600 per month to deal with pain, not including your doctor visit.

It's real. And it is happening.

hlt
Thu, 11/21/2019 - 8:51pm

I am glad that addicts are finally starting to get the help they need. They are getting a lot more attention and help that people who are intractable pain patients are not getting. We pain patients are the ones who are suffering because of them. Opioid medications can work wonders for those in chronic pain. We do not get a high from them, we need them to feel normal like most of the population. Stop demonizing pain patients and try to put yourself in their shoes. You would not deny a diabetic their insulin, would you? This is what you are doing to chronic, intractable pain patients. You can help both the addicts and pain patients by getting mental health experts treating addicts and let doctors treat pain patients as needed. BTW, did you know that when the government is talking about opioid ods and deaths, they do not separate prescription and illicit opioids. This is why you see the numbers of opioid deaths being so high. This is not fair since only >1% of pain patients misuse their medications. In places where opioid (legal and illegal) deaths have been separated in autopsies, the vast majority of the deaths were illicit drugs or mixing of illicit drugs and alcohol, sometimes with prescription opioids, were the main culprits. Deaths from prescription opioids were less than 5% with some of these deaths due to diversion or stealing of relatives pain medication. Please do your homework and you will find that pain patients are NOT the problem in regard to opioid misuse.