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Community Health: Treating Opioid Addiction In The ER

One would be hard-pressed to find anyone in America who hasn’t at least heard about the opioid addiction crisis affecting families and cities across the country. Yet despite a general awareness, many questions still remain about the most effective methods to address this growing epidemic.

According to the National Institutes of Health and its National Institute on Drug Abuse, more than 115 people — across all demographics — die every day in the United States after overdosing on some form of opioid, including prescription pain relievers, heroin and synthetic drugs such as fentanyl. 

The Centers for Disease Control and Prevention reported in March 2018 that opioid overdoses had risen 30 percent nationwide in 2017; in the Midwest, that number is closer to 70 percent. 

In response, a community-wide effort is underway in 
St. Louis using evidence-based research to develop a comprehensive, lasting treatment protocol for people addicted to opioids. Emergency medicine faculty and other health professionals at Barnes-Jewish Hospital are playing an integral role.

“We need to deal with opioid-use disorder just like we would cancer, hypertension or diabetes,” says Robert Poirier, MD, “and that means using medications to manage the disease.” Poirier is a Washington University emergency-medicine specialist at Barnes-Jewish Hospital.

In an effort to enhance treatment options for addiction, Poirier and Washington University colleague Evan Schwarz, MD, director of the Medical Toxicology and Addiction Medicine Clinic, worked to bring EPICC (Engaging Patients in Care Coordination) to area hospitals’ emergency rooms. Barnes-Jewish Hospital is one of 
14 hospitals in the region to participate in EPICC, a community-based program administered by the Behavioral Health Network (BHN) of Greater St. Louis. 

“Drs. Poirier and Schwarz were early champions of EPICC and also have been ongoing leaders in providing medication-assisted treatment in the ER,” says Wendy Orson, BHN’s chief executive officer.

EPICC’S unique combination of medication-assisted treatment and peer counseling, through five participating substance-use treatment providers, allows individuals to manage symptoms while they seek further help. When 
a person is admitted to the emergency room following an opioid overdose, physicians use naloxone, a drug that quickly reverses the depression of the central nervous and respiratory systems caused by opioids. Once revived, the patient immediately begins to experience symptoms of withdrawal, including restlessness, agitation, nausea, vomiting, increased heart rate and sweating. It is in those painful moments that people are often most motivated to seek help; that’s why having a plan in place to connect them with effective resources is critical.

“We talk to patients within a couple hours of admission,” says social worker Angie Hanks, MSW, who works in the emergency room at Barnes-Jewish Hospital. “We’re there as soon as they are awake and able to communicate. If they agree to follow-up treatment, we call the EPICC 24-hour number and within 60 minutes a recovery coach arrives to talk with them.”

EPICC coaches are themselves people in recovery from addiction, and their experiences resonate with patients. According to another of the hospital’s social workers,  Jay Kayser, MSW, most patients want help but don’t know how to find it. EPICC offers them the ability to schedule a follow-up appointment for treatment, sometimes even for the same day, before they are discharged.

The encouragement that coaches provide to these patients, coupled with timely appointment scheduling and enough prescribed medication to get them to that appointment, greatly improves their chances for long-term success. 

According to Orson, about 170 people are referred to EPICC system-wide each month. Of those who meet with a recovery coach, 92 percent are eligible and willing to try the program. Although maintaining prolonged engagement in community-based treatment is challenging for clients and providers alike, 39 percent of individuals who begin treatment are still involved within 30 days after initial hospital contact — on par with success rates of similar innovative treatment models used in other states.

Funding for EPICC, as well as many other directives targeting addiction, comes from the Missouri Department of Mental Health through the Substance Abuse and  Mental Health Services Association (SAMHSA), a  federal agency that is part of the U.S. Department of Health and Human Services.

Rachel Winograd, PhD, assistant research professor at the Missouri Institute of Mental Health, University of Missouri-St. Louis, oversees funding for the project. She says Barnes-Jewish Hospital has remained committed to best practices in the treatment of opioid overdose and in getting physicians the waivers needed to prescribe buprenorphine, one of three medications approved by  the Food and Drug Administration for the treatment  
of opioid-use disorder.

“Addiction is an ongoing health problem like any other that needs sustained funding to slow down death rates from the disease,” says Winograd. “We’re starting to see those rates level off in Missouri, but eventually we want  to reverse them.”

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