On the lapel of her blazer, Dr. Gail D’Onofrio wears a button bearing one word with a line through it: stigma.
D’Onofrio, who chairs Yale’s Department of Emergency Medicine, works to improve outcomes for people with opioid use disorder, and she’s on a crusade against stigma for a simple reason: social fear hinders treatment.
The number-one reason why people don’t go into treatment is stigma,” D’Onofrio said, adding that it’s an obstacle for some doctors as well as for many patients. “We have states where doctors decide whether to treat or not. This is not acceptable.”
More than 42,000 people in the U.S. die each year from opioid overdoses — over 130 deaths a day.
That’s more than die each year from gun violence and car crashes, and more than died from HIV at the height of the AIDS epidemic. In large part due to opioid-related deaths, life expectancy in the U.S. has been on the decline for white males for the past three years, the longest such stretch since the World War I years of 1915-1918.
A new approach
In 2008, when D’Onofrio and Yale collaborator David Fiellin, M.D., director of the Yale Program in Addiction Medicine, received a grant from the National Institute on Drug Abuse to study screening and intervention techniques for drug addiction, opioid abuse was just beginning to receive attention as a major public health concern.
Deaths from prescription opioids first spiked across the U.S. in 1999, in line with increased opioid medication sales. A wave of heroin-related deaths followed: from 2002 to 2013, they increased in the U.S. by 286%. Next, the misuse of fentanyl, an opioid 50-100 times stronger than morphine, emerged as a public health concern, leading to over 28,466 U.S. deaths in 2017 alone.
The results of a 2015 D’Onofrio-Fiellin study published in JAMA represented a landmark in addiction treatment. They discovered that when patients admitted to the emergency department for opioid use disorder were initially treated with buprenorphine — an opioid-based drug for pain and addiction treatment — along with subsequent medical management in primary care, they were twice as likely to remain in addiction treatment 30 days later than patients not given buprenorphine.
“There are changes that occur in the cellular makeup of the brain with opioid use disorder,” said Fiellin, who also administers a drug called suboxone. “These medications stabilize those changes. They prevent cravings and withdrawals, and they block the effects of other opioids.”
Using buprenorphine and suboxone for patients admitted with overdoses and opioid use disorder is now standard practice at Yale New Haven Hospital. Hospital emergency departments in Boston, Philadelphia, and Buffalo, New York, have also begun providing the treatment.
"A lot of the treatment centers that aren’t adopting it are in places that need it most. It’s a huge barrier."
-David Fiellin, M.D.
D’Onofrio and Fiellin are building on their success. In September, they won a $25.5 million lead grant to develop programs for opioid treatment using buprenorphine at emergency departments at 30 urban and community hospitals around the country as part of the National Institutes of Health HEAL Initiative on Opioids. The work involves millions of patients.
Still, D’Onofrio noted, “A lot of the treatment centers that aren’t adopting it are in places that need it most” — Arkansas, Texas, and South Dakota.
This is attributable to reluctance by some doctors to prescribe an opioid to treat opioid addiction, she said, and also to a required federal waiver necessary for prescribing buprenorphine. Obtaining the waiver involves an eight-hour training session.
“It’s a huge barrier,” D’Onofrio said.
(Fiellin said he sees benefit to the training, because it provides an opportunity to educate healthcare providers how to assess and treat addiction.)
At Yale New Haven Hospital, the primary teaching hospital for Yale medical students, all doctors complete the waiver, and all residents have one by the time they graduate, D’Onofrio said. She recently received an award for Outstanding Contribution to Research from the American College of Emergency Physicians and, in November, received the Betty Ford Award from the Association for the Multidisciplinary Education and Research in Substance Use and Addiction.
Patients reclaim their lives
D’Onofrio and Fiellin have seen the fruit of their work firsthand.
Fiellin has patients who have been successfully treated with suboxone for decades. The medication delivers controlled doses of opioids while combatting drug cravings.
One patient using prescription suboxone, a 48-year-old mother living in West Haven who prefers to remain anonymous, has been abstinent from illicit opioids for nearly 10 years. The patient said she started using drugs as a teenager as a means to cope with untreated anxiety, depression and PTSD from childhood abuse. At age 15, she became addicted to heroin and lived on the streets of New Haven.
“I lost everything,” she said. “My home, my son.”
Now, she has a steady job as a home companion, her own car, and an apartment in West Haven she shares with her now-24-year-old son. She checks in with Fiellin every other month.
“I’m still in shock that I’ve been clean this long,” she said. “It’s a miracle.”
Another mom saw her son bounce back from addiction thanks to the Yale treatment program. At age 27, he fell off a ladder while working, broke both ankles, and was prescribed oxycontin. It became an addiction.
“He was lying and stealing” to get drugs, the mother said. “He was crushing it, smoking it. We found foil everywhere.”
Her son was married, with one young child and another on the way.
When the mother finally got him into the treatment program at Yale, doctors administered suboxone.
Now, she said, “He’s a picture-perfect dad. They saved his life.”
It wasn’t just the medication, she said, but the fact that her son was treated “like a human being.”
D’Onofrio and Fiellin are turning these success stories into policy. Their expertise helped guide the Connecticut Governor’s Strategic Plan to Reduce Opioid Deaths, a three-year effort launched in 2016 focused in part on expanding access to evidence-based treatment of opioid use disorder.
“At Yale, we have historically been at the forefront of developing systems of care for addiction across primary care, HIV clinics, ob-gyn offices, and emergency departments that brings treatment to where people are as opposed to people having to go to specialized care,” Fiellin said. “That’s the way the field is moving, and at Yale we are providing a model.”