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Yale and the opioid crisis

June 21, 2017

By Christopher Hoffman

Addiction is a disease, not a moral failing, and must be treated with evidence-based treatments just like any other chronic and relapsing illness.

This was the message that Yale School of Medicine alumni received from Gail D’Onofrio, M.D., M.S., chair and professor of emergency medicine, in a sobering talk about the nation’s exploding opioid epidemic and Yale’s attempts to address it. She spoke during the school’s annual reunion on June 3.

Administering such medications as methadone, buprenorphine and naltrexone, and offering counseling and other individualized social services is the key to retaining patients in treatment and saving lives. D’Onofrio strongly rejected the argument, endorsed by Health and Human Services Secretary Tom Price, that such medications are merely substitutes for illegal opiates, and that going “cold turkey” is the only effective treatment.

“Abstinence treatment does not work,” said D’Onofrio, who is certified in the relatively new specialty of addiction medicine. “It’s a huge risk for overdose death. The only evidence-based treatment is medication assisted treatment, commonly known as MAT.”

Why doesn’t abstinence work? Because opioids rewire the brain, causing lasting biochemical changes that make it all but impossible for the patient to stop using, D’Onofrio said.She likened attempts to resist drug cravings to trying to stop your car from hitting a child, only to discover your brakes don’t work—the brake lines have been destroyed.

D’Onofrio pointed to another flaw in the traditional approach to overdose treatment, one Yale New Haven Hospital (YNHH) has sought to address. After saving an overdose victim’s life, emergency physicians traditionally have done little else. Typically, patients receive a pamphlet and numbers to call for treatment and are then discharged. If addiction is an illness, D’Onofrio said, that makes no sense—no physician would send a heart attack victim home with a list of clinics.

YNHH has introduced a protocol for patients who present with an overdose, have asked for help, or have been identified through screening as having an opioid use disorder. Instead of sending them home with information and phone numbers, emergency physicians initiate treatment with buprenorphine and arrange “a warm handoff” to an office-based medical provider or an opioid treatment program.In addition, they inform the patient about naloxone, the antidote for an opioid overdose, and provide a prescription or a dose to take home. The aim is to treat opioid addiction just as chronic and relapsing diseases as high blood pressure or high blood sugars would be treated—with immediate treatment.

Engagement in treatment can give someone with an opioid use disorder their life back. A key tool is the drug buprenorphine, which reduces withdrawal symptoms and cravings.It is safe and effective in reducing the risk of overdose, drug-related injuries, and infections, she said. “Within 20 minutes a patient in full opioid withdrawal can think clearly and you can have a conversation around how to continue treatment and save their life.”

As leader of the hospital’s emergency department, D’Onofrio has witnessed the unfolding opioid crisis firsthand. Far from abating, the tsunami of addiction only continues to grow, she told her audience. Thanks to opioid overdose deaths, the life expectancy of white men has fallen for the first time in a century, she said. The disease affects every socio-economic group and every county and state. In Philadelphia, a librarian at the public library is now saving an overdose victim with naloxone on the institution’s lawn every day, she said.

The picture is no rosier in Connecticut. In 2015 overdose deaths reached almost 700.‘We know this is rapidly increasing and we expected the official numbers to be significantly increased to date.” D’Onofrio predicted. The rapid influx of synthetic opioids such as fentanyl has fueled this crisis. She went so far as to call for putting the antidote naloxone in public places such as coffee houses and in automatic defibrillator stations.

In June 2016, the problem reached crisis proportions in New Haven. Twelve people—three of whom died—overdosed in 24 hours. The cause: the deadly synthetic opioid fentanyl, 50 times more powerful than heroin, was being sold as cocaine and people naïve to opioids were snorting it. Pre-hospital providers—such first responders as emergency medical services and fire departments—ran out of naloxone, as several doses were needed to reverse this potent opioid, and emergency supplies were provided by Yale New Haven Hospital and Bridgeport Hospital.

In response to the exploding number of overdose deaths, Connecticut Gov. Dannel P. Malloy appointed a task force to address the issues and develop a strategic plan. Led by a Yale team that includes D’Onofrio; David A. Fiellin, M.D., professor of medicine; Robert Heimer, Ph.D., professor of epidemiology and public health and of pharmacology; and William C. Becker, M.D., assistant professor of medicine, and with broad input from stakeholders and agencies throughout the State, the Connecticut Opioid REsponse initiative was developed. This initiative is now being implemented with multiple strategies including legislative changes to improve data sharing throughout state; improved access to treatment; reducing overdose deaths by expanding access to naloxone; increasing adherence to opioid prescribing guidelines among providers; and increasing the community understanding of opioid use disorder and the most effective and evidence-based responses to promote treatment uptake and decrease stigma.

D’Onofrio wants to take the destigmatizing of addiction a step further, arguing that doctors and the media need to adopt new language in talking about the disease. Instead of “addict,” she suggested saying “person with an addiction” or “person with an opioid use disorder.”

“We’re trying to get the word out that this is a disease and we need to treat it like a disease and therefore people would be more willing to come forward to get the treatment they need.It is like all chronic diseases and relapses are expected and should not be interpreted as a moral failing or lack of willpower D’Onofrio said.

Submitted by Tiffany Penn on June 21, 2017