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D'Onofrio highlights heroes fighting opioid epidemic in Emergency Medicine conference keynote

June 15, 2018
by John Curtis

When Gail D’Onofrio, MD, MS, finished med school at Boston University in 1987, she stayed on for a residency at Boston City Hospital that thrust her into the heart of what she called the “big 1980s cocaine epidemic.” It was a baptism by fire.

“I was in the war zone every day,” recalled D’Onofrio, now professor and chair of emergency medicine at Yale. “All I did was try to save lives and they were almost all related to drug use.”

That experience left her with lessons that have guided her career in medicine ever since. In Boston she treated patients for drug and alcohol use and realized that different drugs require different treatments. And she came to see that the emergency department was more than a shop where people got patched up and sent on their way. “It’s not enough to bring a patient back from an opioid overdose. I am saving your life, but I need to keep your life by getting you in treatment,” she said.

In May, D’Onofrio and her department were honored at the annual meeting of the Society for Academic Emergency Medicine (SAEM), the field’s research arm. D’Onofrio was selected to give the keynote address, and Yale residents and faculty members received awards and accolades.

The department was honored for efforts to recruit, mentor, and support women in emergency medicine and to support research that focuses on increasing gender equity and improving the health of women (D’Onofrio won a similar award for her individual efforts to advance women in emergency medicine in 2016).

Just as she sees the role of the emergency department as more than “treat ’em and street ’em,” D’Onofrio believes that as chair, she must do more than just manage the department. She also nurtures the careers of faculty and residents—women and men alike. At Yale’s emergency department about 40 percent of the faculty are women and women hold half the academic and clinical leadership roles.

“In general women beget women,” D’Onofrio said, “I don’t go out and try to recruit women, but because I am here, and our program has developed a national reputation for excellence, women are attracted to come to Yale as residents and as faculty. When they are here I am particularly interested in faculty development for everyone, male or female. This is important not only for the individual faculty member’s advancement but for the advancement of the field and the continual creation of new knowledge.”

Her support of faculty and house staff appears to be paying off. At the SAEM conference, the Best Resident Researcher Award went to fourth-year resident James Daley, MD, MPH, MS, for his work on resuscitation. Pooja Agrawal, MD, assistant professor of emergency medicine, and director of global health education in the Section of Global Health & International Emergency Medicine, won the 2018 Momentum Award from the Academy of Women in Academic Emergency Medicine, for her service in recruitment, promotion, retention, and advancement of women. Christine Ngaruiya, MD, MSc, assistant professor of emergency medicine, who was born in Nebraska but grew up in Kenya, won the Global Emergency Medicine Academy (GEMA) Young Physician Award, for her commitment to the academy, her leadership potential, and having served GEMA with distinction. Federico Vaca, MD, MPH, professor and vice chair of faculty affairs in the Department of Emergency Medicine, whose expertise is in traffic injuries and impaired driving, was invited to participate in the meeting’s prestigious National Grand Rounds.

When D’Onofrio was starting out in Boston, she had no inkling that her research and application of innovative drug use treatment would propel her to national prominence. (She’s also an expert in women and heart disease.) “I have always been interested in problems and solving them,” she said.

When Gov. Dannell Malloy needed expert advice on how to handle Connecticut’s opioid crisis, he turned to David Fiellin, MD, professor of medicine, emergency medicine, and public health; D’Onofrio; William Becker, MD, assistant professor in the Department of Medicine; and Robert Heimer, PhD, professor of epidemiology in the School of Public Health to work with many state partners to develop Connecticut’s Strategic plan to reduce overdose deaths. In the fall of 2016, the Connecticut Opioid REsponse (CORE) initiative issued a report that recommended six strategies, all of which are being implemented by the state government.

A year earlier, D’Onofrio and colleagues had published a clinical trial in JAMA: The Journal of the American Medical Association reporting the first evidence that ED-initiated buprenorphine with follow-up in primary care for ongoing medical management in ED patients with opioid use disorder (OUD) improved engagement in addiction treatment and reduced illicit opioid use at 30 days, decreased hospitalizations, and was cost effective.

We need to have someone in the ED that can help the clinicians with this challenging population and interface with the community.

Gail D'Onofrio

For the study, D’Onofrio partnered with colleagues including Fiellin and Patrick G. O’Connor, MD, MPH, both leaders in initiating medication treatment for patients with addictions in the primary care setting; Michael Pantalon, PhD, senior research scientist in emergency medicine and Steven Bernstein, MD, professor of emergency medicine and public health; Marek Chawarski, PhD, associate professor of psychiatry; and Susan Busch, PhD, professor in the School of Public Health. “When you think about it, why were we not starting treatment for a life-threatening illness in the ED?” D’Onofrio asked. "Buprenorphine is a partial opioid agonist that has proven efficacy in reducing withdrawal symptoms, easing cravings, and preventing complications of injection opioid drug use such as HIV, hepatitis C, injection site infections, and reducing contact with the judicial system. Effective treatment allows individuals to “get a life” meaning connect with family and friends, obtain employment, and engage in their community. It does not make sense that we would send patients out with a pamphlet or “good luck to you” discharge response. We already initiate treatment for other ED newly diagnosed illnesses like hypertension and diabetes with a warm hand off to primary care, so why is this any different?"

“ED-initiated buprenorphine was really a game-changer,” D’Onofrio said. “Individuals with OUD often only have contact with the health care system through the ED. It makes sense to start treatment and link patients to continuing care.” Now EDs around the country are steadily adopting this best practice. D’Onofrio and Fiellin along with their team and new additions, Kathryn Hawk, MD, MHS, assistant professor of emergency medicine and Jennifer Edelman MD, MHS, assistant professor of medicine, are now funded by NIDA to study the implementation of this practice in four sites around the country as well as several under resourced EDs in New Hampshire and Bellevue Hospital in NYC in collaboration with another emergency physician mentee at New York University, Ryan McCormack, MD.

D’Onofrio has also championed screening, brief intervention, and referral to treatment (SBIRT) for alcohol and other drug use in ED settings. Along with Pantalon, D’Onofrio developed and tested the Brief Negotiation Interview, a nonjudgmental conversation using some motivational interviewing techniques that the HPAs and other ED practitioners use to motivate patients to engage in treatment and reduce their drug use. D’Onofrio started a program called Project ASSERT that trains health promotion advocates (HPAs) in the ED to provide brief interventions and help people with addictions access treatment, community resources, and stay in treatment. The program sponsored by Yale New Haven Hospital, is now in its 19th year and has five HPAs covering both the York Street and Saint Raphael Campuses. “We need to have someone in the ED that can help the clinicians with this challenging population and interface with the community,” D’Onofrio said. Two thirds of patients that are linked with treatment programs by Project ASSERT, enroll in a program.

As the SAEM conference approached, Catherine Urbain, an editorial assistant in emergency medicine, suggested that D’Onofrio submit a proposal for the keynote speech. D’Onofrio was reluctant. “You don’t think I have enough to do?” she asked.

“There is never a woman up on that stage, ever,” Urbain replied, “and you have the most relevant, pertinent topic.”

In her keynote, “The Opioid Crisis: Emergency Physicians as Innovators, Policymakers, and Heroes,” D’Onofrio traced the origins of the crisis in the United States—unscrupulous marketing of opioids by pharmaceutical companies and over prescribing by physicians, among other causes—and pointed out that emergency physicians are uniquely positioned to find solutions. She focused on three physicians, Andrew Herring, MD, in Oakland, Calif., Rachel Haroz, MD, in Camden, N.J., and Ross Sullivan, MD, in Syracuse, N.Y. “I found these wonderful emergency physicians who are very innovative, problem-solvers that found a way to provide solutions for their communities, hard hit by the opioid crisis,” she said. When no one else stepped up in their hospitals and communities, they did! Herring created a protocol for ED-initiated buprenorphine and opened his own clinic to continue treatment. His work is now being expanded throughout California. In Camden, Haroz also developed ED protocols for buprenorphine initiation and started a multidisciplinary clinic offering medication-based treatment and a plethora of support services for patient with OUD. She has been instrumental in working with pregnant women with OUD during and after delivery. Sullivan opened a bridge clinic that offers treatment starting with a dose of buprenorphine and including a peer counselor who helps patients access social services. He has demonstrated that patients remain in treatment and reduce ED visits.

Currently D’Onofrio is working with other emergency physicians at Yale, Arjun Venkatesh MD, MBA, MHS, assistant professor of emergency medicine, and Hawk to engage with the American College of Emergency Physicians to promote best practices regarding patients with OUD and developing quality outcomes measures. Their work hopes to reach over 1,000 EDs in the next three years to make care that is common at Yale standard across the nation. In addition, she has received a grant from NIDA with Edward Melnick, MD, MHS, assistant professor of emergency medicine, to develop and test a user-centered IT solution to integrate ED-initiation of buprenorphine and referral to ongoing treatment into routine emergency care.

Throughout her efforts, D’Onofrio sees that the emergency department as the locus of the community and its caregivers.

“We really are the front door of the hospital and we reflect the community. Whenever there is increased violence in the community, that is our problem. When there is an increase in drug use and death, we see it immediately. For example, the ED staff were the first to notice the multiple influx of patients presenting with opioid overdose in June of 2016. Instead of cocaine, people were unknowingly snorting the synthetic opioid fentanyl, 50 times more potent than heroin. The ED quickly notified the health department, police and prehospital personnel. Their actions were instrumental in warning the public. “Lives were undoubtedly saved due to this quick community response,” D’Onofrio said. “Overall, our mission is to improve the health of our community.”

Submitted by Adrian Bonenberger on June 15, 2018