The Ongoing Battle Against Addiction

August 31, 2018

Research conducted by Gail D’Onofrio, MD, and her colleagues on buprenorphine treatment initiated in the emergency department is being adopted by hospitals around the U.S.

Research conducted by Gail D’Onofrio, MD, and her colleagues on buprenorphine treatment initiated in the emergency department is being adopted by hospitals around the U.S.

Earlier this month, within a 24-hour period, scores of people in New Haven were exposed to a blend of synthetic cannabinoids, presenting with symptoms that closely resembled those of an opioid overdose. Although toxicology tests later ruled out opioids, this public health crisis underscores our nation’s continuing struggles with opioid use disorder. Today is International Overdose Awareness Day, a fitting time to recognize our faculty’s exceptional work around addiction, which spans all three of the school’s missions and has placed Yale at the forefront of an area of medicine that touches many lives.

Research conducted at Yale is having a significant impact in several ways. In the hospital setting, the work of Gail D’Onofrio, MD, MS, and her colleagues on emergency department-initiated buprenorphine treatment, for example, is now being adopted into practice around the country. The Department of Emergency Medicine has created a website as a resource for providers seeking information about this novel and effective strategy. Matthew Grossman, MD, developed an innovative approach to treat opioid-dependent newborns and reduce their withdrawal time by replacing drug therapy with increased contact with their mothers. The approach is being used in hospitals across the U.S. For about four decades, Robert D. Kerns, PhD, has researched the impact of pain on veterans and military service members, and effective ways to reduce reliance on opioid therapy for chronic pain management. Srinivas Muvvala, MD, MPH, is playing a key role in the battle against opioid use in Connecticut through a federally funded grant intended to make medication-assisted treatment—which combines medication and counseling—available to those who suffer from opioid use disorder.

In the laboratory, Stephen Waxman, MD, PhD, is conducting research on painkilling drugs that block sodium channels, instead of stimulating opioid receptors, as a possible avenue to reduce opioid use. Joel Gelernter, MD, and his colleagues are studying the genetics of opioid dependence. They have published research identifying gene variants and pathways that influence risk and have identified a gene variant that affects therapeutic opioid (methadone and morphine) requirements, which could lead to personalized treatment.

Dr. D’Onofrio is a renowned expert on Screening Brief Intervention & Referral to Treatment (SBIRT), an early intervention and treatment approach widely used for substance use disorder. For the past 18 years she has served as director of Project ASSERT (Alcohol & Substance Abuse Services, Education, & Referral to Treatment) in the Yale New Haven Hospital Emergency Department, which provides SBIRT for patients with substance use disorders. She and Patrick O’Connor, MD, MPH, led the effort to make addiction medicine an official medical subspecialty in 2016. Dr. O’Connor was also instrumental in integrating addiction treatment into primary care, performing the first randomized trial of primary care-based buprenorphine treatment, and has recruited several leading addiction medicine-focused researchers and clinician educators to Yale.

The Yale Program in Addiction Medicine, established by Dr. O’Connor in 2017 and led by David Fiellin, MD, is addressing substance use disorder in a variety of ways. These include programs to treat substance use disorders in the inpatient, Emergency Department, and outpatient settings; an Addiction Medicine Fellowship, led by Jeanette Tetrault, MD; career development and training programs for providers; and the creation of an inpatient Addiction Medicine Consultation Service. Together with his colleagues, Dr. Fiellin also led the Connecticut Opioid REsponse (CORE) initiative, which issued a report in 2016 recommending six strategies to combat the opioid crisis: increased access to treatment with methadone and buprenorphine; accelerated entry into treatment for those at high risk of overdose; reduction of overprescribing opioids; increased access to naloxone; increase data sharing among agencies, clinics, and treatment centers; and an increased understanding of opioid use disorder.

Educating the next generation of clinicians is essential in order for us to continue making strides in treating addiction. This training begins as soon as medical students arrive on campus. During the first week of Orientation, they attend the Introduction to the Profession course, which includes a session entitled Opioid Use Disorder: From Bench to Bedside to Washington. Under the leadership of Dr. Tetrault, Dr. Muvvala, and their colleagues on a medical school committee charged with creating an addiction “thread” throughout the curriculum, content has also been added to, and updated in, the preclinical and clinical curriculum to ensure that our graduating physicians are prepared to help address the national opioid epidemic from both a prevention and treatment perspective. This training continues in residency during which all primary care residents at Yale New Haven Hospital are trained in the treatment of opioid use disorder using buprenorphine and SBIRT.

First-year students in the Physician Associate program learn about the full spectrum of services needed to support patients with opioid use disorder, including prevention, diagnosis, treatment, overdose reversal medications, and counseling. In their clinical year, students apply this knowledge to directly care for patients and their families affected by the opioid epidemic under the supervision of YSM faculty. Substance use disorders and the opioid epidemic are covered in the didactic portion of the Physician Assistant Online program, where a series of lectures on opioid prescribing and overdose treatment is being developed for the clinical year. PAs were among the many clinicians who recently cared for the patients who suffered adverse effects from synthetic cannabinoids on the New Haven Green.

On September 5, in honor of International Overdose Awareness Day, the Addiction Medicine Collaborative at the School of Public Health is sponsoring “The Public Health Response to Drug Overdose,” a panel discussion moderated by Dean Sten Vermund, MD, PhD. This will be one of the many discussions taking place at Yale and in the community as we continue to seek ways to influence policy around substance use disorders and their effects on our society.

The response of those who treated the patients in connection with the recent emergency in New Haven is commendable. Hopefully, we will not have to face a similar situation in the future. Nevertheless, substance use disorder is a continuing crisis in our city and our country. At the School of Medicine, we are committed to pursuing the research, education, and clinical excellence required to overcome it.