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With a new study showing alarming rates of mortality among patients with opioid use disorder (OUD) who are seen in general medical settings, experts stress that healthcare organizations and policymakers must create innovative solutions to ensure that OUD is diagnosed at an early stage, and that all care settings are equipped with the training and mechanisms to link these patients with effective treatment.
In yet more evidence of the toll that opioid use is taking on Americans, investigators report that patients with opioid use disorder (OUD) who are seen in general medical settings demonstrate much higher rates of mortality than the general population. In a population of 2,576 adults with OUD in a large healthcare system, researchers found that 476 patients died after four years of follow-up for a mortality rate of 18.1%, 10 times that of the general population.1
Another notable finding from this research: The average age of the participants when first diagnosed with OUD was 41 years, and the patients exhibited high rates of other physical and mental health conditions as well as additional types of substance use disorders. In fact, while 19% of the deaths were directly attributable to OUD, most of the patients died from other causes, such as cardiovascular disease, cancer, and infectious diseases such as hepatitis C. Nonetheless, investigators noted that such health complications likely worsened as a result of OUD.
The authors noted that while other studies have found mortality rates among patients with OUD to be roughly four times higher than the general population, most of these studies have been conducted among patients treated in specialty addiction clinics. Their conclusion was that much more must be done in general medical settings, including the emergency environment as well as primary care, to identify OUD in patients at an earlier stage and link them with effective treatment.
Indeed, some states are making progress along these lines with innovative solutions designed to connect frontline providers with critical information at the time patients with OUD present to an ED, and more effective approaches for linking these patients with appropriate care.
Although this study did not address why patients with OUD are diagnosed at such a late stage, Andrew Saxon, MD, one of the co-authors of the paper and the director of the Center for Excellence in Substance Abuse Treatment and Education (CESATE) in the VA Puget Sound Health Care System in Seattle, believes there are several contributing factors.
“There is no convenient and easy way to screen for opioid use disorder or any other type of substance use disorder other than alcohol and tobacco in primary care settings,” Saxon observes. “Primary care physicians are being asked to take care of a plethora of problems in a very short visit while also, depending on the health system, being mandated to screen for a whole variety of different disorders.”
In addition, Saxon notes some patients are not aware they have a problem with opioids while others are reluctant to disclose such a problem.
“They know if they tell their doctor they are having a problem with opioids the doctor might cut them off, so they do everything they can to disguise they have a disorder ... or at least to disguise the fact that they know they are not taking the medication as prescribed,” he says.
On top of these barriers, Saxon notes that many physicians lack the training to diagnose and treat patients with OUD.
Saxon, who spent four years working as an emergency physician, notes that many of the same barriers that primary care physicians face are evident in busy EDs as well, although emergency physicians often see patients who present with the consequences of an OUD.
The diagnosis may be clear in the case of an overdose, but there are more subtle signs of OUD as well.
“Emergency physicians are under incredible pressure to move people through ... but they see people coming in with symptoms of withdrawal ... and pain complaints may be out of proportion to what an injury seems to be,” he says.
Larissa Mooney, MD, associate clinical professor in the UCLA Department of Psychiatry and Biobehavioral Sciences, director of the UCLA Addiction Medicine Clinic, and a co-author of the study, explains that the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) identifies 11 criteria for an OUD. ()
“What it boils down to in terms of the diagnosis is loss of control, overuse, and use even despite harmful consequences,” she explains, noting that cravings also are on the list of criteria. “That is how we define addiction or a substance use disorder.”
Mooney notes there are screening instruments such as the Drug Abuse Screening Test () that frontline clinicians can use to assess risk. For patients with chronic pain, she suggests the Screener and Opioid Assessment for Patients with Pain ().
“These instruments can be administered in just a few minutes, especially if you have a multidisciplinary team or you have a nurse or a social worker who can administer the screen,” Mooney advises.
While such tools do not necessarily provide the clinician with a diagnosis, they can create a clinical picture to prompt clinicians to delve into the issue more deeply, she says.
However, when busy providers lack training in this area or resources for referral, they may be less inclined to go down the road of a potential OUD diagnosis. There is literature about the reasons why providers may not be screening for these disorders.
“Of course, one of the reasons is time. Other reasons include that [OUD] is not on their radar, they lack expertise, or they don’t know what to do if the person endorses [the diagnosis],” Mooney says.
Although the barriers to diagnosis are substantial, one irony is that patients with OUD tend to use the healthcare system frequently, so clinicians are missing opportunities to intervene.
“We know that untreated substance use disorders complicate the treatment of other chronic medical illnesses, so individuals with substance use disorders have higher rates of psychiatric and medical comorbidities, they are seen more frequently in primary care, and they are seen more frequently in the ED,” Mooney says. “And the substance use is making those other conditions harder to treat, so these patients tend to have poor clinical outcomes for other medical conditions and higher mortality rates.”
Left untreated, a certain percentage of patients who have become addicted to prescription opioids will switch to heroin because they have run out of their prescription supply or their substance abuse has become too costly, Mooney adds.
“Then, a certain percentage that use heroin will start using via IV, and some people addicted to prescription opioids can also use them via IV, and then you introduce all new risk factors like infectious disease transmission,” she says.
The stunning data regarding the mortality and morbidity associated with OUD are a wake-up call for providers in all settings to do more, Mooney stresses. “This highlights an opportunity for us to think about new and innovative ways to address this problem earlier,” she says. “Primary care [offices] and emergency departments are often either a first point of contact for patients with this disorder or they are places where these patients are frequently being seen.”
Most of the patients with OUD never make it to a specialty addiction treatment clinic or facility, Mooney notes. “Only a small percentage of these patients seek treatment or get referred there,” she says. “I don’t think the specialty clinics or facilities can even handle the need with this opioid epidemic right now.”
One promising model being used in some emergency settings is Screening, Brief Intervention, and Referral to Treatment, or SBIRT. (), but it requires the ED to engage in partnerships with treatment facilities, primary care providers, or addiction specialists who can take over the care of patients once they have been discharged from the ED.
In the SBIRT model, patients experiencing withdrawal from opioids receive a brief conversation or intervention during which a clinician will educate the patient about his or her substance use and the risks involved. The patient then can receive an initial dose of buprenorphine or another FDA-approved medication for opioid addiction while in the ED, and then the clinician will hand off care to a partnering provider who will take over management of the patient with an evidence-based medication-assisted treatment (MAT) plan.
Mooney notes that SBIRT is a reimbursable procedure that clinicians can bill for, but she stresses that training is an important component, and health systems must figure out how they can make this type of multidisciplinary program available to patients most efficiently.
“Opioid use disorder and overdose deaths are on the rise, and we really need to think about ways to integrate screening, identification, and treatment in general healthcare settings before these patients reach the point of a very severe disorder or a fatality,” Mooney stresses. “This is an opportunity for us to work on ways to identify OUD earlier on in the course of the illness and in multiple types of healthcare settings where these patients are being seen.”
While most experts agree that healthcare organizations need to employ systems-level approaches to make headway in dealing with the opioid crisis, Washington has shown that tackling the problem at an even higher level can deliver broader dividends.
“What is important about [our] model is that it is multifaceted,” observes Daniel Lessler, MD, MPH, the chief medical officer of the Washington State Health Care Authority in Olympia, WA. “We are not just doing this or that. It is a much more comprehensive approach.”
The multi-year state effort has involved a collaboration between the Washington chapter of the American College of Emergency Physicians (ACEP) as well as the Washington State Hospital Association and the Washington State Health Care Authority, which governs Medicaid, and the results are impressive.
“There has been a continual reduction in opiate deaths from prescription opiates in this state, year over year, for several years now, so our prescription opiates are implicated in fewer opiate deaths,” he says.
Lessler acknowledges that at the same time, deaths related to heroin or synthetic “street” fentanyl have increased, although he notes that such deaths have leveled off in the past year or two.
In addition to the gains related to adverse outcomes related to prescription opioids, there have been significant improvements in provider prescription practices.
“What we have seen is a marked reduction in the number of ED-initiated opiate prescriptions, number one, and number two, a marked reduction in the number of pills prescribed when an opiate prescription is provided,” Lessler observes. “Fewer opiate prescriptions and fewer pills per opiate prescription.”
Several factors contributed to these improvements, but clinical leadership has been key, Lessler notes. First, emergency physicians in the state, led by the state chapter of ACEP, developed and disseminated a clinical policy about opioid prescribing in the emergency setting. In turn, the state Medicaid program has worked with EDs in the state to collect data on opioid prescribing and then feed that data back to individual EDs.
“That has, in many cases, been not just at the ED level, but at the provider level within the ED,” Lessler observes. “Here is where leadership comes in again, because you have a medical director of the ED who actually sits down with the whole team or individuals and reviews that feedback. I think that is a critical part.”
Another critical piece of the state’s approach is the development of a health information exchange through which all the EDs in the state have access to medical information about patients who have accessed care in any ED.
“If a person goes to an ED in Yakima, is prescribed pain medicine, and is given a care plan that is placed in his medical record, and then that same person goes to an ED in Seattle the next day, that Seattle ED will immediately know what that patient received in Yakima, what was done, whether there is a care plan, and what that care plan is, particularly in terms of opiate management,” Lessler explains.
This prevents patients from accessing prescriptions for opioids at multiple locations, but it also offers an opportunity to identify patients with an OUD and to take steps to intervene. For this population, the state Medicaid program has developed a patient review and coordination (PRC) program.
“It basically involves connecting patients with a care manager who will help to coordinate their care,” Lessler says.
For example, the care coordinator may contact the patient to discuss his or her pain management needs or to complete an assessment to determine if the patient has an OUD. The care manager then can connect the patient to appropriate resources, Lessler explains.
The state continues to be challenged with a dearth of both pain specialists and mental healthcare providers, particularly in rural parts of the state, notes Lessler, who adds that there has been progress on that front. For example, pain specialists at the University of Washington (UW) have developed a teleconference model to support physicians of all types who treat patients with complex pain conditions.
“The twice-weekly conference has psychiatrists, pain specialists, rehabilitation physicians, and addiction specialists seated around a table, and [providers] can attend via teleconferencing,” Lessler says. “Cases get presented and discussed.”
In addition, the state has worked with UW to develop a hotline staffed by trained PharmDs that physicians can use to present a case and get help on everything from how to taper the dose for a patient who is on a powerful pain medication to how to manage complex pain medicine regimens.
“It could be for any provider who is struggling to manage a patient who has been on opiates for chronic pain and is not doing well,” Lessler observes. “The hotline offers real-time assistance in terms of how to manage patients in that kind of complex situation.”
The two programs, the teleconference model and the PharmD hotline, refer physicians to the other resource so that providers in need of specialty assistance are well aware of both options, Lessler observes.
As far as mental health is concerned, there are numerous initiatives in the works. The state is considering telemedicine solutions in this area as well, and it has taken steps to ensure that MAT is available broadly through Medicaid.
“We have removed virtually all restrictions and prior authorization [requirements],” Lessler observes. “We are working with the practice community where we have providers who can supply Suboxone [buprenorphine and naloxone], and we encourage them to do that.”
Lessler notes that the number of patients on Suboxone in the state has tripled in recent years, but he stresses there is more to do. The state just received an $11 million grant from the Substance Abuse and Mental Health Services Administration to work toward implementing a “hub and spoke” model in which there will be a hub of providers that can handle the initial inductions, in which patients are placed on Suboxone and stabilized, and then there will be providers who can pick up the care of these patients, managing them on an ongoing basis.
The state also has a mandate to pursue what Lessler refers to as behavioral health integration, whereby mental healthcare and chemical dependency treatment are administered and paid for through the same system that administers and pays for physical healthcare.
“When you pool the money and you hold a single entity accountable for the whole person, that is what drives toward better care,” Lessler says. “Financial integration doesn’t guarantee clinical integration, but without beginning with the financial integration, we are not going to get clinical integration, so that is where we are headed.”
The mandate from state lawmakers is that by 2020, Medicaid will be providing fully integrated physical, mental, and behavioral healthcare, Lessler adds. It’s just one more piece to an ongoing improvement process, he says.
Lessler advises colleagues that there is no simple solution for making progress on the opioid crisis. “Whatever you do, to succeed it is going to take a lot of hard work,” he says. “You need to find the leadership, you’ve got to engage multiple stakeholders, and you need that collaboration.”
Financial Disclosure: Physician Editor Robert Bitterman, Author Dorothy Brooks, Editor Jonathan Springston, Nurse Planner Diana S. Contino, and Executive Editor Shelly Morrow Mark report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Editorial Advisory Board Member Caral Edelberg discloses that she is founder, chairman, majority stockholder, and consultant for Edelberg and Associates.