ED Chair Develops Program To Reduce Opiate Abuse
Massachusetts is facing an unprecedented opiate crisis, and the severity of the issue has never been clearer for those combating it on the front lines: doctors and nurses in Baystate Health's emergency departments across western Massachusetts. In the first two months of the 2015-16 fiscal year, Baystate Medical Center in Springfield treated three times the number of suspected heroin overdose victims compared with the same two months in 2014. This rate would extrapolate out to nearly one overdose victim every day for one year.
“In all my years of being an emergency physician at hospitals across the state, I have never seen a more serious situation than the one we are currently in,” said Dr. Niels Rathlev, Chair of Emergency Medicine at Baystate Medical Center. “The problem with heroin is you never quite know what is in it-it can be laced with more powerful drugs than one can handle, especially for patients who are in recovery and relapse.”
During one weekend in November, at least 45 patients were treated for suspected heroin overdoses at Baystate Wing Hospital and Baystate Medical Center. It’s an epidemic that Dr. Rathlev has been actively combating for several years. He believes a large part of the critical response to this crisis is prevention, and the ability to limit opiate addictions by responsibly prescribing narcotic medications. Rathlev has been regionally and nationally recognized for an electronic monitoring system that he created, which aggregates frequent emergency department patients who request opiate prescriptions into one system. This helps doctors quickly see that their patient may have an opiate issue, without spending hours digging through several databases.
“We created an electronic alert so that when a doctor opens up a patient chart, the first thing that appears is a one page document, detailing past opiate prescriptions, concerns, and recommendations to appropriately treat the patient with opiates,” Rathlev said. “It takes 30 seconds to read, but can really help get patients moving in the right direction. We want to prevent addiction, but be sure we are appropriately caring for the patient.”
A “frequent user” is defined as someone who has visited the emergency department four times or more in one year, and is still being managed by a primary care physician. Before an electronic alert is created for a patient, their case is reviewed by a team of doctors, nurses, social workers, and primary care physicians. The results have been strong. In a two year period, Baystate emergency physicians decreased the number of opioid prescriptions given to patients, and thereby helped control opiate availability in the community. They also substantially decreased the number of opiate pills that those in the electronic system received. Rathlev’s next step is continuing to work with the Department of Public Health and Massachusetts Hospital Association to expand the program statewide.
“We are hoping this is step one towards implementation at other emergency departments. Clearly we need to make sure that when we prevent opiate abuse in our emergency department so that a patient can’t drive an hour down the road and acquire the same medications that we avoided prescribing,” he said. “We are reducing the number of pills that are on the street and available for abuse.”
While focused on encouraging prevention, Baystate Health has taken significant additional measures to save those who are already addicted to heroin, including:
- Expanded distribution of nasal Narcan, the drug reversing antidote to heroin, to rural areas of Massachusetts. Instituted a standing prescription order at the Baystate Medical Center Pharmacy for Narcan. This allows anyone in the community, especially loved ones of known addicts, to pick up the lifesaving prescription for a nominal fee.
- Established relationships with local agencies that will provide recovery coaches at the bedside of addicts in the emergency department. These coaches are often recovering addicts themselves who patients can easily relate to. Coaches screen patients, help provide them referrals into programs, and then attempt to get substance-dependent patients connected with medication assisted therapy. Also made mental health counselors available for immediate consults in emergency department.
- Launched emergency department clinical studies that examine the possibility of one’s predisposition to chronic pain. When a willing car accident victim arrives in the emergency department, for example, tests are done to determine if a patient’s genetic features predisposes them to chronic pain or PTSD. This could clearly impact how a patient’s care is managed following their injury and manage predispositions for opiate addictions.
- Convened a Baystate Health Addiction Task Force to conduct a system-wide needs assessment and make recommendations about enhancement of behavioral health services for patients with substance use disorders and office based substance abuse treatment methods.
Rathlev says there is still much work to be done before the opiate crisis is in control, but that progress is slowly being made.
“There is much more public awareness about it, we are talking a lot more about it,” he said. “I think a major issue has stigma and a code of silence in that this wasn’t something families talked about. You hid it and therefore it was never really managed. We have to get past that by treating this as a public health emergency, and be aggressive in combatting it so we can save lives.”