Addiction Medicine and the Opioid Crisis

The opioid crisis is a public health epidemic of epic proportions affecting thousands of families right here in St. Louis, all across our country, and around the world.

World-class addiction medicine experts at Barnes-Jewish and Washington University School of Medicine are on the front line of the opioid crisis, and their work is impacting the national debate on how to best tackle the problem.

Below top experts on opioid use disorder weigh in on what is being done, and what still needs to happen, to solve this growing public health crisis.

Question: There’s been a lot in the news about the opioid epidemic. How does this affect our region?

Answer:
Evan S. Schwarz, MD, Associate Professor of Emergency Medicine, Medical Toxicology Section Chief, and Director of the Outpatient Medical Toxicology and Addiction Medicine Clinic

In 2017, we had 49,000 Americans die from an opioid overdose. To put that in perspective, if you look at the number of Americans who died in the Vietnam War or the number of Americans who died at the peak of the HIV epidemic in 1995, they were in the 50,000s. So, people we lost just due to opioids have almost equaled both of those totals. And the number unfortunately keeps climbing.

Opioid overdoses increased 70 percent between 2016 and 2017 in the Midwest alone, and Missouri is in the top-third of U.S. states most affected. Every day, between five and ten of these patients come through the Barnes-Jewish Hospital emergency room doors—and this number continues to grow.

Question: What is being done at Barnes-Jewish Hospital and Washington University School of Medicine to address the opioid crisis?

Answer:
Robert F. Poirier Jr., MD, MBA, Assistant Professor, Emergency Medicine, Clinical Chief of Emergency Medicine, and Director of ED Patient Safety, Quality, and Performance Improvement

At the end of 2016, we started a program called EPICC (Engaging Patients in Coordinated Care). In the past, when someone with an overdose came into the emergency department, we would resuscitate them, give them a piece of paper, and say, “Call a number on here and try to get into rehab or follow-up.”

The problem is that this doesn’t work. The way that addiction works is that as soon as we reverse the effects of opioids in someone’s body, all of a sudden a craving overtakes them. The addiction is so strong that they immediately want to go back out and get to where they were before.

We started the EPICC program as a pilot program at the Barnes-Jewish Hospital emergency department. When someone comes in with an overdose, we call a recovery coach. The recovery coach, who is often a former addict, gives these patients the hope that they can make it through, because often there is no hope out there. We then connect the patient within a day or two to a substance abuse treatment center.

We started to operationalize this plan in December 2016. In May 2019, at Barnes-Jewish Hospital, we referred 90 patients to get into treatment. My goal is to get that up to 150 to 160 per month, but we’ve made great strides.

The good thing is, the percentage of patients who are referred to EPICC and then agree to work with a recovery coach is very high. This referral-to-enrollment rate at Barnes-Jewish Hospital is 95 percent.

Question: How do we intervene earlier and prevent overdose deaths for people with opioid use disorder?

Answer:
Laura J. Bierut, MD, Alumni Endowed Professor of Psychiatry and Director of the Health & Behavior Research Center

My career as a physician-scientist has been discovering genetic underpinnings of addiction. My view of addiction is actually many steps before an individual comes to the emergency room with an overdose.

As I look at the cascade of events moving from drug initiation to misuse to opioid use disorder, I think we’re having a failure to intervene at these earlier times and prevent opioid use disorder from transitioning to overdose and death.  

We know most people with opioid use disorder are interfacing with health care systems. They’re going to primary care providers, they’re in the hospital, and they’re going to emergency care. Yet we have this terrible leakage of these patients.

But the mantra I have is, “We should not let the sun set on anyone with opiate use disorder without connecting them to treatment.”

We have protocols that if someone has a stroke or a heart attack, we have time limits to get these individuals in treatment. We should be approaching the opioid epidemic in the same way. We should be making sure patients are connected, engaged in treatment, and on this path. We need to implement this in a very precise and efficient manner.

Question: How can the broader community come together to help patients with opioid get appropriate treatment?

Answer:
Dr. Bierut

We are building toward a system that we’re calling the “No Wrong Door” model. What we know is individuals with opiate use disorder are really affecting so many different aspects of our system. They’re interfacing with behavioral health centers, mental health clinics, hospitals, the justice system, public health departments, the foster care system, and so on.

This is a person-centered model. When people are interacting with these different systems, we look at how to identify a person with opioid use disorder and how to connect them to care.

What we have at this institution are incredible areas of excellence: emergency department, psychiatry, internal medicine, OB/GYN—all of these groups are now really starting to approach the opioid crisis.

Dr. Poirier:

Our goal is to create a Center of Excellence for Substance Abuse Disorder. We need to attack this problem on multiple fronts. We need to hit it from prevention before it even starts; and then we need to target it in the middle while people are getting addicted and learn how to prevent that; and then once they’re addicted, we have to get them treatment otherwise they have a high likelihood of dying. We’ve got a crisis. 50,000—and some of the recent data says 75,000—people in the U.S. will die this year from opioid use disorder.

All three—education, research and clinical care—are key. Integrating all the services that we’re providing from all aspects is crucial. And a Center of Excellence will help us formulate this model and bring everybody together. It’s like planting a seed that grows into a large tree and it spreads its roots and its leaves everywhere.

How You Can Help

The Foundation for Barnes-Jewish Hospital provides support where and when it’s needed most to help solve the most pressing health care issues in our community. If you are interested in supporting the collaborative efforts happening across toxicology, psychiatry, and the Emergency Department to combat this epidemic, contact Jaclyn Stewart-Strothmann, 314-286-0450. The Healthy Future Fund (area of greatest need) also gives us the ability and flexibility to combat some of the most pressing community health needs in our community, including the opioid crisis.