Asking About Opioids: A Treatment Plan Can Make All The Difference

Nov 22, 2017
Originally published on November 22, 2017 7:32 am

For years, doctors have asked people about tobacco use and excessive drinking in the hopes that the answers could help lead people to cut down or quit.

But screening alone isn't usually sufficient to change behavior.

As opioid use hits record highs in the U.S., Christiana Care Health System in Delaware is starting to ask people about opioid use — and then go further.

In November 2016, Christiana Care staff started asking patients during routine visits and in the emergency room questions like these:

"Have you used heroin or prescription pain medications other than what was prescribed in the past week?"

"Do you get sick if you if you cannot use heroin, methadone or prescription pain medications?"

The hospital's chief of addiction medicine, Dr. Terry Horton, worked to make questions about opioid use standard protocol because emergency room doctors at Christiana Care see about 300 patients a month go through withdrawals. It's called Project Engage.

"We can actually leverage that withdrawal by identifying it quickly, treating it rapidly and using it to break the vicious cycle they're in," he says.

Horton and his team try to break that cycle by immediately giving drugs like Suboxone to ease withdrawal symptoms. Health care workers also pair patients with addiction counselors and get them enrolled in community-based drug treatment program before they've even left the hospital.

And so far, Christiana Care has been able to steer two-thirds of patients with opioid addiction into drug treatment, says Horton.

"And of those, a significant portion, more than 60 percent, are actually in treatment a month later in the community," he says.

There have been other benefits. He says Christiana Care is seeing a reduction in readmission rates and the number of patients leaving the hospital against medical advice.

But screening alone isn't necessarily a recipe for treatment. Efforts to screen for tobacco use, for example, found that only about a fifth of tobacco users got any actual assistance with quitting. Dr. Richard Saitz, chair and professor of community health sciences at Boston University School of Public Health, says screening generally identifies people who use drugs — legal and illegal — and drink excessively.

"There have been thousands, even hundreds of thousands of people now identified in these programs," he says. "How many of them go and seek treatment as the result of brief intervention after ... identification by screening is very close to zero. It just doesn't happen."

The Centers for Disease Control and Prevention and the U.S. Preventative Services Task Force have seen it the same way. Currently, no U.S. government agency recommends screenings for illicit drugs like heroin based on "insufficient evidence" that it will help people reduce drug use. The USPSTF is currently reviewing screening effectiveness for opioids, both prescription and illegal. Even though, Saitz says, screening still may be useful for doctors to have a full picture of their patients.

And Saitz notes Christiana Care's program goes beyond screening people. The health system is treating opioid addiction as a disease, with medicine and in-house specialists. He says that's not common in screening programs, nor the American health system in general.

"What we do with alcohol and other drug-use disorder is notice it and maybe, at best, we'll tell the patient that they ought to find some help somewhere. And often that's it," he says.

Saitz and Horton agree, the best way to curb opioid addiction is to connect patients directly with treatment, instead of leaving it up to patients to follow up on referrals, which is typically how it's done.

They say identifying someone with an opioid addiction and giving them a piece of paper with a phone number to call is prescription for failure.

This story is part of a reporting partnership with NPR and Kaiser Health News. James Morrison is freelance journalist based in North Carolina, you can find him on Twitter at @jcmorrisn.

Copyright 2018 NPR. To see more, visit http://www.npr.org/.

RACHEL MARTIN, HOST:

We're going to explore, now, how the opioid crisis is changing the way that doctors work. Some physicians are asking new questions, like whether patients use prescription painkillers or heroin. Here's reporter, James Morrison.

JAMES MORRISON, BYLINE: It's likely a doctor has asked you how many alcoholic drinks you have in a week or whether you use tobacco, but you may not have heard these questions.

SUSAN ACHENBACH: Have you used heroin or prescription pain medications other than what was prescribed in the last week?

UNIDENTIFIED MAN: No.

ACHENBACH: Do you get sick if you cannot use heroin, methadone or prescription pain medications?

UNIDENTIFIED MAN: No.

MORRISON: That's nurse Susan Achenbach with the Christiana Care Health System in Northern Delaware getting information from a new patient. Starting last fall, doctors and nurses there began asking every patient about opioid use.

Because of the opioid epidemic, ER doctors at Christiana Care see 300 patients a month go through withdrawals. That's what led the Health System's chief of addiction medicine, Dr. Terry Horton, to make questions about opioid use standard protocol.

TERRY HORTON: We can actually leverage that opiate withdrawal by identifying it quickly, treating it rapidly and using that as an opportunity to break the vicious cycle that they're in.

MORRISON: Horton and his team break that cycle by immediately giving drugs like Suboxone to prevent withdrawal symptoms. It also pair patients with an addiction counselor and enrolls them in a community-based drug treatment program while they're in the hospital.

And so far, Horton says Christiana Care has been able to steer two-thirds of patients with an opiate addiction into drug treatment.

HORTON: Of those, a significant portion, we're - more than 60 percent are actually in care a month later in the community.

MORRISON: He says Christiana Care is also seeing a reduction in readmission rates and the number of patients leaving against medical advice.

But not everyone is sold on screening for opioid abuse. Richard Saitz with the Boston School of Medicine says screening identifies drug users but it doesn't stop drug use.

RICHARD SAITZ: There have been thousands, maybe even hundreds of thousands of people now identified in these programs. How many of them actually go and seek treatment as a result of identification by screening is very close to zero. It just - it just doesn't happen.

MORRISON: Agencies like the CDC and the U.S. Preventative Services Task Force agree. Currently, no U.S. government agency recommends screening and brief interventions for illicit drugs based on insufficient evidence.

But Saitz notes Christiana Care's program goes beyond screening people.

The health system is treating opioid addiction like a disease, with medicine and in-house specialists. He says that's not common in screening programs or the American health system in general.

SAITZ: What we do with alcohol and other drug-use disorder is we notice it and then maybe, at best, we'll tell the patient that they ought to find some help somewhere. And often, that's it.

MORRISON: Saitz and Horton agree, the best way to curb opioid addiction is to make every aspect of treatment available within a health system. Instead of outsourcing it to psychiatrists and independent programs, they say identifying someone with an opiate addiction and then giving them a piece of paper with a number to call is a prescription for failure. For NPR News, I'm James Morrison in Wilmington, Del.

MARTIN: And that story comes to us as part of a reporting partnership with Kaiser Health News. Transcript provided by NPR, Copyright NPR.