(image courtesy medicine.buffalo.edu)
January 10, 2018
The Western New York community has enlisted experts from the Jacobs School of Medicine and Biomedical Sciences to help combat the national opioid epidemic, which has reached crisis proportions.
“The big thing about the opiate court is the philosophical change that this is an illness that needs state-of-the-art treatment and not criminal behavior that needs punishment.”
Richard D. Blondell, MD
Professor of family medicine and vice chair of addiction medicine
Opiate Intervention Court First of Its Kind in Country
UB has already been recognized as one of the institutions nationwide at the forefront of the fight against the opioid epidemic, but several new initiatives have recently further raised its profile.
One of the most unique collaborations to result is the creation of the first Opiate Crisis Intervention Court in the nation.
Funded through a grant from the Bureau of Justice Assistance in the U.S. Department of Justice, the pilot program was initiated in May in Buffalo City Court. It gives opioid-addicted defendants arrested for non-violent crimes an opportunity to enter treatment before going through the criminal court system.
The Department of Family Medicine and UB’s Primary Care Research Institute (PCRI) are responsible for evaluation and case management.
The Erie County Department of Mental Health and UB family medicine jointly created the HOPE (Healthy Outcomes Partnership and Education) of Erie County program to provide critical time intervention for justice-involved individuals.
“UB has become the ‘go to’ place for these highly unique services due to our tradition of community engagement,” says John S. Taylor, executive director of development for the PCRI.
Protocols Seek to Provide Safety and Stability
“With individuals in the criminal justice system who are at risk of addiction or are opioid addicted, there is so much chaos in their lives,” says Dede Berdine, program director of HOPE of Erie County at the PCRI.
“So many deaths were occurring between defendants’ first court appearance and the next court date that officials realized they needed to do something different, and it led to the opiate intervention court,” she says.
A special opioid docket was created, and participants must attend court every day for 30 days to meet with City Court Judge Craig Hannah for a 30-minute session — and they have 30 days to engage in treatment.
Hannah talks to each participant to make sure they are staying on track. The ultimate goal is to save lives.
“We want to make sure they stay alive and stabilize their treatment connection,” Taylor says.
The offices of the district attorney and public defender have both agreed to delay criminal court proceedings until intervention is achieved.
“Everything is suspended until they know the individuals are safe,” Berdine says.
Jeffrey Smith, treatment court liaison for the Eighth Judicial District, says the success rate of the opiate intervention court is measured in terms of survival.
“We have had almost 200 people in the program since May, and no one has died,” he says. “It’s a win if we can get them through the court system without them dying.”
Smith says Judge Hannah has been the right man to oversee the new court.
“He is a very kind man, and he really cares about the work that he is doing,” he says. “He calls the participants clients instead of defendants and treats them with dignity. He listens to them and is firm but fair.”
Addictions Often Lead to Criminal Behavior
Richard D. Blondell, MD, professor of family medicine and vice chair of addiction medicine, is medical director of the opiate court program and determines what the rapid treatment connection protocols should be for its participants.
Blondell notes that people who have addictions often end up doing things that are illegal to support their habit.
“And many times these are not hardened criminals, but they are driven to commit these acts due to the nature of drug addiction and compulsion to use.”
The prevailing thought is: As long as these individuals have an opiate addiction, they will remain involved in criminal activity.
“So rather than just dealing with the criminal activity, we want to deal with the root cause of the activity,” Blondell says. “The idea is if you fix that, the criminal activity will cease on its own.”
Treatments for Opioid Addiction Have Evolved
Addiction changes the chemistry of the brain: “It’s like driving your car through a big puddle of water. It is very easy to screw up the wiring, but very hard to correct it.”
Richard D. Blondell, MD
Professor of family medicine and vice chair of addiction medicine
He notes studies show that incarceration is not particularly productive in mitigating addiction.
“From that realization years ago, the concept of the drug court evolved, but the problem was we didn’t really have good ways to treat addiction,” Blondell says.
Traditional, abstinence-based approaches through psychotherapy and counseling generally do not produce very successful results.
But now more specific and effective therapies for opioid addiction, known as medication-assisted treatment (MAT), have evolved.
Examples of opioid medications are methadone, buprenorphine (also marketed as Suboxone when it is mixed with naloxone) and naltrexone, which can be given as an oral tablet or a once-a-month injection called Vivitrol.
“The big thing about the opiate court is the philosophical change that this is an illness that needs state-of-the-art treatment and not criminal behavior that needs punishment,” Blondell says.
“Critics often say that this is a choice they made, this is bad behavior, and this is not really a disease,” he adds. “But it is the brain that produces behavior. If you change how the brain works, then you are in fact changing behavior.”
Blondell says addiction physically changes the chemistry of the brain.
“It’s like driving your car through a big puddle of water. It is very easy to screw up the wiring, but very hard to correct it.”
Evidence Supports Use of Medication in Treatment
Gale R. Burstein, MD, MPH
Medication-assisted treatment is the only evidence-based treatment for long-term therapy, according to Gale R. Burstein, MD, MPH, Erie County commissioner of health and a clinical professor of pediatrics.
“We know when people struggling with opioid addiction go fully through detoxification, they oftentimes feel it was such a troubling experience that they do not want to go through it again. They may perceive incorrectly that they just won’t start using anymore and that it won’t be a problem,” she says.
“But from a neurophysiologic standpoint, that is really impossible,” Burstein adds. “We know there is almost 100 percent failure rate with detox and abstinence only for opioid addiction. People will eventually relapse.”
She notes that an individual who is incarcerated and goes through full withdrawal will actually be worse off when they leave the holding center or jail.
“First of all, they are still addicted and have lost much of their tolerance, so if they resume taking the same dose, they are at high risk of overdosing and potentially dying.”
Burstein says the goal of streamlining people directly into MAT — thus helping them avoid withdrawal — has other benefits as well.
“Same-day MAT initiation is more cost effective from both a health care standpoint and a societal standpoint,” she says. “And methadone and buprenorphine are very inexpensive.”
Mantra Used to Be Patients Should Have No Pain
Nancy H. Nielsen, MD, PhD
Education and training programs have worked to lessen the problem of overprescription of opioids by medical providers, says Nancy H. Nielsen, MD, PhD.
One of the main contributing factors to the addiction epidemic is the overprescription of opioids.
Nancy H. Nielsen, MD, PhD, senior associate dean for health policy, says physicians are beginning to change the way they deal with chronic pain patients.
“There is no question the numbers for opioid prescriptions are down, but it is still a major problem,” she notes.
Nielsen points out that physicians who have been practicing medicine for decades undertook training in an era where they were under scrutiny to ensure patients had no pain.
“Pain was the fifth vital sign, and there were patient satisfaction surveys that asked if they had any pain at all,” she says. “It just became a mantra that patients should have no pain.”
Nielsen says doctors were told — through a couple of faulty studies and much promotion — that the opioid drugs were not addictive, were safer than they actually are and lasted longer than they do.
If a child went to a dentist for wisdom teeth extraction, it was not uncommon for them to be given 60 to 90 pain pills.
“It turns out it was not only unnecessary, but also unwise,” she says. “As we now understand the dangers of addicting people, even with relatively short-term use of opioids, physicians have cut way back on prescribing.”
Data Show Progress in Lowering Opioid Prescriptions
“It’s the right thing to do, but it is also happening because of increasing scrutiny of physicians by state and federal government agencies,” Nielsen says.
In every state except Missouri, there are prescription drug monitoring programs that allow physicians to log in to a system and see any controlled substances a patient has been prescribed.
“That has stopped the ‘doctor shopping’ that used to occur because now we can see exactly when and what types of medications were prescribed to a particular patient,” Nielsen says.
Burstein says objective data show that urging physicians to consider modifying their subscribing practices is working.
“According to Erie County Medicaid data, this year for the first time, hydrocodone has dropped from the number one prescribed drug to number five,” she says. “It has been number one since we started looking at the data.”
County Task Force Pools Community Resources
Burstein says although strides have been made, much work remains to be done.
“It is a huge public health crisis,” she says. “Right now we are seeing about one suspected opioid overdose death per day in the medical examiner’s office.”
Burstein oversees the Erie County Opiate Epidemic Task Force, which was created in January 2016 and consists of seven committees that meet regularly and report back to the group.
“We realized early on that no one county department or other government agency could take this on themselves because it is such a huge and complex problem,” she says.
The seven committees include law enforcement, hospitals and emergency departments, health care providers, substance abuse treatment providers, naloxone trainers, community educators and affected families.
“They each work in their own area of expertise,” Burstein notes. “The aim of the task force is to bring all of these disciplines and specialties together to work on this problem collaboratively rather than in silos.”
UB Leads Certification Training for Medical Providers
Among the initiatives Erie County is undertaking is a partnership with UBMD and Paul Updike, MD, medical director of chemical dependency services for the Catholic Health System, to train physicians, nurse practitioners and physician’s assistants so they will be eligible to become certified to prescribe buprenorphine for medication-assisted treatment.
UB offers continuing medical education credits for the certification training, and about 150 prescribers have been trained thus far.
UB’s Research Institute on Addictions is also leading a statewide program to train medical professionals in high-need regions, such as rural and tribal areas, in medication-assisted treatment.
Another pilot program, the Opioid Overdose Project, works in conjunction with law enforcement so that police officers who have performed a naloxone (Narcan) rescue can return the next day to visit the resuscitated individual with a trained peer counselor to talk about options for harm reduction and MAT and try to encourage them to get into the appropriate care.
“First responders are very frustrated because it is not uncommon for them to return to the same homes multiple times a day to resuscitate somebody,” Burstein says. “This gives them a tool to get people the appropriate care so they won’t continue to use and overdose.”
Burstein says officials have been very aggressive in training first responders in resuscitation of overdose victims because the difference between life and death can be a couple of minutes, especially with all the high-potency fentanyl and fentanyl analogues available on the streets.
“According to the medical literature, for every overdose death there are 30 saved, so it is very important,” she says.
Emergency Room Physicians Becoming More Proactive
“Emergency room doctors used to see two Narcan rescues a week. Now they are seeing 10 a shift.”
Nancy H. Nielsen, MD, PhD
Senior associate dean for health policy
Important innovations are also occurring at area hospital emergency rooms.
A pilot program spearheaded by the Department of Emergency Medicine and Erie County is allowing ER doctors to become more proactive in helping addicted patients.
Joshua J. Lynch, DO, clinical assistant professor of emergency medicine, is leading efforts in training emergency department physicians so they will be able to prescribe buprenorphine for patients coming to any of the emergency departments with an opioid-related problem.
“They will be able to counsel them about the availability of medication-assisted treatment and have the ability to prescribe buprenorphine or Suboxone right in the ER to start MAT,” Burstein says. “They are planning to prescribe a three-day supply of buprenorphine or Suboxone and set up an appointment or referral with a prescriber who will agree to continue treatment.”
Nielsen says being able to start treating opioid-addicted patients immediately in the ER is an important new development.
“That is the teachable moment. They have just hit rock bottom and almost died,” she says. “We cannot let them go through withdrawal, because if they do, they are going to go back and use.”
The number of instances where opioid-addicted individuals have been transported to the ER has dramatically increased in recent years, Nielsen notes.
“ER doctors used to see two Narcan rescues a week. Now they are seeing 10 a shift,” she says.
Nielsen says the ER program is “a key project that we are going to evaluate from a research standpoint.”
Research is Vital Component UB Adds to Endeavor
Leading-edge research is one of the primary components UB brings to the fight against opioid addiction.
“We already have in place some very good treatment providers in the region, so when UB looked at how it should attack the opioid problem, we decided to partner with those entities and embed our experts by contract into their existing programs,” Nielsen says.
“Importantly, we need much better research in this area. We cannot keep doing the same things we have been doing,” she says. “There is a wealth of data, but we must learn from it.”
Nielsen says there are about 160 UB faculty members actively conducting research on various aspects of addiction.
“They are everywhere. They are in psychology, the law school, social work, arts and sciences, engineering, architecture and urban planning,” she says.
“We need to make sure we connect the dots between these people,” Nielsen says. “We need new educational offerings to strengthen the knowledge base of those studying the helping professions, be it legal, social work or clinical.”
Evaluations of Health-Related Programs Important Tool
Burstein says UB has been a great partner for evaluation of new health-related programs.
Linda S. Kahn, PhD, professor of family medicine, is in the early stages of conducting a quantitative analysis of the opiate intervention court program in conjunction with court officials.
The researchers will look at the profiles of the people referred to treatment.
“This is not just an inner city problem,” Burstein says. “The majority of opioid-related deaths we are seeing are predominantly young white males, ages 20 to 39, with about half residing in the suburbs.”
But focusing on the deaths tells an incomplete story, according to Burstein.
“Health care providers’ prescribing practices are changing, and there is greater access to evidence-based medication-assisted treatment,” she says. “We’re not doubling the number of deaths each year anymore; the rate of rise has decreased.”
“We are making changes in our community to care for those individuals who are struggling with addiction, so the number of deaths doesn’t tell the whole story.”
“It is so sad, and so many of these deaths are among people that are young and had their whole lives ahead of them,” Burstein says. “But I hope we can focus on the positives of the programs in place for helping people.”