In many doctor's offices and hospitals across the country, the response to someone seeking addiction treatment is simple: "We don't do that here."
We are living through the deadliest drug epidemic in American history. Overdose is now the leading cause of death for Americans under age 50. "We don't do that here" cannot be an option.
The exclusion of substance use disorder treatment from somatic care settings is in part a function of outdated regulations. These can be changed: the federal government should re-schedule methadone so that it can be prescribed by more physicians and also eliminate the buprenorphine training requirement. Even within the current regulatory environment, though, we can and must do more to involve America's traditional healthcare institutions in our response to the tragedy unfolding around us.
Last week, the Baltimore City Health Department convened all 11 hospitals in the city to launch the Levels of Care for Baltimore City Hospitals Responding to the Opioid Epidemic. It will enshrine best practices for hospitals and publicly recognize those hospitals that successfully implement them. A hospital can be Level 1, 2, or 3—with a Level 1 hospital providing the most comprehensive response. The initiative is based on a similar program in Rhode Island, one of the only places in the country where overdose deaths decreased last year.
The Levels of Care initiative is born of a recognition that hospitals' opioid-related protocols have become increasingly important. In recent years, the rate of opioid-related emergency department visits and inpatient stays has increased dramatically, rising by 99% and 64%, respectively, from 2005 to 2014. Between 2015 and 2016, overdose-related ED visits rose more than 5% per quarter across the country. And the in-hospital mortality rate for patients admitted with an opioid-related diagnosis has more than quadrupled over the past two decades.
There are three kinds of interventions that hospitals should adopt in response to these trends.
First, and most immediately, hospitals can help patients at high risk for overdose by prescribing or dispensing naloxone, the medication that reverses an opioid overdose. In one study, nearly one-third of ED patients who received naloxone and later witnessed an overdose used their naloxone to save the person's life.
Second, hospitals can treat the disease—opioid use disorder—of which opioid overdose is a symptom. A 2015 study found that initiating addiction treatment for patients in the ED, rather than simply referring them to treatment at a community-based provider, led to a dramatic increase in the likelihood that patients were still engaged in treatment 30 days later—78% compared to 45%. Another study found similar results for initiating addiction treatment for inpatients; six months after the intervention, median opioid use was nearly 75% lower among patients receiving treatment.
Recently, both hospitals and community-based providers have begun to employ peer recovery specialists—people themselves in recovery from addiction—to support patients diagnosed with substance use disorder. While this is a new practice, peers appear to improve the efficacy of treatment along multiple dimensions.
Finally, hospitals can prevent cases of opioid use disorder from arising in the first place. While the percentage of Americans whose opioid use begins with heroin has risen, prescription painkillers remain a common initiating opioid. Different mechanisms for reducing opioid prescribing are being tested across the country; there's even evidence that guidelines alone can reduce the prescribing rate.
In Baltimore, we'll finalize the exact protocols articulated in the Levels of Care over the next few months based on feedback from the public and our hospitals. The underlying principle is clear: healthcare institutions alone cannot end this epidemic, but it cannot be ended without them. Addiction is a disease, and we will not roll back the tide of overdose deaths unless we treat it like one. That means making the full spectrum of addiction treatment available in our traditional healthcare institutions.
Evan Behrle is special adviser for opioid policy at the Baltimore City Health Department; Dr. Shelly Choo is senior medical adviser at the health department and Dr. Leana Wen is health commissioner of Baltimore.
