According to Jeffrey Sternlicht, MD, GBMC HealthCare’s Chairman of Emergency Department Services, and the only ED physician on Maryland’s Behavioral Health Advisory Council, GBMC is pursuing several strategies to combat the deadly effects of opioid dependence. He presented these strategies at the Annual Medical Staff Meeting in July 2018, including first dose medication-assisted treatment for those who meet criteria and follow up for definitive outpatient treatment. However, it must be noted that the Emergency Department cannot function as an addiction treatment center and GBMC physicians should not refer patients with addiction or other behavioral health issues to the ED, as other venues can be very effective and less taxing on the ED’s limited resources. “Emergency medicine has significantly changed as a result of the opioid epidemic,” says Dr. Sternlicht. “Many of us within the specialty, including physicians, advanced practitioners, nurses, technicians, administrators, and support staff members, are now expected to fulfill the roles of psychiatrists, social workers, or discharge planners to get help for the overwhelming number of addicted patients in the ED.”
Safer Prescribing and Decreasing the Opioid Supply Leading up to the height of over prescription in 2012, it was widely taught and believed that opioids were not addictive, and many physician readers will recall being evaluated on their ability to treat and alleviate pain, which was at one time classified as a fifth vital sign. In fact, the opioids were (and continue to be) highly addictive; patients began to dictate their care, specifying their need for certain painkillers in escalating doses to live pain free and seeking the medication from different healthcare providers. Unable to refuse prescriptions to their patients for fear of damage to their careers, many physicians understandably complied. The problem may sound familiar – it’s similar to the over prescription of antibiotics and subsequent threat of antibiotic resistance that has plagued physicians for years. Now, there are evidence-based guidelines for prescribing the lowest doses and shortest courses of opioids, only if the decision is made to use opioids. The Maryland College of Emergency Physicians and Maryland Hospital Association also developed clinical pain standards in 2015 to support physicians as they reduce the frequency and quantity of opioid prescriptions.
The Quality Pain Assessment and Treatment Team (QPATT) – a multidisciplinary team consisting of physicians, nurses, advanced practice providers, counselors, and physical therapists – was formed to ensure GBMC is prepared to assess, treat, and refer patients with pain in a responsible and evidence-based manner. Led by Joseph Fuscaldo, MD, Medical Director of Quality for GBMC Hospital, the team is targeting treatment protocols and pathways to address the broader problem and various clinical situations. “Our work includes emphasizing alternatives to opioid (ALTOs) such as non-pharmacologic options as well as other medications and delivery methods that minimize risk to the patient,” explains Dr. Fuscaldo.
Several alternatives currently being considered or implemented by the QPATT include:
- Enhanced recovery after surgery (ERAS) protocols to lessen pain and improve outcomes by minimizing the amount of stress the body endures during surgery
- Intravenous Lidocaine administered postoperatively to reduce pain
- Ultrasound-guided nerve blocks utilized as long-lasting local anesthetic
- Low-dose Ketamine administered within the hospital setting only
- Utilization of electronic medical record system to prompt prescribers with recommended lower doses and fewer pills for those patents who require acute opioids
In March 2018, GBMC began to provide initial Medical Assisted Treatment (MAT) with suboxone in the ED, if a patient meets certain criteria, followed by a peer recovery coach facilitating the warm handoff to a recovery program. Additional support is also now available for overdose survivors. Patients with a history of overdose are “flagged” in their medical record and peer recovery coach follows up with them several days after their discharge to ensure their needs are being met.
The opioid epidemic is a complex problem that will be with us for a generation. GBMC is working to remain on the leading edge of treating opioid use disorder and developing tactics to decrease future patients becoming dependent on prescription drugs.
Physicians who have patients in need of opioid intervention have several resources available.
- The Sheppard Pratt Integrated Behavioral Health at GBMC Health Partners collaborative partnership, which rolled out in November 2016, provides patients with access to full-time licensed certified social workers (known as behavioral health specialists) within GBMC’s primary care practices, along with visiting Sheppard Pratt psychiatrists and substance use counselors from Kolmac Outpatient Recovery Centers. In the past year, approximately 86,000 patients have been screened for substance use disorder and more than 44,000 patients have been screened for depression in the primary care setting.
- Kolmac Outpatient Recovery Center is available for direct referrals for medical detoxification from any substance, including alcohol. Kolmac has six locations, with one on the campus of Sheppard Pratt in the Gibson Building. Call 410-296-2232.
- Mosaic Community Services, part of the Sheppard Pratt Health System, offers a variety of programs, including addiction recovery services. Visit http://www.mosaicinc.org/programs-services/ for a complete list. Referrals can be faxed to 443-612-1400.
- The Baltimore County REACH (Resource, Education, and Advocacy County Help) line offers peer support services or referrals to treatment. Call 410-88-REACH (887-3224).