Selected Podcast
Managing Opioid Use Disorder in the ED and the Institution
In recent years, there has been much discussion about reducing the prescription of opioids for pain management but what does it look like to identify and treat a patient suffering from an opioid use disorder? Dr. Reuben Strayer discusses that conversation, effective treatments, and the history of the opioid problem.
Featured Speaker:
Reuben Strayer, MD
Reuben Strayer was born on the shores of Lake Michigan but raised and schooled in Texas until moving to balmy Montreal for a residency in emergency medicine. His clinical areas of interest include airway management, analgesia, opioid misuse, procedural sedation, agitation, decision-making and error. His extra-clinical areas of interest include sweeping generalizations and jalapeño peppers. He tweets @emupdates and writes at emupdates.com. Transcription:
Managing Opioid Use Disorder in the ED and the Institution
Prakash Chandran (Host): Recently a troubling statistic was released showing drug overdose deaths have topped 100,000 annually in the US. Just over 75% of those deaths were due to opioid use. In recent years, there has been much discussion about reducing the prescription of opioids for pain management, but what does it actually look like to identify and treat a patient who is already suffering from opioid use disorder? Here to educate us about those conversations, effective treatments and the history of the problem is Dr. Reuben Strayer, he's an Emergency Physician and Associate Medical Director, as well as the Director of Addiction Medicine for the Department of Emergency Medicine at Maimonides Medical Center. This is Maimo Med Talk. I'm your host Prakash Chandran. So, Dr. Strayer, thank you so much for joining us today. I truly appreciate it. I'd love to get started by asking what exactly do you do at Maimonides?
Reuben Strayer, MD (Guest): Hi Prakash, it's a pleasure to be with you. I'm an Emergency Doc, as you mentioned. And I also do Addiction Medicine. So, in addition to seeing patients in the emergency room, I organize addiction programming for the department and for the hospital. And I run the hospital's buprenorphine clinic. We call it the MAT Clinic which provides ongoing medication based treatment for patients with opioid use disorder.
Host: So you just mentioned opioid use disorder. What exactly is that?
Dr. Strayer: So opioid use disorder is the formal name, the DSM name, for opioid addiction and opioid addiction, like all forms of addiction, have to do with loss of control. So people with addiction continue to use substances or do activities, even though they know that those substances or activities are harming them, even though they would like to cut down or stop, they can't. So people with opioid use disorder are affected by what is often a very powerful addiction because opioids are so closely tied to our normal functioning. Our brain releases its own opioids. We call them endorphins and these chemicals are closely tied to the brain's reward system. So opioid use disorder, OUD has a profound effect on people who suffer from it. It rewires their brain circuits in such a way that causes all sorts of harmful behavior.
Host: And I'd like to just follow up with a more general question. What exactly is considered an opioid?
Dr. Strayer: Opioid is the most general term for a chemical that activates the immune receptors in our brain and other parts of the body. The easiest way to understand opioids is to think of them as derivatives of opium, which is of course made from the poppy. And these are loosely under the umbrella of what's commonly called narcotics. Although that's a much more general legal term that we have preferred to avoid. But opioids are those substances that cause the spectrum of effects of opium and they include opium, heroin, morphine, hydromorphone, Dilaudid, Oxycontin, codiene, Percocet, and others.
Host: Okay, thanks for that description. So moving on historically, how have emergency rooms and hospitals treated patients with opioid addiction?
Dr. Strayer: Poorly. I was trained to treat people with opioid addiction mostly by giving them a piece of paper with some phone numbers on it, with a referral and a slap on the back and a good luck to ya. I was never really trained to manage addiction properly. I was trained to manage some of the consequences of addiction. So for example, opioid withdrawal, I had some training in managing opioid withdrawal. I certainly had training in managing opioid overdose or the terrible skin or lung or heart infections that people who inject opioids are subject to. But I received no training and most of my colleagues in emergency medicine and throughout the hospital received no training on how to manage the addiction itself.
So we would routinely send these patients who came in with injection harms, overdose or just people who came in asking for help; we would routinely send them back out to the street in withdrawal with a piece of paper and a referral. And this was always an inactive stigma driven approach, but until fairly recently we didn't know better and we didn't have the tools to do better. Fortunately now we do.
Host: And I guess just a related question. What do you feel like changed? Like more recently now, you said you have the tools and maybe the education. Can you just speak broadly around that moment when things started to change, and you started to approach things differently?
Dr. Strayer: changed is that opioid addiction became a manageable, relatively contained problem within a small section of the population, a relatively small problem you didn't have to focus on because it didn't confront you that often. And then in the nineties, and the otts the prevalence of opioid addiction and opioid use disorder have skyrocketed and I'll only speak for emergency medicine, but the number of patients that we would see in the emergency department with opiod addiction went from occasional patients, maybe one, every few shifts to multiple patients per shift. And the way that we were trained to manage these patients, classically, we all recognize was not helping these patients. It wasn't improving their lives. In fact, many of these patients just got worse and worse utilizing the strategies that we were taught which was not really to treat the addiction and to hand out percocet prescriptions with a very low threshold until we gave out a lot of Percocets, when I was training and when we began to realize how much harm we were causing with these, again, stigma driven approaches and misinformed approaches, a group of us within emergency medicine, decided to learn more about addiction, how to treat it and to disseminate what we've learned throughout the emergency medicine community. And now I'm proud to say that the treatment of opioid addiction is a part of most emergency medicine training programs and many emergency departments across the country are doing much better for patients with OUD and both in terms of treating OUD and preventing it.
Host: Yeah, that's amazing to hear. So, I guess just a more basic question. How are patients with OUD or opioid use disorder identified in the first place?
Dr. Strayer: So there's a spectrum of ways that patients with OUD can present to the emergency department. The most obvious patients present with addiction harms that are very obvious. So, for example, nonfatal overdose or the severe infections that I alluded to earlier. They can also come in, in withdrawal and they will often say things like I last used heroin 12 hours ago or 24 hours ago, and now I'm terribly dope sick, and I need help.
And then some of them will come in and just say, I'm feeling okay now, but I'm tired of living this kind of life. I'm ready for help. I'm ready for recovery. So they've basically self identified. There are also a variety of patients who have occult opioid use disorder where it's not obvious, and those patients require a little bit more digging. You may have to ask some focused questions, which they may or may not be willing to answer, honestly, because of the stigma associated with addiction. Some of these patients become revealed as having opioid use disorder when they go into withdrawal 12 hours or 24 hours later after you've admitted them to the hospital for their pneumonia or whatever it is, and they start to withdraw on the floor.
That's when they're identified as having opioid use disorder. And then there are I guess a third set of patients who have what we often call chronic pain, it often goes under the umbrella of chronic pain. These are patients who are generally getting a supply of prescription opioids from their prescriber or prescribers and present to the emergency department, not with addiction harms per se, or a request for help, but with pain. And these are some of the most challenging patients to manage because many of these patients do have opioid use disorder, but they don't, they themselves don't recognize it as such.
Host: Hmm. So tell me when OUD is identified, how do you actually go about initiating the conversation with the patient? Like, take me through what exactly that sounds like.
Dr. Strayer: So there are as many ways to do this as there are providers, but the way I think about it is in two steps. So the first question is, is this person who has opioid use disorder, are they revealed to themselves mostly, as having opioid use disorder? Do they themselves understand that they have a problem with opioids, that they have opioid addiction?
That's the first question. And then if they do know themselves that they have an unhealthy relationship with opioids, are they interested in getting help? Are they interested in recovery? So the first two questions that I'm trying to answer for myself is, is this patient revealed as having OUD and if so, are they willing to be treated?
Every provider approaches these conversations differently, but most addiction experts would advocate for a motivational interviewing style where you try to elicit the patient's own goals and values and guide the patient to recognition that their use of in this case, opioids is interfering with those goals and in so doing, you can hopefully nudge them from unrevealed to revealed. And then in those patients who are revealed as having OUD from unwilling to be treated for OUD to willing.
Host: Interesting. So for the patients that are revealed, as you've just covered, what are the most effective treatments and harm reduction practices?
Dr. Strayer: Well, we've learned a lot about this over the past decade or so. And we know now without any doubt, that the most effective treatment for opioid use disorder, for opioid addiction is medication based treatment. There are three FDA approved medications for OUD, buprenorphine, often known by its trade name, Suboxone, methadone, and then the opioid antagonist naltrexone, which is usually administered in a long-acting form trade name, Vivitrol as a monthly depot.
So, those are the most important treatments for opioid addiction. The one that's most relevant to my work as an emergency physician is buprenorphine because I can treat opioid withdrawal and transition the patient to sustained buprenorphine maintenance immediately in the emergency department, all at once by treating withdrawal with buprenorphine in the emergency department. Methadone has a much more limited use from an emergency perspective because it can only be administered for addiction in what are known as opioid treatment programs, OTPs colloquially known as methadone clinics. Vivitrol, which is the third recognized treatment for opioid addiction requires a sustained period of opioid abstinence and is generally initiated in a clinic based setting.
So those are three treatments for addiction for opioid addiction. Again, the one that we would consider first line, both in the ED and in most addiction clinics would be buprenorphine. There are also a series of harm reduction efforts that apply to everyone with opioid addiction, whether they wish to be treated with one of the three medications I just described or not. Those harm reduction efforts include a take-home naloxone.
So nasal naloxone that you can dispense to the patient and anyone that knows the patient for use, if the patient overdoses on opioids at home. We dispense take home naloxone to anyone who wants in the Maimonides emergency department. They don't have to register to be seen. They can just present themselves asking for a take home naloxone kit and we will give it to them.
Other harm reduction efforts include instructions and supplies for safe injection. So syringe exchange, education on how to avoid infections and other consequences of intravenous drug use, screening for infectious diseases like HIV and hepatitis, screening for pregnancy, looking for housing insecurity and food insecurity. Those are the types of harm reduction efforts we undertake in our emergency department all the time, both in patients who are willing to be treated for opioid addiction, and then perhaps more importantly, in those patients who are not yet ready for recovery.
Host: So Dr. Strayer, just as we start to close here at Maimonides, what are emergency clinicians doing to prevent the development of OUD in patients who are presenting with acute pain?
Dr. Strayer: For patients who are not already using opioids, we call them opioid naive patients, there is a lot that you can do as a provider, as a prescriber to make sure that they are not set down the path of opioid addiction by your prescription.
Myself, and many of my colleagues were taught that doesn't happen, that people don't develop opioid addiction from a prescription for pain. But now we know it happens. Now we know that that training was sophisticated industry marketing, masquerading as training for physicians, and that we were essentially duped. The consequences of that disinformation have been profound and have led directly to the opioid addiction and overdose epidemic that we're in the middle of. But we now understand as providers how much harm we can do with prescription for 30 Percocets, for example. And so the most important way to prevent opioid naive people from developing opioid addiction is to not expose them to opioids.
So we have all become much more judicious opioid prescribers. Maimonides has done some of the most important work in this area under Sergey Motov and his team in the areas of opioid alternatives especially with ketamine as an opioid alternative for severe acute pain. And then again, in the domain of judicious prescribing, not only from the emergency department, but throughout the hospital. And the department of surgery under the leadership of Pat Borgen have fairly dramatically reduced their opioid prescribing in collaboration with Sergey and his team to tremendous effect.
Host: Well, Dr. Strayer, this has been a fascinating conversation. I wanted to just ask if you had anything else that you'd like to share with our audience today about OUD or anything else that we covered before we close here?
Dr. Strayer: The most important thing for folks to remember about opioid addiction is that it is a disease. It is not a moral failing. It's not a failure of willpower. It's a disease caused by a combination of environmental factors, like exposure to opioids, social factors, like despair, and how connected one is in the community and then genetic factors, which may be the most important determinant of all, and that there are very effective treatments. So if you know anyone who's affected by opioid addiction, encourage them to get help. There's very effective treatments available for OUD.
Host: Dr. Strayer, thank you so much for educating us today.
Dr. Strayer: It was a real pleasure to speak with you Prakash.
Prakash Chandran (Host): To learn more about Maimonides Medical Center, please visit maimo.org. And that is spelled M-A-I-M-O.org. You can also check out all of our other podcasts for more topics that might interest you. This has been Maimo Med Talk. I'm your host Prakash Chandran. Thank you so much. And we'll talk next time.
Managing Opioid Use Disorder in the ED and the Institution
Prakash Chandran (Host): Recently a troubling statistic was released showing drug overdose deaths have topped 100,000 annually in the US. Just over 75% of those deaths were due to opioid use. In recent years, there has been much discussion about reducing the prescription of opioids for pain management, but what does it actually look like to identify and treat a patient who is already suffering from opioid use disorder? Here to educate us about those conversations, effective treatments and the history of the problem is Dr. Reuben Strayer, he's an Emergency Physician and Associate Medical Director, as well as the Director of Addiction Medicine for the Department of Emergency Medicine at Maimonides Medical Center. This is Maimo Med Talk. I'm your host Prakash Chandran. So, Dr. Strayer, thank you so much for joining us today. I truly appreciate it. I'd love to get started by asking what exactly do you do at Maimonides?
Reuben Strayer, MD (Guest): Hi Prakash, it's a pleasure to be with you. I'm an Emergency Doc, as you mentioned. And I also do Addiction Medicine. So, in addition to seeing patients in the emergency room, I organize addiction programming for the department and for the hospital. And I run the hospital's buprenorphine clinic. We call it the MAT Clinic which provides ongoing medication based treatment for patients with opioid use disorder.
Host: So you just mentioned opioid use disorder. What exactly is that?
Dr. Strayer: So opioid use disorder is the formal name, the DSM name, for opioid addiction and opioid addiction, like all forms of addiction, have to do with loss of control. So people with addiction continue to use substances or do activities, even though they know that those substances or activities are harming them, even though they would like to cut down or stop, they can't. So people with opioid use disorder are affected by what is often a very powerful addiction because opioids are so closely tied to our normal functioning. Our brain releases its own opioids. We call them endorphins and these chemicals are closely tied to the brain's reward system. So opioid use disorder, OUD has a profound effect on people who suffer from it. It rewires their brain circuits in such a way that causes all sorts of harmful behavior.
Host: And I'd like to just follow up with a more general question. What exactly is considered an opioid?
Dr. Strayer: Opioid is the most general term for a chemical that activates the immune receptors in our brain and other parts of the body. The easiest way to understand opioids is to think of them as derivatives of opium, which is of course made from the poppy. And these are loosely under the umbrella of what's commonly called narcotics. Although that's a much more general legal term that we have preferred to avoid. But opioids are those substances that cause the spectrum of effects of opium and they include opium, heroin, morphine, hydromorphone, Dilaudid, Oxycontin, codiene, Percocet, and others.
Host: Okay, thanks for that description. So moving on historically, how have emergency rooms and hospitals treated patients with opioid addiction?
Dr. Strayer: Poorly. I was trained to treat people with opioid addiction mostly by giving them a piece of paper with some phone numbers on it, with a referral and a slap on the back and a good luck to ya. I was never really trained to manage addiction properly. I was trained to manage some of the consequences of addiction. So for example, opioid withdrawal, I had some training in managing opioid withdrawal. I certainly had training in managing opioid overdose or the terrible skin or lung or heart infections that people who inject opioids are subject to. But I received no training and most of my colleagues in emergency medicine and throughout the hospital received no training on how to manage the addiction itself.
So we would routinely send these patients who came in with injection harms, overdose or just people who came in asking for help; we would routinely send them back out to the street in withdrawal with a piece of paper and a referral. And this was always an inactive stigma driven approach, but until fairly recently we didn't know better and we didn't have the tools to do better. Fortunately now we do.
Host: And I guess just a related question. What do you feel like changed? Like more recently now, you said you have the tools and maybe the education. Can you just speak broadly around that moment when things started to change, and you started to approach things differently?
Dr. Strayer: changed is that opioid addiction became a manageable, relatively contained problem within a small section of the population, a relatively small problem you didn't have to focus on because it didn't confront you that often. And then in the nineties, and the otts the prevalence of opioid addiction and opioid use disorder have skyrocketed and I'll only speak for emergency medicine, but the number of patients that we would see in the emergency department with opiod addiction went from occasional patients, maybe one, every few shifts to multiple patients per shift. And the way that we were trained to manage these patients, classically, we all recognize was not helping these patients. It wasn't improving their lives. In fact, many of these patients just got worse and worse utilizing the strategies that we were taught which was not really to treat the addiction and to hand out percocet prescriptions with a very low threshold until we gave out a lot of Percocets, when I was training and when we began to realize how much harm we were causing with these, again, stigma driven approaches and misinformed approaches, a group of us within emergency medicine, decided to learn more about addiction, how to treat it and to disseminate what we've learned throughout the emergency medicine community. And now I'm proud to say that the treatment of opioid addiction is a part of most emergency medicine training programs and many emergency departments across the country are doing much better for patients with OUD and both in terms of treating OUD and preventing it.
Host: Yeah, that's amazing to hear. So, I guess just a more basic question. How are patients with OUD or opioid use disorder identified in the first place?
Dr. Strayer: So there's a spectrum of ways that patients with OUD can present to the emergency department. The most obvious patients present with addiction harms that are very obvious. So, for example, nonfatal overdose or the severe infections that I alluded to earlier. They can also come in, in withdrawal and they will often say things like I last used heroin 12 hours ago or 24 hours ago, and now I'm terribly dope sick, and I need help.
And then some of them will come in and just say, I'm feeling okay now, but I'm tired of living this kind of life. I'm ready for help. I'm ready for recovery. So they've basically self identified. There are also a variety of patients who have occult opioid use disorder where it's not obvious, and those patients require a little bit more digging. You may have to ask some focused questions, which they may or may not be willing to answer, honestly, because of the stigma associated with addiction. Some of these patients become revealed as having opioid use disorder when they go into withdrawal 12 hours or 24 hours later after you've admitted them to the hospital for their pneumonia or whatever it is, and they start to withdraw on the floor.
That's when they're identified as having opioid use disorder. And then there are I guess a third set of patients who have what we often call chronic pain, it often goes under the umbrella of chronic pain. These are patients who are generally getting a supply of prescription opioids from their prescriber or prescribers and present to the emergency department, not with addiction harms per se, or a request for help, but with pain. And these are some of the most challenging patients to manage because many of these patients do have opioid use disorder, but they don't, they themselves don't recognize it as such.
Host: Hmm. So tell me when OUD is identified, how do you actually go about initiating the conversation with the patient? Like, take me through what exactly that sounds like.
Dr. Strayer: So there are as many ways to do this as there are providers, but the way I think about it is in two steps. So the first question is, is this person who has opioid use disorder, are they revealed to themselves mostly, as having opioid use disorder? Do they themselves understand that they have a problem with opioids, that they have opioid addiction?
That's the first question. And then if they do know themselves that they have an unhealthy relationship with opioids, are they interested in getting help? Are they interested in recovery? So the first two questions that I'm trying to answer for myself is, is this patient revealed as having OUD and if so, are they willing to be treated?
Every provider approaches these conversations differently, but most addiction experts would advocate for a motivational interviewing style where you try to elicit the patient's own goals and values and guide the patient to recognition that their use of in this case, opioids is interfering with those goals and in so doing, you can hopefully nudge them from unrevealed to revealed. And then in those patients who are revealed as having OUD from unwilling to be treated for OUD to willing.
Host: Interesting. So for the patients that are revealed, as you've just covered, what are the most effective treatments and harm reduction practices?
Dr. Strayer: Well, we've learned a lot about this over the past decade or so. And we know now without any doubt, that the most effective treatment for opioid use disorder, for opioid addiction is medication based treatment. There are three FDA approved medications for OUD, buprenorphine, often known by its trade name, Suboxone, methadone, and then the opioid antagonist naltrexone, which is usually administered in a long-acting form trade name, Vivitrol as a monthly depot.
So, those are the most important treatments for opioid addiction. The one that's most relevant to my work as an emergency physician is buprenorphine because I can treat opioid withdrawal and transition the patient to sustained buprenorphine maintenance immediately in the emergency department, all at once by treating withdrawal with buprenorphine in the emergency department. Methadone has a much more limited use from an emergency perspective because it can only be administered for addiction in what are known as opioid treatment programs, OTPs colloquially known as methadone clinics. Vivitrol, which is the third recognized treatment for opioid addiction requires a sustained period of opioid abstinence and is generally initiated in a clinic based setting.
So those are three treatments for addiction for opioid addiction. Again, the one that we would consider first line, both in the ED and in most addiction clinics would be buprenorphine. There are also a series of harm reduction efforts that apply to everyone with opioid addiction, whether they wish to be treated with one of the three medications I just described or not. Those harm reduction efforts include a take-home naloxone.
So nasal naloxone that you can dispense to the patient and anyone that knows the patient for use, if the patient overdoses on opioids at home. We dispense take home naloxone to anyone who wants in the Maimonides emergency department. They don't have to register to be seen. They can just present themselves asking for a take home naloxone kit and we will give it to them.
Other harm reduction efforts include instructions and supplies for safe injection. So syringe exchange, education on how to avoid infections and other consequences of intravenous drug use, screening for infectious diseases like HIV and hepatitis, screening for pregnancy, looking for housing insecurity and food insecurity. Those are the types of harm reduction efforts we undertake in our emergency department all the time, both in patients who are willing to be treated for opioid addiction, and then perhaps more importantly, in those patients who are not yet ready for recovery.
Host: So Dr. Strayer, just as we start to close here at Maimonides, what are emergency clinicians doing to prevent the development of OUD in patients who are presenting with acute pain?
Dr. Strayer: For patients who are not already using opioids, we call them opioid naive patients, there is a lot that you can do as a provider, as a prescriber to make sure that they are not set down the path of opioid addiction by your prescription.
Myself, and many of my colleagues were taught that doesn't happen, that people don't develop opioid addiction from a prescription for pain. But now we know it happens. Now we know that that training was sophisticated industry marketing, masquerading as training for physicians, and that we were essentially duped. The consequences of that disinformation have been profound and have led directly to the opioid addiction and overdose epidemic that we're in the middle of. But we now understand as providers how much harm we can do with prescription for 30 Percocets, for example. And so the most important way to prevent opioid naive people from developing opioid addiction is to not expose them to opioids.
So we have all become much more judicious opioid prescribers. Maimonides has done some of the most important work in this area under Sergey Motov and his team in the areas of opioid alternatives especially with ketamine as an opioid alternative for severe acute pain. And then again, in the domain of judicious prescribing, not only from the emergency department, but throughout the hospital. And the department of surgery under the leadership of Pat Borgen have fairly dramatically reduced their opioid prescribing in collaboration with Sergey and his team to tremendous effect.
Host: Well, Dr. Strayer, this has been a fascinating conversation. I wanted to just ask if you had anything else that you'd like to share with our audience today about OUD or anything else that we covered before we close here?
Dr. Strayer: The most important thing for folks to remember about opioid addiction is that it is a disease. It is not a moral failing. It's not a failure of willpower. It's a disease caused by a combination of environmental factors, like exposure to opioids, social factors, like despair, and how connected one is in the community and then genetic factors, which may be the most important determinant of all, and that there are very effective treatments. So if you know anyone who's affected by opioid addiction, encourage them to get help. There's very effective treatments available for OUD.
Host: Dr. Strayer, thank you so much for educating us today.
Dr. Strayer: It was a real pleasure to speak with you Prakash.
Prakash Chandran (Host): To learn more about Maimonides Medical Center, please visit maimo.org. And that is spelled M-A-I-M-O.org. You can also check out all of our other podcasts for more topics that might interest you. This has been Maimo Med Talk. I'm your host Prakash Chandran. Thank you so much. And we'll talk next time.