A major hole in the healthcare system has many hospitals and health systems fueling the nation's opioid epidemic — unintentionally or not.
A medical bioethicist from a top U.S. hospital is sounding the alarm on it, based on his firsthand experience. In his new book "In Pain: A Bioethicist's Personal Struggle with Opioids," Travis Rieder, PhD, details his recovery after a 2015 motorcycle accident that crushed his foot and triggered six surgeries in a span of months. Physicians prescribed him large doses of opioid painkillers — morphine, fentanyl, Dilaudid, oxycodone and OxyContin. But when he wanted to taper off the powerful drugs, those same physicians were of little help.
"We called everybody, and a bunch of them wouldn't even talk to me," he told NPR. "And this includes the pain management team. They would not speak with me, and the message they sent through a nurse was, 'We prescribe opioids, but we don't help with tapering.'"
Dr. Rieder, a medical bioethicist with Johns Hopkins University's Berman Institute of Bioethics, compared his experience of trying to get off prescription pain medication to a game of hot potato. "The patient is the potato," he told NPR. "Everybody had a reason to send me to somebody else."
Are hospital leaders asleep at the wheel? How could such a major vacuum of care exist amid a nationwide opioid crisis?
To shed more light on the problem, Becker's caught up with Gregory Rudolf, MD. Dr. Rudolf is board-certified in pain medicine and addiction medicine, and since 2004 has worked in a multidisciplinary pain management clinic at Swedish Medical Center in Seattle. "We deal with the issue of opioid management every day and try to be at forefront of best practices," he told Becker's.
Dual training in both pain and addiction medicine is unusual. "We have a lot of siloing when we talk about opioid problems and the issues of tapering, detox and the opioid crisis," said Dr. Rudolf. "Part of the problem is there is sort of the pain camp and the addiction camp. It's not that they are in opposition in the way they think, it's just that the skill sets are quite different."
Read on for specific guidance on how hospitals can improve patient access to detox resources and settings.
Question: One of the most striking insights from Dr. Rieder is the "hot potato" effect that he and other patients experiencing opioid dependency or abuse may encounter when seeking clinical guidance to taper off the substance. Do hospital leaders and health system administrators realize this occurs?
Dr. Gregory Rudolf: You could think of it as a blind spot. Hospital administrators may not be aware that their providers in the pain specialty, if they have them, may not have a lot of skill or experience with helping people through tapering and withdrawal. That's what Travis talked about — his pain specialist didn't offer any ideas for how to taper off opioids. That would probably come as a surprise to hospital administrators.
It's also important to know that inpatient detox services are not found at every hospital. Systems that offer inpatient withdrawal management are actually few and far between, for a variety of reasons. A lot of it has to do with the economics of that service.
Q: Can you expand on that? Why do economics make inpatient detox care an irregular service?
GR: When hospital administrators look at the types of services they want to deliver, they may not jump to the idea of having a detox unit from a financial standpoint — they know it's probably not the biggest moneymaker in and of itself compared to a surgical specialty or other known profitable service. But when it comes to providing really important services in the community and the indirect medical cost savings when you get people help for their addiction … those preventive, hidden savings make a compelling case for a hospital system to say, "This is a service we want to strengthen within our hospital."
Here in Seattle, I'm lucky. We are not only well-represented in the pain specialty setting with a robust offering of services, but we also have an inpatient detox unit at Swedish. We have a strong team of doctors who are experts in addiction; I'm just one of them. There's no shortage of physicians to consult.
Q: Got it. So in addition to looking at the economics differently, what are the two most important things a hospital executive can do within the next year to improve patient access to detox resources and settings?
GR: Well, one thing that hospitals can do in the short-term is become as familiar as possible with local resources in the community and who provides inpatient and outpatient treatment for substance use disorders. Then make sure your hospital is in contact with venues doing good, evidence-based care, and physicians know these services are available in the community. You may not have those services within your system, but you at least need to have a pipeline and know where to refer patients.
One more tangible thing hospital administrators can push is training more doctors on the use of buprenorphine, which requires doctors to complete an eight-hour course and get trained to prescribe and manage the medicine, per federal regulation. Buprenorphine is a strongly evidence-based treatment for opioid use disorder, particularly when used along with other recommended interventions like counseling and peer support groups. However, it is dramatically underutilized both in the context of treatment of addiction and treatment of pain, as it is also a potent pain reliever.
At Swedish, we have two different residency training programs for family doctors, both of which require the residents to be licensed to prescribe buprenorphine in order to graduate. Many hospital systems do not necessarily talk about these services as being important for doctors to be trained in, experienced with and knowledgeable about. We need to make sure our doctors coming out of medical school are armed with skills helpful in the opioid crisis, such as opioid tapering and use of buprenorphine. Patients should be given options.
There are also methadone maintenance clinics available in some communities for those with longer-term opioid addiction who might benefit from a more structured and monitored approach, typically involving daily observed dosing. Is there a methadone clinic locally you can make sure your doctors know about?
Another underutilized medication with good evidence in the treatment of opioid use disorder is called naltrexone, which is an opioid receptor blocker. So instead of an opioid substitute, like buprenorphine or methadone, this medication blocks opioid receptors. The patient experiences no effect from using opioids and cravings are reduced. For patients who don't want or need opioid substitution to stay on the right path in their recovery, naltrexone is an option to strongly consider. But there are challenges in getting patients started on it, because they have to go through withdrawal and be off the opioid they were using for about a week, which is challenging on multiple levels. Here again, having an expert in addiction medicine available is useful.
Q: Let me revisit Dr. Rieder's story again. His care team ignored him when he asked for support to taper off opioids, and finally someone referred him to addiction medicine — a methadone clinic, specifically. When he visited a methadone clinic, he was turned away and told he was not addicted to heroin and was not fighting for his life. This seems like a big gap in detox settings. Where do methadone clinics fit in, and when is it appropriate to refer patients there?
GR: This goes back to what I was saying about how the pain camp is siloed from [the] addiction camp. When his pain management providers didn't feel they could give him guidance with tapering, he had a hard time with that process and was met with shrugged shoulders.
He was told he could seek addiction treatment, but the methadone clinic setting, specifically, is not really designed to help people taper prescribed opioids in short-term fashion. People like Travis who are taking medication as prescribed and are not engaging in aberrant behaviors but get to the point where they want to discontinue it — the methadone clinic isn't really set up for them. It's more for people who are using illegal opioids like heroin, getting pills from street sources, or are otherwise out of control with their use of their prescriptions.
The methadone clinics, at least those I'm familiar with, are really designed to get people stabilized on methadone and be kept on it for at least six months to stabilize their addiction, which often involves lifestyle changes in addition to medication treatment. When you come into a methadone clinic with the agenda of tapering over a few weeks, that is not consistent with their purpose in the sphere.
Q: What's one thing about your work that has surprised you?
GR: I'm regularly surprised and inspired by the courage and resiliency of people with substance use problems who I encounter when they seek treatment. With proper treatment and support, including medical and behavioral interventions and regular monitoring to avoid relapse, we do see patients succeed. Not only in recovery from addiction, but in their personal and professional lives.
I think there is a tendency of providers of medical care to be skeptical and judgmental. There is a lot of stigma attached to people who use drugs, and they encounter it every time they interface with the medical system. Rather than having a "not in my backyard" mindset, hospitals should be thinking of this as an opportunity to provide lifesaving, life-changing care that will have effects on promoting the hospital in the local community.
Q: Are there any approaches to opioid detoxification or tapering that you'd like to challenge or dispel?
GR: Unfortunately, a lot of licensed providers of addiction treatment and pain treatment — individuals and organizations — do not provide evidence-based care, and they do not use best practices or medications to treat substance abuse disorders or manage withdrawal. These are places that don't want to embrace current evidence of what works, and that's unfortunate.
Detox by itself is not effective for substance abuse disorders. That is only the first step to get past withdrawal, then there is the challenge of recovery. Even people who do rehab for a two- to four-week stint, their success rates go down dramatically if they don't do outpatient care. It's relatively easy to stay sober in the facility. Use of appropriate medication coupled with longitudinal treatment, which might start in the inpatient setting, then outpatient substance use disorder treatment along with frequent points of contact and monitoring by the medical team — this is the formula for success. The people who are going through this long-term process, with medication included, have better outcomes.
Another concept gaining traction is contingency, which is like probation. When you come out of jail, you have to answer to a probation officer. There is more talk in the addiction community and lots of good research to support the use of contingency. Evidence shows it's effective when some consequences are attached, which don't have to be negative; they can be positive consequences. People are trying to think out of the box and use all of the best evidence available to keep patients from making impulsive, bad choices that send them in the wrong direction.