By Fran Kritz
Every day at Cooper University Hospital in Camden, N.J., emergency room doctors treat, on average, five to fifteen patients who have overdosed on opioids.
Some die, but many are revived and quickly discharged—usually in search of drugs.
Rachel Haroz, MD, an emergency room physician and toxicologist at Cooper, has seen many patients return to the ER, again and again. One came back more than 100 times in one year, Haroz and another staffer assert.
Sometimes they return for other drug-related problems, including psychiatric crises or injection-related infectious diseases, like the heart-valve inflammation known as endocarditis.
“We know we can’t get a handle on those other conditions until we treat the addiction,” says Haroz.
About a year and a half ago, doctors at Cooper took steps to end this cycle of despair. In conjunction with the hospital’s Urban Health Institute, they opened their own outpatient addiction treatment center: Outreach Clinic. It gives patients a viable treatment option. They faced long wait-lists at existing methadone clinics, and lacked the cash, identification, or insurance required by other facilities.
The clinic is located on the Cooper Hospital campus, a short walk from the ER. If patients need a state-issued identification—legally required to receive certain medications—hospital staff help them get it. If patients can’t afford to pay, staff help them seek insurance reimbursement and treat them regardless.
Where the law permits, it’s medically appropriate, and the patient agrees, doctors begin providing medication-assisted treatment, or MAT, right in the emergency room. A study last year in the Journal of General Internal Medicine found that patients who started MAT in the ER had a better chance of staying in treatment for two months than those who were merely counseled about, or referred to, treatment opportunities—the standard practice at hospitals.
“If you’re having a heart attack, do you want me to tell you about heart attacks, or treat you for the condition?” asks Gail D’Onofrio, MD, in an interview with Opioid Watch. D’Onofrio is chief of emergency medicine at Yale-New Haven Hospital, and the lead author of that study.
(By law, hospital personnel are not permitted to give one of the MAT medications, methadone, unless the patient is suffering from active withdrawal symptoms. MAT is a long-term regimen in which the patient is prescribed one of three opioid-substitution medications—methadone, buprenorphine, or naltrexone—to stanch cravings and block euphoria if the patient does take other opioids. There is broad consensus in the public health community that MAT is the safest and most effective therapy for opioid use disorder, yet fewer such programs exist than detox programs aiming for abstinence. MAT is also controversial because it contemplates lifetime maintenance on the medication, two of which—buprenorphine and methadone—are themselves opioids.)
Cooper is at the forefront of a movement among hospitals to start doing more with opioid overdose patients than simply reviving, stabilizing, and discharging. About a third of overdose victims will have another overdose within a year, according to addiction psychiatrist Adam Bisaga’s new book, Overcoming Opioid Addiction. For intravenous heroin users, he writes, half who survive an overdose will eventually die of another one.
“You have a chance in the ER to do something to prevent it,” Bisaga told Opioid Watch in a recent interview. “If you don’t make sure you do everything possible to hook this person up with treatment, many of these people will die.” (Other New Jersey hospitals have begun hiring former drug-users to make a connection with overdose patients in the ER and to urge them to seek treatment.)
Between 2014 and 2016, Camden County had 475 drug overdose deaths, the highest per-capita rate in the state.
Located just across the Benjamin Franklin Bridge from Philadelphia, the city of Camden has the third-lowest median income in the U.S. It was once home to RCA Victor, and still hosts Campbell Soup’s corporate headquarters. But Camden’s economy has stagnated since World War II, as manufacturing and shipbuilding jobs dried up. Today, the Cooper University Health Care system, with its 7,000 workers, is one of the city’s biggest employers. In fact, the hospital campus is a rare bright spot in a town that otherwise looks tired and broken, like the patients one sees at Cooper’s ER and clinic.
The clinic is staffed by physicians trained in addiction medicine, nurses, social workers, and behavioral health staff. The staff work with patients to choose the medication and dose appropriate for them. But treatment also includes individual behavioral and group therapy. For many patients, their drug use is associated with a history of abuse, mental illness, homelessness, poverty, or all of these issues. Therapists work with patients to address their personal trauma, explore why they sought out drugs in the first place, and help them identify skills and consider school and work options.
“We’re not stuck in one treatment modality,” says Iris Jones, an addiction therapist at Cooper.
Many of the clinic staff also spend time at the hospital’s emergency room. They recognize when people are seeking help without saying so. Family members who bring a relative in for an injury or illness may let slip that the patient is abusing drugs. Or patients may come in for a suspiciously mild illness or injury—a tip-off that they may want to be asked about their drug use, says Haroz.
Staffers in the ER also come across patients they know from the clinic, who have relapsed. The staffers do not give up. “When people are struggling, we don’t kick them out, we bring them closer,” says Kaitlan Baston, MD, the clinic’s medical director.
“I wouldn’t say to a diabetes patient: ‘Well, you didn’t work out yesterday and you ate chocolate cake, so no insulin for you,’” says Zinta Zapp, MD, a third year ER resident who plans to specialize in addiction medicine.
The need in Camden far exceeds what the Outreach Clinic can currently offer. There is sometimes a several-day waiting period to start treatment, Haroz says—though pregnant women are always accepted immediately. The clinic is only open weekdays, but doctors are on call 24/7 for patients seeking help, she continues, and will see them in the emergency room to discuss and either give or prescribe MAT, if needed.
“With more funding, we’d double our staff and expand our hours,” she says. She hopes an upcoming clinical trial, which will be including Cooper hospital and the clinic, will further establish the value of ER-initiated MAT, spurring more financial support.