By Steven R. Carson, RN, BSN, MHA, CEO, Temple Center for Population Health, LLC
When more than 72,000 Americans died from overdoses of prescription and illicit opioids in 2017, the crisis was declared a nationwide public health emergency.
Of those deaths, 5,456 occurred in Pennsylvania — most of them in the Kensington neighborhood, near Temple University Hospital - Episcopal Campus.
What does this mean for Temple Care Integrated Network (TCIN) partners managing their patients with Opioid Use Disorder (OUD)?
Opioid addiction is more difficult to treat than other substance abuse disorders because physical dependence on prescription pain relievers like oxycodone, synthetic opioids like fentanyl, or illicit substances like heroin can occur in as few as four to eight weeks. Fentanyl is 50 times more potent than heroin and 100 times more potent than morphine and is often available as illegally manufactured counterfeit pills. Contributing to the difficulty is the fact that more than half the predisposition to OUD is genetic.
Temple and the Max Planck Institute have identified more than 1,000 changes in the brain after a single exposure to an opioid; some can be seen under a microscope. With repeated opioid overuse, the tips of nerve cells wither, impairing cognitive function. The user’s brain becomes very sensitive to the lack of opioids, driving the user to crave more opioids to avoid the stress of withdrawal. When chronic users abruptly stop using opioids, severe symptoms including cramps, diarrhea, restlessness, anxiety, nausea, vomiting, and insomnia occur.
Chronic Lifelong Disease
OUD is officially recognized in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, as a chronic lifelong disease. Mental health problems often accompany the physical illnesses associated with OUD. However, only one in four people with OUD receives specialty treatment, according to the American Psychiatric Association.
Healthcare services and costs are severely impacted by incidents of patients with OUD seeking use of hospital (ER and inpatient) and other care resources. A study published in 2017 in the journal Healthcare found that patients with OUD use costly levels of care like ER visits more often than general populations. However, patients with OUD who accessed integrated residential treatment for concurrent substance abuse and mental health disorders were far less likely to seek subsequent substance use care through the ER or hospital admission, resulting in significant savings over pretreatment costs.
Evidence-based care in the form of office-based opioid treatment (OBOT) using FDA-approved drugs — buprenorphine and naltrexone — has proven effective in conjunction with counseling and behavioral therapies that include education about relapse prevention. These drugs generally block the effects, reducing withdrawal symptoms and cravings and preventing the feeling of euphoria. Buprenorphine is on the World Health Organization list of essential medicines whose access is critical for those interested in pharmacologic treatment of opioid use disorder. In order to prescribe buprenorphine, physicians and NP/PAs must attain a waiver (download guidance on how to set up an OBOT program in your office [PDF]).
To help TCIN partners confront the challenges of treating their patients with OUD, Temple Health’s Substance Abuse Task Force was created to change the opioid treatment paradigm for North Philadelphia. Temple’s TRUST (Temple Recovery Using Scientific Treatments) program provides community physicians with greater access to the expertise, resources, and evidence-based treatments used by Temple University Hospital.