With opioids in wide circulation, Dr. Gail D’Onofrio, chief of emergency medicine at the hospital and chair of emergency medicine at Yale School of Medicine, isn’t sure that one-day spike will stand as a record.
“To be honest, no, I don’t expect the numbers to get better,” D’Onofrio said. “We’re going to have more treatment options in Connecticut, I think, more safe prescribing — but I don’t know that we’ll see improvements in the numbers of people using.”
Lisa Chedekel Photo.
Dr. Gail D’Onofrio, chief of emergency medicine.
D’Onofrio’s concerns are borne out in a recent report by the Agency for Healthcare Research and Quality (AHRQ) that ranks Connecticut the 5th highest among 30 states in the rate of opioid-related emergency department (ED) visits — 254.6 per 100,000 population in 2014, well above national rate of 177.7. For inpatient stays related to opioid use, the state ranked 7th highest among 44 states, at 337.5 stays per 100,000 – above the national rate of 224.6.
Leading in ED visits was Massachusetts, followed by Maryland, Rhode Island and Ohio. States with the lowest rates were Iowa, with just 45.1 visits per 100,000 population, Nebraska and South Dakota.
The report shows that Connecticut’s rate of opioid-related inpatient stays increased 28.5 percent between 2009 and 2014, while its rate of ED visits increased 35 percent. Nationally, those rates increased 23.8 percent for inpatients and 65.6 percent for ED visits.
The hospital data comes as the state medical examiner’s office reported that 917 people died from overdoses in 2016 – a 25 percent increase over 2015. The largest increase involved the synthetic opioid fentanyl, which was responsible for the June overdoses at Yale New Haven.
D’Onofrio and Dr. David Fiellin, professor of medicine at Yale, said that while fentanyl, which is 50 to 100 times more potent than morphine, is not a ‘new’ drug, its availability outside of medical settings has skyrocketed. The dual use of opioids and benzodiazepines is also fueling the death rate, they said; in Connecticut, the tranquilizers are involved in nearly half of fatal overdoses.
In October, a Yale-led group convened by Gov. Dannel Malloy issued a report recommending ways to reduce overdose deaths. The CORE (Connecticut Opioid REsponse) report, of which D’Onofrio and Fiellin were co-authors, calls for increasing access to treatment, especially with the medication buprenorphine, which reduces opioid cravings; targeting overdose survivors for education and treatment programs; increasing physician adherence to prescribing guidelines; and increasing access to overdose-reversing naloxone, among other initiatives.
According to the CORE report, the number of non-fatal, opioid-related overdoses treated at Connecticut’s acute-care hospitals increased from 895 in 2012, to 1,217 in 2014 – a 36 percent jump.
While there’s nothing to stop some overdose survivors from walking out of the ED after being revived by naloxone (Narcan), Yale has expanded its interventions, including starting opioid users on buprenorphine and referring them to primary care. A 2015 study led by D’Onofrio and Fiellin found that ED patients who received buprenorphine that was continued in primary care were twice as likely as other opioid users to remain engaged in treatment within 30 days. Yale has received a federal grant to pilot the buprenorphine intervention at four other hospitals around the country.
Yale’s ED team, which includes outreach workers, offers brief counseling and referrals to all opioid users, in hopes of connecting them to treatment programs, D’Onofrio said. While she said New Haven has enough treatment slots, other areas of the state do not, and treatment is further hampered by a shortage of providers who accept Medicaid and other forms of insurance, as well as co-pays and deductibles that limit access to buprenorphine and other medications, the CORE report says.
D’Onofrio said that, given that illicit opioid addiction often stems from a medical prescription, one key to reducing use is educating and closely monitoring prescribers. The state report shows that a small subset — about 10 percent — of prescribers write out more than 500 controlled-substance prescriptions a year. It recommends identifying prescribers who provide patients with high amounts or dosages of opioids.
The state has passed a number of laws intended to combat the opioid epidemic, including requiring first responders to carry Narcan, limiting initial opioid prescriptions to seven-day supplies in most cases, and requiring pharmacies to enter information about controlled substances into the electronic Connecticut Prescription Monitoring and Reporting System (CPMRS) by the next business day.
Gov. Dannel Malloy recently proposed several new measures, including requiring all opiate prescriptions to be filled out electronically, and encouraging state agencies to share information on opiate prescribing. Some lawmakers have proposed even tougher restrictions, including barring primary-care providers from prescribing opioids and requiring health insurers to cover long-term addiction treatment.
On the federal level, a group of Senators including Connecticut’s Richard Blumenthal and Chris Murphy recently re-introduced the Budgeting for Opioid Addiction Treatment Act (LifeBOAT Act), which would establish a funding stream to expand addiction treatment from a tax equal to one cent per milligram on the sale of active opioids b a manufacturer or importer.
D’Onofrio and Fiellin said there is no ‘typical’ opioid user, so targeting interventions to certain populations is difficult. The Yale ED has treated professors, lawyers, housewives and homeless people for opioid addiction. Statistics from the state medical examiner’s office show that about 75 percent of the 2016 overdose deaths were of men and 78 percent were white, with ages ranging from 17 to 73. About half were in their 30s and 40s.
For now, D’Onofrio said, expanding access to naloxone is critical.
“I think we really need to get as much Narcan out into the world as possible,” she said. “If I had my way? It would be in every Starbucks.”
C-HIT is hosting a free Community Forum on women and opioid addiction on April 6 in New Britain. For information and to register click here.
