Battling the opioid epidemic

The approach is based on an innovative plan called Project ECHO, or Extension for Community Healthcare Outcomes, that is being used by the University of New Mexico. The goal of this model is to break down the walls between specialty and primary care by linking experts at an academic ‘hub’ with primary care doctors and nurses in nearby communities.

Basically, medication-assisted treatments involve using any one of a number of medications to help people with opioid dependence become more functional. Methadone can only be dispensed through an opioid treatment program, of which there are 16 in South Carolina. “They are not in every county and sometimes they are miles apart,” Brady said.

Another medication, buprenorphine, is now available in an implant that lasts six months and is expected to soon be available in an injectable form that will last one month. 

“There are physicians who are able to prescribe buprenorphine in South Carolina, but they are all focused in our urban areas. In Georgetown, there are only five physicians and Horry County is one of our worst areas as far as overdoses go.”

Doctors are limited to how many people they can treat. Another issue is cost. Medicaid just started covering buprenorphine in the state, and even with that, it can take several layers of authorization to get it approved, she said. “And a lot of insurances don’t cover it.”

The network will help with that. In the short term, it will provide medications for people who can’t afford them. The SC MAT ACCESS project will also raise awareness and provide linkage to treatment programs that are part of the Department of Alcohol and Other Drug Abuse Services. “DAODAS  has programs in most counties throughout South Carolina. They are doing state-of-the-art addiction treatment, but many do not offer MAT,” Brady said. “There are too few of them, and people aren’t referred to them from their primary care. Even when they are, payment is a problem, and these centers are operating on a shoestring budget.”

Lack of funding and insurance coverage will have to be addressed, Brady said. MUSC doctors and researchers will have strong representation at the 2017 SC Governor’s Opioid Summit and are working with state legislators to come up with solutions. 

The Substance Abuse and Mental Health Services Administration issues block grants to every state for the treatment of addictions. It funds DAODAS, and each state is supposed to match that grant. “Some states do more than match it. Some states, like California, they give extra. SAMHSA has the right to take it away if your state doesn’t match it.”

Brady said she’s glad to see more engagement from state legislators to address the opioid epidemic. 

Changing culture 

To stem the opioid crisis, it’s important to get to the root of the problem. It’s not just about “addicts” out searching for drugs, she said.

“There is a lot pain. Pain is the No. 1 reason people go to the doctor. You can’t ignore it, but we need to find better ways to treat it. Doctors have gotten a bit of a bad rap in all this because much of the opioid epidemic stems from medications that are prescribed. But in the 1990s, they called pain the fifth vital sign. Doctors have been pushed pretty aggressively to manage pain. Adequate treatment of pain is one of the leading indicators of patient satisfaction.”

There has been very little research about alternative treatments for pain, but what research has shown so far is that opiates are one of the most effective, at least in the short term, treatments available, she said.

Long term, it’s a different story, so one goal of the network will be to teach doctors better methods for pain management and to develop new options.

“Doctors have gotten little education about opioids and the dependence-producing capabilities or about alternate ways of managing pain. Insurers often don’t pay for alternative, multi-modal treatments of pain. Insurers, all too often, also don’t pay for the treatment of addictions. This is an opportunity to change some of this for the better.”

At the 2017 SC Governor’s Opioid Summit, MUSC clinicians and researchers will be lobbying for sustainable change. Among those attending will be Kelly Barth, a psychiatrist and internal medicine doctor at MUSC Health who specializes in the management of chronic pain and opioid dependence.

She’s excited to be starting the MUSC Health Intensive Program for Pain Rehabilitation, a three-week outpatient program where pain patients receive daily physical therapy, psychotherapy and medical management — all while being weaned off their opioid pain medications. “We need a civilized exit plan so we’re not abruptly taking people off their pain medications,” Barth said. "There’s a huge need to treat chronic pain. We need to change the culture of how we treat pain.”   

Attitudes about addiction also need to change, Brady said.

“In the long run, we must leverage this for sustainability. We must use this bully pulpit afforded by the opioid epidemic and his short-term funding to create an opportunity to talk about an infrastructure and systems for early detection and prevention and systems to access treatment. We have to make it more acceptable and accessible.”

She hopes more people will realize addiction is a disease. “We have effective treatments. We need to come out of the closet as far as our awareness of these addictions. We need to destigmatize these disorders so people will feel more comfortable accessing the effective treatments we do have.”

There’s a need for public figures to talk about it, but also for people to open up in their private and social settings to start conversations, she said.

“If you think about this, one in four to five people in the U.S. has had an addiction at some point in their life. They are all over the place — your boss, your friends — but they probably don’t talk about it. Addictions affect people of all races, religions and socioeconomic class. They are curable, so it’s critically important that we encourage people to get the treatment they need.”

What you should know about opioid use

Dr. Kathleen Brady's top tips for patients:

• You can take responsibility for your pain management. If you’ve had a procedure that causes pain, you should take opiates as needed. But if you take an opiate daily for three weeks or more, you are going to have some level of physical dependency. 
   
• Ask your doctor about tapering. Take opioids only as needed and supplement with other non-opioid type medications.
   
• Opioids are not the best treatment for chronic pain. If the pain turns from acute to chronic, then seek alternative treatments, such as electrical stimulation treatments or other medications. Antidepressants, non-steroidals like Ibuprofen and anti-seizure medicines can work.
   
• When you are prescribed opiates, treat them with care. Many of the overdoses in kids are teenagers raiding their family’s medicine cabinets. These should be kept in locked compartments and disposed of properly. It’s a recipe for disaster.
   
• Beware of new drug imports. Brady said fentanyl is probably 10 times as potent as morphine. Carfentanil, used to tranquilize large animals, is 1,000 times more potent. “Carfentanil, especially, will kill you in a second, and it’s getting mixed in with other drugs. People think they are buying heroin.”

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MUSC researchers pictured in lead photo, from left to right

Colleen Halliday-Boykins, an associate professor in the Department of Psychiatry and Behavioral Sciences specializing in racial disparities in youth vulnerability to substance use and abuse

Constance Guille, an associate professor in the Department of Psychiatry and Behavioral Sciences specializing in reproductive psychiatry with a focus on opioid use disorder in pregnancy

Ray Anton, a distinguished university professor in the Department of Psychiatry and Behavioral Sciences, specializing in alcohol use disorders, pharmaceutical therapy and biomarker lab tests for alcohol use

Angela Moreland-Johnson, assistant professor in Department of Psychiatry and Behavioral Sciences, specializing in trauma-related consequences and health disparities 

Sarah Book, a professor in the Department of Psychiatry and Behavioral Sciences specializing in the treatment of addiction and psychiatric co-morbidities

Sudie Back, a professor in the Department of Psychiatry and Behavioral Sciences specializing in addiction and post-traumatic stress disorder

Justin Gass, an assistant professor in the Department of Neuroscience specializing in addiction and post-traumatic stress disorder

Nathaniel Baker, a research instructor in the Department of Public Health Sciences specializing in data analysis and biostatistics

Aimee McRae-Clark, a professor in the Department of Psychiatry and Behavioral Science and director of the Office of Research Integrity specializing in medication development for substance use disorders

Jacqueline McGinty, a professor in the Department of Neuroscience, specializing in addiction biology

Ebele Compean, a resident in the Drug Abuse Research Treatment Program in the Department of Psychiatry and Behavioral Sciences

Kevin Gray, a professor in the Department of Psychiatry and Behavioral Sciences and director of child and adolescent psychiatry specializing in substance use disorders in adolescents and young adults

Christopher Cowan, the William E. Murray Endowed Chair of Excellence, specializing in brain development, autism spectrum disorders and drug addiction

Howard C. Becker, a professor and director of the Charleston Alcohol Research Center, specializing in the neuropsychopharmacology of alcohol addiction

Peter Kalivas, a professor and chairman of the Department of Neuroscience specializing in neurobiology and synaptic plasticity 

Colleen Hanlon, an associate professor in the Department of Psychiatry and Behavioral Sciences specializing in developing brain stimulation as a new treatment for cocaine, alcohol and opiate dependence

Michael Saladin, a professor in the College of Health Professions specializing in addictions, trauma, stress, learning and memory

Kelly Barth, an associate professor in the Department of Psychiatry and Behavioral Sciences specializing in opioids and other pain medications

Lynneice Bowen, a resident in the Drug Abuse Research Treatment Program in the Department of Psychiatry and Behavioral Sciences

Elizabeth Santa Ana, associate professor in the Department of Psychiatry and Behavioral Sciences specializing in testing new ways to deliver evidence-based treatments, group motivational interviewing targeting substance use disorders and tobacco dependence and home-based telehealth for people with substance use disorders

Kathleen Brady is in front.