The front lines of the opioid crisis run straight through Philadelphia's emergency rooms.
They are where doctors have to decide whether to prescribe opioid medication for patients presenting with acute pain due to injury or illness — and risk setting off or feeding an addiction. And these are the places where doctors can reach patients already in addiction, coming to the ER after an overdose or for injection-related wound care.
As rates of addiction and overdose deaths have mounted in the Philadelphia region, ER doctors have worked to change the way they prescribe opioid medication and addiction treatments.
"Emergency departments have really rallied to trying to be on the front lines," said Jeanmarie Perrone, director of the division of medical toxicology at the Perelman School of Medicine emergency medicine department. Since 2012, physicians from 21 emergency departments around the region have been meeting periodically to share data and compare their efforts to combat the crisis.
A case study by Perrone and colleagues at Thomas Jefferson University Hospital and Penn Presbyterian Medical Center, published recently on the New England Journal of Medicine's Catalyst website, found that opioid prescribing had dropped by an average of 37 percent between 2011 and 2016 at eight area hospitals in the working group. Fifteen hospitals in the group have gone on to develop new opioid-prescribing guidelines; before they started meeting, only four hospitals in the group had done so.
"Efforts to galvanize the network of EDs across an urban center can have significant impact on a potentially higher-risk, city-wide population and can rapidly change patient and provider expectations about opioid use," the authors wrote. The report goes on to say that even though emergency doctors specialize in acute problems, they also can be "ideal partners and agents in developing innovative approaches to public health issues" by giving people in addiction medication to encourage their recovery.
Perrone has led efforts in Penn's emergency departments to prescribe suboxone, one of the medicines that, research shows, greatly increases the chances of a lasting recovery. Suboxone itself is an opioid; used as directed, it works to stave off the withdrawal pains that send people back to using, without creating euphoric effects. Patients have to be several hours from their last dose of heroin to start suboxone, so it's not always advisable to prescribe it directly from the ER — but emergency physicians in the area are working to help patients gain access to treatment as easily as possible.
Too often, Perrone said, patients get their overdoses reversed through naloxone administration, or are treated for an addiction-related injury or illness, and then are sent out of the hospital without immediate help to stay away from heroin. "It's about building a culture where everyone thinks about it, for every patient," Perrone said.
Still, physicians are quick to note the irony surrounding hospitals' efforts to combat the opioid crisis: State regulators and insurance companies restrict doctors from dispensing high doses of opioids for pain relief. Yet it can be even harder to prescribe treatment to fight an opioid addiction.
Since last fall, Penn Presbyterian's ER has run a version of "warm handoffs," connecting its patients with treatment directly with the help of peer specialists who have been through addiction and recovery themselves. But before then, hospital policy dictated that doctors could prescribe suboxone only for a patient who was already on it and just needed a prescription renewed.
Perrone and her colleagues lobbied administrators to allow new suboxone prescriptions so they could take advantage of the crucial hours when a patient may be shaken by a crisis, and open to help. Other area hospitals, like Temple University, also employ this practice.
The change is more than a matter of hospital policy, though. Any doctor can dose a patient with suboxone in the hospital. But U.S. Drug Enforcement Administration regulations allow only physicians who have had extra training to send a patient home with a suboxone prescription. ER doctors don't want to stand in for long-term treatment, which also includes talk therapy and other interventions. But they do want patients to have enough to tide them over until they can get into a treatment clinic.
Not all doctors want to get that training, said Rachel Haroz, an emergency medicine physician at Cooper University Health Care.
"People really felt uncomfortable getting a special license to treat what they call 'drug addicts,' " she said. "And we didn't treat them, for so long. We did nothing for them — if anything, we gave them a bunch of papers and they walked."
Haroz helps run her health system's addiction clinic, which opened in 2015 and takes patients from the emergency room and other departments around the hospital. When it opened, it was one of the first of its kind in the country. Initially, Haroz wanted to model the hospital's suboxone program on similar initiatives at other hospitals, where physicians were able to link patients with outpatient-addiction treatment within a few days after their hospital visit.
"But we didn't have any providers — we had nowhere to send them to," she said. "So we said, OK, we have to start our own." Temple University Hospital now runs a similar clinic.
Doctors at Philadelphia-area emergency rooms were among the first to see the prescription-fueled crisis. Some have been cutting back on opioid prescribing for more than five years, since first noticing an uptick in ER patients complaining of pain and asking for specific drugs to soothe it.
Daniel del Portal, who helped draft Temple University Hospital's opioid-prescribing guidelines — the first of their kind in the city — remembers conversations with pain patients when he was a resident.
"It was like a case-by-case negotiation" over the patient's risk of addiction, he said. But those discussions have gotten easier.
"In the past five years, we've gone from, 'Doc, give me the strongest thing you've got,' to 'I don't want that, I'm not looking for something like that.' Word has gotten out into the community about the risk of these drugs."
Chronic pain patients have said that insurer and government crackdowns on opioid prescribing have made it harder for them to access the medications they need to get through daily life.
"We looked at chronic pain" while coming up with Temple's ER guidelines, del Portal said, "and we felt the ER wasn't the best place to manage that." The guidelines also recognize research indicating that opioids are not the solution for all kinds of acute pain.
Under Temple's guidelines, doctors are discouraged from dispensing opioids to patients with acute or chronic dental or back pain, migraines, or chronic abdominal pain, and won't prescribe opioids to patients who run out of pain meds. They try to refer chronic pain patients to pain-management programs that can treat them more holistically than busy ER doctors can.
"We're trying to keep opioid-naive patients opioid-naive, unless they've failed other therapies," he said. "If we need to prescribe opioids, it's for short-term therapy. Most ERs are saying, 'We're giving you enough to get through a few days.' "
Del Portal's colleague Joseph D'Orazio, the director of the Division of Medical Toxicology in the emergency department at Temple's Lewis Katz School of Medicine, said he's been encouraged by "buzz" around prescribing and administering addiction treatment from emergency departments — but EDs are still just beginning to figure out how to do it.
"We are on the front line, and we are best equipped to manage addiction in an acute scenario — we manage drug overdoses more than any other type of physician," he said. "We're adept at understanding those problems — we're just not very comfortable treating these problems. We're going in the right direction, but we've still got a long way to go."