“We have to own our piece of it and hold each other accountable.”
Stephen Leffler, MD, saw the opioid epidemic develop first-hand treating patients in the University of Vermont Medical Center’s Emergency Department, and now helps shape the response to it as a senior leader. He shares his perspective on how we got here, what seems to be working and what challenges lie ahead. Watch the video highlight or read the full interview below.
How did we get here?
About 10 years ago, maybe even a little longer than that we started seeing people come in to emergency rooms in Burlington and rural areas with opiate-related overdoses and serious illnesses like heart valve infections, skin infections, and bone infections. We weren’t seeing that, I’ll tell you, 15 or 20 years ago. At that same time, there was a big push about the pain score and that everyone should lead a pain-free life, and there were some new medicines around that allowed people to take opiates on a longer-term basis than had been done in the past. We started seeing the side effects of that, started seeing people that were getting addicted and were having life-threatening illnesses, and we started seeing some overdoses and people dying.
At first, it wasn’t totally clear that these people were getting addicted from medications we were prescribing. But over time it became quite clear that, while it was done in good faith to help their pain, those prescriptions were causing complications and side effects such as addiction, and building tolerance so people needed higher doses. So, we started thinking about, “What’s our role in this? How can we help cut down on people becoming addicted to opiates, and how can we help treat people compassionately who have developed substance use disorder?”
About four or five years ago, we started using our electronic medical record and our prescribing tools to get a baseline measurement of how many opiates we were prescribing. Then we worked with our pain specialists to say, “What do you think a safe dose is for someone to be on? What’s the right amount that will give patients the most benefit with the lowest risk possible?” They came up with some general guidelines. We overlaid those guidelines onto our providers to look at what people were prescribing, and shared the data with people who were falling outside that limit in prescribing. We didn’t accuse them of anything. We just said, “Look, we think this is probably the best for your patients”, and that had an immediate effect. Pretty quickly those providers were able to have good conversations with their patients and start bringing them back into compliance with what we thought were the best practice guidelines at the time.
We also were able to show all providers what their data looked like. I’m an emergency physician. How my prescribing patterns as an ER doc compared to my peers … it was enlightening information, and it was quite a bit of variability to start with. But by continually showing people the data and letting people know who appeared to have best practices, we’ve decreased prescribing opiates by more than 60% across UVM Medical Center providers over the last three and a half years. We’ve done that without a significant increase in patient complaints. We’ve done that in a way that’s compassionate to our patients, and now we have almost every patient that we care for who needs opiates – and some people definitely do need them – into what we consider to be safe prescribing practices. So, by doing that, we’ve been able to decrease the number of people getting large prescriptions, and that helps decrease the number of pills that are getting onto the street accidentally.
There have been some positive developments in the epidemic – opiate overdose deaths held nearly steady statewide and dropped 50% in Chittenden County in 2018, and waiting lists for treatment have been virtually eliminated over the past two years. What’s behind those changes?
Looking at the death rate for Chittenden County and for the state, I believe, shows that we’re on the right track, that we have the right people coming together, in a regular way, to start making a difference in the epidemic that we’re in. First, reducing the amount of opiates prescribed, as I just mentioned. We’ve gotten many, many more people with substance use disorder into treatment. We still have work to do there. We’re doing a lot of research around the right number of pills for our patients after acute care surgery to go home with, or after injuries, and also research around the best way to treat people with substance use disorder. But, we can’t declare it a victory. This (overdose deaths) is maybe the first battle where it looks like we’re going to win, but this is going to be a 20-year issue, a generational issue, where we have to, number one, stop any new patients from becoming addicted from prescription opiates. We have to get every person out there who has substance use disorder into treatment. That’s not just medication. That’s often times addressing other issues in their lives to help them maintain good treatment. And we have to continue our research so that we know the best ways to treat people with acute pain and chronic pain and the best ways to manage people who have substance use disorder for the long-term, just as we manage a chronic illness.
The UVM Health Network is just one of many groups working together to combat this epidemic. Do you think partnerships have played a big role in the progress that has been made?
Dealing with something as complex as substance use disorder takes more than any one entity could do. It takes more than doctors prescribing medications, more than our police departments arresting people and putting them in jail, more than our mayors and governors talking about this, more than our teachers educating our youth. It takes all those pieces together. I heard U.S. Senator Patrick Leahy about five years ago say, “We cannot arrest our way out of this problem”, which I thought was a brilliant thing to say. I’ve taken what he said and built on it. We can’t arrest our way out of the problem. We can’t prescribe our way out of the problem. We can’t have meetings to get out of the problem. We can’t legislate our way out of the problem. We’ll have to come together, own our piece of it, work together, hold each other accountable in a way that all those things working together will end new patients entering into this substance abuse epidemic and compassionately treat people who already have a chronic illness, which is substance abuse disorder.
How has the view of this patient population changed?
Ten years ago, we thought people who had substance use disorder had a moral failing, that they had done something wrong and if they chose to, they could stop. Then the literature started becoming much more clear that this was much bigger than a choice or moral decision, that addiction had chemical effects on your brain that were really out of your control. We started having a shift in thinking, to thinking this is much more like hypertension or diabetes. I will tell you that as recently as five or six years ago, if someone was getting treated for substance use disorder with medications and they had a slip-up and they used heroin over the weekend or something like that – which we know is part of the course of the illness – we would cut them off from treatment, take their medication away, which would basically drive them back to using heroin regularly because they have an addiction issue.
The flip side of that is people who have high blood pressure or high cholesterol, if they go out to McDonald’s today and eat two Big Macs and a large fry and their doctor sees them tomorrow and their cholesterol’s up, we don’t take away their cholesterol medicine for life. We don’t force them out of the practice. So, we started having that conversation between the doctors and other providers regularly, and trying to help people understand this is a chronic illness. There are many chronic illnesses we treat for life with medication. We don’t have big issues with that, and treating this substance use disorder for life for people who need it is not that different than treating people with hypertension. We know that the treatment works. It gets people back to work, back to productive members of society. It lets them be part of their families again and gets them back to being healthy.
Initially, providers were saying, “I can’t manage this population in my practice. It’s going to be difficult to do. They’re going to be very time-consuming”, but we’ve put supports in the practices to help the providers. And these patients move seamlessly through the practices identical to everyone else. It really has not been a significant burden. Interestingly, when you look at this population, they were always our patients. Many, many of these people were already in our practices, in our Emergency Departments, in our walk-in clinics. We were treating them for chronic illnesses like diabetes, low back pain, hypertension, and if they were getting treated for substance use disorder they had to go somewhere else to get that, so it was not coordinated, seamless care. Or they were not getting treated at all and they were getting their prescriptions illicitly. So, over the last three to five years, as we’ve started to bring these patients in and by treating the whole patient – mental health issues, substance abuse disorder issues and their chronic illnesses – we’ve been able to coordinate their care much better.
This is best for the patients. It’s best for the system. It’s best for our providers, ’cause then they know everything that’s going on with that patient. When the patients were getting their treatment for substance use disorder at some other site, it was very hard to coordinate the care and you wouldn’t understand all the intricacies of medication reactions and things like that. When they’re getting it all through their primary care provider, which is the model that we strongly support, you can take care of the whole patient.
Can you tell us about the research happening at the UVM Medical Center and Larner College of Medicine?
We’re doing research right now on prescribing and treatment on multiple levels. First, one of our surgical residents is doing a large project on understanding how many pills you actually need for adequate pain control after an operation – such as getting your gallbladder out or a knee replacement. What we’re finding is it’s not uncommon at all for people to go home with many more pills than they need. A lot of people only need 10 or 15 pills. So, we’re going to publish that data and then we’re going to have some guidelines to help people understand what the right number is and why.
For many years we’ve had researchers who have done a lot of work on the most efficient way to give medication to people in treatment. Can you use long-acting meds? Which meds work better? Suboxone? Methadone? Are there ways to give people a week’s worth or two week’s worth safely? What are the impacts of that?
Just recently, I’m very proud to say that our Emergency Department is doing a big research project on medication assisted therapy on demand. So, if a patient shows up in the ED with substance use disorder, they can get started on medication right away. They get a three-day-supply, and then get plugged into resources to ensure they can continue the treatment. For most of my 25 years as an emergency physician, if we had someone come in with an opiate overdose, we would give them a strong medication which would put them in withdrawal. They’d be miserable. They’d want to get out of the ER as fast as they could. We would send them out with no further treatment except for the medication to save their life right then, and they would immediately go out and start using again. More than a couple of times in my career I’ve seen people come in on a Friday and a Saturday, and then not come in on Sunday because they died. So, treating people humanely with medication at a time of crisis in their lives is safe for them and it can save lives.
In what ways does being an academic medical center affect how we are involved?
Like any hospital, we have an obligation to our patients to meet their needs, and one of the needs right now is to prevent new addictions and treat patients who have addiction compassionately. But as an academic medical center, we also have an obligation to train our leaders how to manage this population, both in primary care and acute care, and we have an obligation to do research to increase the knowledge of how to manage this population.
How daunting is this challenge and where do you think the epidemic is headed?
I strongly believe we’re going to have people with substance use disorder for the next generation. This is a 20 to 30 year problem. We will not solve this problem this year or this month. It’s great news that we’re seeing some decrease in deaths in Vermont. That’s fantastic, but we have not won this war. It’s critically important in this epidemic that we decrease people entering into substance use disorder, and follow safe and appropriate prescribing protocols so we can decrease the opiates that are in our communities. Equally important, people with substance use disorder must get long-term compassionate treatment, low-barrier treatment to medications as therapy if that’s what they need. There will be a group of people who will be on medication assisted therapy the rest of their lives. That’s reasonable and appropriate. We know for a fact some of them will have relapses. We should expect that and manage that. That doesn’t mean we cut them off from medication. It means we double down on their treatments like we do for any other chronic illness.
Is this the biggest health crisis you’ve seen in your career?
In terms of this being the greatest challenge we’ve faced as a medical community, over the course of time, there have been all kinds of different epidemics that have come up at different times. If you look at Vermont in the 1920’s, we had the pandemic flu which, in my town of Hinesburg, killed 1,500 people – more than half the population. At that time, they didn’t really have good treatments. They didn’t really know how to care for people. They just knew that people were dying like crazy. Since then, we’ve been able to develop good vaccines for the flu, better treatments, and now, even when we see bad flu outbreaks, we can manage that. Cars kill many people, but over our lifetimes, we’ve seen cars become remarkably safer. We have much better ways to deal with that.
There’s no doubt we’re in an epidemic of deaths due to opiates. I’m optimistic that we’re doing the right things to turn the tide on that, that we’ll address it, and then something else will come along. So, I think this is the issue of the day. It won’t be fixed in a day, but I do think that five years from now we’ll see far fewer people coming in with substance use disorder. And we’ll have so many more people in treatment that it will be a manageable problem in the same way that we still see some deaths from car accidents, and we know ways to make an impact.
Exactly five years ago, Rolling Stone Magazine published an image on its cover of an iconic Vermont woodsman – complete with plaid shirt, wool cap and axe – sitting on a stump in the woods by himself shooting heroin. If you had to draw a picture today that captures the state of the epidemic in our region what would you show?
The Rolling Stone cover showed someone using heroin alone, which is actually not uncommon for people who use drugs like that. What I would tell you now is we are not leaving those people alone. Now we’re surrounding them with a team of people who are trying to keep them protected and safe, who are helping them get back to a productive life. I would say the difference now is it goes from that picture of one person alone on the stump to a full team around them shielding them from the needle.
This video was directed by Michael Carrese, with the UVM Health Network.