Opioid-related emergency room visits at Erie County Medical Center more than doubled from 2009 to 2016, a startling rise reflective of the addiction epidemic in Western New York and across the country.
The growth mirrors an increase in opioid deaths and, like the fatalities tied to drug abuse, the patients come from every corner of the region – urban, suburban and rural.
An examination of nearly 17,000 opioid-related patient visits at one of Buffalo's busiest hospitals offers a snapshot of the epidemic, and suggests current estimates of hospital visits connected to opioid use in the region are underestimated.
Data from ECMC also reveal the central role emergency departments have come to play in the wake of the extraordinary expansion in the use of narcotic pain relievers in the United States and the growing abuse of heroin.
Among the results:
- Opioid-related visits to ECMC's emergency room, including users of prescription painkillers and heroin, increased from 921 in 2009 to 2,070 in 2016. By 2016, an average 11.4 patients per day came for an opioid-related visit in an ER that saw about 190 patients daily.
- The numbers show the changing nature of the epidemic, as heroin tightened its grip on more individuals. In 2009, only 11.6 percent of all opioid-related visits involved heroin. By 2016, it was 69.6 percent.
- Similarly, the medical center saw a dramatic uptick in heroin overdose patients. Heroin overdoses accounted for 1.6 of every 1,000 opioid visits in 2009 but 18.5 in 2016, a nearly twelve-fold increase.
In recent years, as the opioid epidemic swept the nation, emergency room doctors have been pressured to reduce their prescribing of addictive painkillers for chronic pain. But now, so many patients arrive in emergency rooms with a history of opioid use that emergency rooms are coming to be seen as a potentially ideal place to start addiction treatment.
This represents a fundamental change for a hospital service focused on stabilizing patients with immediate medical concerns and referring them elsewhere for follow-up care.
"Emergency departments can be a real-time source of information on public health problems like this one. They can also be a foot in the door to getting people addicted to drugs the care they need," said Dr. Ronald Moscati, an emergency room physician and co-leader of a seven-year study of opioid-related visits at the medical center. "It's a horrible disease and very difficult to treat."
More visits from outside the city
The review by Moscati and his colleagues attempted a truer accounting of the ways opioid use is pushing people into hospitals. Most hospitals track opioid-related visits by looking at counts of addicted patients who arrive in emergency rooms seeking detoxification, suffering from withdrawal symptoms or having overdosed. But in many other cases – such as patients who injure themselves or feel ill for other reasons – opioids turn out to be a contributing factor.
ECMC sought to track all the reasons opioid users land in the emergency room.
Of the 462,983 patient visits to the ECMC emergency department from June 2009 through June 2016, 3.6 percent, or 16,712, had an opioid connection, particularly patients who overdosed on drugs or requested detoxification treatment.
As the years went on, a greater share of the opioid-related visits came from outside the City of Buffalo, jumping from 42 percent in 2009 to a high of 62 percent in 2014.
Whites represented 59 percent of the patients in 2009 but, otherwise, accounted for about 82 percent of opioid-related cases each year afterward. Most of the patients – 63 percent on average – were male. The median age grew from 28 to 31.
The statistics include patients who may have visited the emergency room multiple times. But the researchers say the trends at ECMC represent those in the larger community because the emergency department receives a majority of the opioid overdose patients in the region, and is the only emergency department to offer specialized services for trauma, psychiatric emergencies and acute substance abuse detoxification.
"There is no mystery to what we found," Moscati said. "We've confirmed in an objective way what was an impression of what is happening, and that gives us better insight for targeting education and treatment."
The chart review, which was organized by the University at Buffalo emergency medicine department, suggests a way to improve regional surveillance of opioid trends, much like the flu and other communicable diseases are tracked. It also argues for greater involvement in addiction care by emergency medicine doctors.
"We see this as a potential way to see the changes in the overall picture over time," said Heather Lindstrom, research director of UB Emergency Medicine and a co-author of the study.
Starting addiction treatment in the ER
Addicts looking for help confront a health system with a shortage of treatment options, especially access to buprenorphine, a medication also known as Suboxone that is used to reduce cravings. In 2015, fewer than 20 percent of people in the United States who needed addiction treatment received it, according to the National Survey on Drug Use and Health sponsored by the Department of Health and Human Services.
Emergency room doctors focus on evaluating and stabilizing seriously ill and injured patients. But as physicians, advocates and public health officials grapple with the challenges of how to deal with a mounting number of opioid addictions and overdoses, they are looking at the emergency department as a place to start addiction treatment.
"Historically, in the emergency department, we've given people with addiction problems a list of phone numbers for treatment at discharge after their immediate concerns have been taken care of. But too many of them leave, use again and overdose again," said Dr. Joshua Lynch, an emergency room doctor at ECMC and Kaleida Health involved in an initiative in Erie County to establish medication-assisted addiction treatment in emergency rooms.
Opioids include the illegal drug heroin, as well as powerful pain relievers available by prescription, such as oxycodone, hydrocodone and fentanyl. Experts say an explosion in the use of prescription opioids in the past few decades led to increased use of heroin.
"There is no overnight fix. Policies have to change. The stigma of addiction has to change. Doctors need to be trained," he said. "But we should be treating addiction like any other medical problem."
The idea of starting treatment in the emergency room got a big boost from a 2015 Yale University study that found that individuals with opioid addiction who were treated with the medication buprenorphine in the emergency room were more likely to stick with treatment beyond the emergency room by a large margin – 78 percent compared to 37 percent of patients who were seen in the emergency department and given a referral for care elsewhere.
Lynch, who also chairs the hospital group in the Erie County Opiate Epidemic Task Force, said the project here will take that idea a step further with formal links between emergency departments and addiction treatment services, such as Evergreen Health and others in Buffalo. For most opioid-users, the goal is to screen potential candidates, and ensure they leave the hospital with a treatment plan and a definitive link to a place to get treated. A smaller portion who need medication would receive short-term supplies of buprenorphine or other medications, and linkage to addiction services.
None of this will be easy.
Overcoming health system challenges
Doctors must be trained and certified to prescribe buprenorphine, which is also an opioid. Currently, there are only about four emergency doctors in the area with such training, and addiction patients can be difficult to treat in a busy emergency room. To get physician buy-in, referring treatment services must be reliably available at all hours. To truly succeed, more primary care doctors must be certified in buprenorphine prescribing and willing to follow opioid-addicted patients once they have completed addiction treatment.
There are more than 900,000 doctors in the U.S. who can prescribe addictive painkillers, but only 37,000 who can prescribe buprenorphine.
"This is not just an emergency room or addiction doctor issue. The entire medical community needs to step up," said Lynch, who anticipates starting addiction treatment at ECMC and Millard Fillmore Suburban Hospital later this year once about a dozen emergency doctors receive training to prescribe buprenorphine.
The county is seeking funding to operate the initiative as a study that will involve UBMD emergency medicine doctors affiliated the University at Buffalo and Columbia University, which has experience in designing research on substance abuse and counseling.
"We have the one study from Yale that looks promising. We want to see if the strategy is effective," said Dr. Gale R. Burstein, county health commissioner. "But you first need to build capacity for medication-assisted treatment. There is no sense in screening people for possible treatment if there is no treatment."
Meanwhile, the county continues to maintain a 24-hour addiction hotline, and is making slow but steady progress training primary care physicians, nurse practitioners and physician assistants to use buprenorphine. That effort moves forward against a strong headwind. Primary care physicians have been reluctant to take on patients with drug addiction problems, especially with the need to perform regular drug testing and a common perception, real or not, that they may be held criminally liable if a patient dies of an opioid overdose.
Patient advocates like Debra Smith applaud the effort.
"One of the biggest situations families face is that someone goes to the emergency room to be stabilized, but they are released after the medical emergency is addressed. That's their job. They save someone and then release them. The problem is it does not meet the needs of the addiction," said Smith, whose 26-year-old son, Nathaniel, died in 2015 from an opioid overdose.
Smith, who also serves on the county's opiate task force, said she's impressed that physicians and public health officials here have taken the concern seriously and are doing something about it.
"They don't have all the answers, but they're trying to deal with this," she said.