Doctoring During the Addiction Crisis
From policy makers to clinicians to patients and families in crisis, people across the country are turning to Boston Medical Center because of its expertise and leadership in caring for patients with addiction. Among the busiest, most comprehensive treatment centers for behavioral health and addiction treatment in the country, BMC has long been an epicenter of innovation, creating replicable care models in the field, providing training to those at the front lines of the opioid crisis sweeping the nation, and conducting research. Now, BMC has established the Grayken Center for Addiction Medicine.
Listen as Alexander Y. Walley, MD and Jessica Gray, MD discuss the Grayken Center for Addiction Medicine as a way to help turn the tide on this national crisis.
Alexander Y. Walley, MD and Jessica Gray, MD
Alexander Walley, MD is the founder of the Inpatient Addiction Medicine Consult Service, medical director of FASTER PATHS and the director of the Addiction Medicine Fellowship Program at Boston Medical Center. Dr. Walley also serves as an associate professor of medicine at Boston University School of Medicine and is the medical director of the Opioid Overdose Prevention Pilot Program at the Massachusetts Department of Public Health. His extensive research on the impact of state supported overdose education and nasal naloxone distribution resulted in the nationwide expansion of naloxone among first responders to prevent the rate of opioid-related overdose deaths. Walley’s other research endeavors focus on the medical complications of drug use.
Jessica Gray, MD is a fellow in addiction medicine at Boston Medical Center. One of the first in the nation, the Addiction Medicine Fellowship Program provides clinical-focus training so providers can become board certified in addiction medicine and for those interested, offers a second year of mentored research projects and a Masters in Epidemiology or Health Services Research.
Melanie Cole (Host): From policy makers to clinicians to patients and families in crisis, people across the country are turning to Boston Medical Center because of its expertise in leadership in caring for patients with addiction. BMC has established the Grayken Center for Addiction Medicine to help turn the tide on this national crisis. My guests today are Dr. Alexander Walley. He's the director of Addiction Medicine Fellowship Program at Boston Medical Center and Dr. Jessica Gray. She's a fellow in addiction medicine at Boston Medical Center. Welcome to the show, doctors. Dr. Walley, I'd like to start with you. What's going on with the addiction crisis in this country that we're facing right now?
Dr. Alexander Walley (Guest): Addiction is not a new issue in the United States but it is certainly one that's garnered a lot more attention recently, I think, really because of the recognition of increases in opioid overdose deaths. Opioid overdose is the leading cause of overdose, and overdoses are now the leading cause of accidental preventable injury deaths in the United States, exceeding now motor vehicle accidents, firearm deaths, and falls. So, I think that's really what is putting people's attention on this issue of addiction. Of course, opioids aren't the only substances that people have addictions to--alcohols are probably responsible for more deaths and more public health harms than even opioids and that's, of course, been with us for quite a long time. We all know about the harms of tobacco smoking and cigarettes. Now we're faced with changes in the legal parameters around marijuana. So, I think that this is an issue that is definitely new in the forefront and is here to stay and we're going to be facing that for quite some time now.
Melanie Cole: Dr. Walley, I'm sticking with you for a second. What are doctors saying about this addiction crisis as some of the lead-ins or causes? I mean, we see back pain and people going on pain medication for that, or neck pain or various fibromyalgias and things, and are these starting to turn that tide, are these what are starting to cause these addictions? What are doctors saying?
Dr. Walley: I'm glad you asked that Melanie. In the 1990s, there was a recognition of our responsibility in health care of treating pain more aggressively and, at the same time that happened, there was a lot of investment by the pharmaceutical companies in developing new opioid pain medications and as much as they invested in researching these medications or, actually quite a lot more than they invested in researching, they invested in marketing them to physicians and to patients. So, the result was this dramatic increase in opioid prescribing for chronic pain and actually without a lot of really good research. I think it's widely recognized that that dramatic expansion in prescribing of prescription opioids for pain has resulted in greater exposure to opioids and, for many people, a transition to addiction. So, that expansion continued through 2000 and 2010. In the late part of that decade, there was a recognition that opioid prescribing was playing a role in the increases in opioid overdose deaths and opioid addiction. Since 2010, we've seen some reductions in opioid prescribing and, unfortunately, we have a new emergence of heroin use and specifically Fentanyl, another synthetic opioid that has been introduced into the heroin supply, that is actually 40 times more potent than heroin. So, the combination of heroin and Fentanyl appears to be driving even more dramatic increases in opiate overdose deaths. That's what we're really seeing now. In Massachusetts, for example, where in 2012 we had about 690 opioid overdose deaths. In 2016, we had almost 2000. So, we've had this tripling of overdose deaths in a short period of time which, certainly, prescription opioids and increased prescribing laid the groundwork for that but what we're really seeing now that's killing people is this heroin and heroin tainted with Fentanyl.
Melanie Cole: How do you walk that fine line, Dr. Walley? Physicians need to ensure that their patient’s pain is properly assessed and managed but that obligation to provide pain relief needs to be balanced with the crisis that we're seeing. So, how do you do that as a physician?
Dr. Walley: What we teach our trainees here and what we try to explain to our patients is that we need to take a risk/benefit approach. We have a better understanding now of the risks of prescribing opioids and those need to be balanced with the benefit that we can demonstrate when we prescribe these medications. Because it's a risk/benefit, we don't actually know in any individual case what's going to happen until it happens. The patient who gets pain relief from an opioid and is able to function and get back to doing what they need to do every day, then that’s obviously an instance where the pain medication was the right thing to do. There are going to be episodes, which you want to try to limit, where people do develop addictions to opioids and when that happens, we need to be prepared to treat people for the addiction that develops. We're lucky with opioids that we have good treatments that are available. Obviously, the best thing to do is to prevent it in the first place but when it happens we need to be ready and have a treatment available for people. So, that's what we try to do.
Melanie Cole: Dr. Gray, how do you provide care both outpatient and inpatient? And speak a little bit about the model of providing care where people are, and tell us about the program at Boston Medical Center?
Dr. Jessica Gray (Guest): Sure. Thanks, Melanie. I'm a family medicine doctor by training and actually was working in a clinic in Dorchester before I started this fellowship. I was having so many conversations with patients with their families about how addiction really has touched all aspects of their lives. We were finding it as a basis of so many people's problems when they presented to their primary care doctor, not just opiates, like Dr. Walley said, but alcohol, tobacco, marijuana, everything was disrupting people's lives. So, I really wanted more training in actually how to manage these issues that were affecting my patients. So, I came to BMC fellowship. It's taking a very broad view on how to get people help and how to treat people. I guess my role as a fellow is exploring all of the many ways that we can get in and educate providers, and educate patients and their families on managing the disease which is really chronic and long term. I spend a lot of my time on our inpatient consult service, the addiction consult service, where we're helping primary teams manage addiction, manage the sequelae of addiction and figuring out how to get people into treatment who otherwise were having trouble doing that. We also work with the emergency department in a program called “Faster Path” which we a call low barrier access to treatment for opiates and alcohol. In partnering with them, we've really been able to help people where they are and get access to treatment which I think has been a really wonderful step forward. I'm also working with our family medicine department and our internal medicine department in the [inaudible 09:04] clinic, helping people get stabilized on medicines for their use disorders as well as all over the city. Addiction touches every part of people's lives and so being able to provide services in every aspect is important and that's what the training is giving me, which is great.
Melanie Cole: Dr. Walley, how do you know that you're being successful as far as outcomes and cost and hospitalizations? What are you seeing?
Dr. Walley: I think a common experience for a lot of physician trainees and nurse trainees and even social worker trainees is that they have the experience in their typical educational exposure, seeing people who aren't doing well in the midst of their addiction and that's sort of why they're coming in to the hospital or why they're coming to the emergency department. Those of us who get to take care of patients from that period and then on, so those experiences that Dr. Gray is getting in seeing patients over time, what we've seen in those cases is that the treatment works and patients get better. That's really, I think, what's really rewarding to do this personally as a job and as an educator and then it translates to real experiences where people's lives get better. So, that's an important part of what we do. So, we're seeing results and you are asking about how we know that it's working. There's a lot of different ways we can measure it. My favorite way to measure it is with the patients that I care for and just having them tell me about how their lives are getting better and their families are coming back together and they're going back to work, etc. We're also involved in thinking about larger policy issues like how is it affecting the hospital, and whether patients are being readmitted for preventable illnesses like infections from injecting drugs. We are seeing that patients that are touched by the addiction consult service that are initiated on treatment are less likely to be readmitted for the same infection and are more likely to get into treatment and put their lives back together. We do have a window and a focus on both the individual level of benefits and outcomes of treatment as well as the system level impact that we're trying to have.
Melanie Cole: Dr. Gray, wrap it up for us in your words on what you want people to know about the Addiction Center at Boston Medical Center?
Dr. Gray: I think that there's a lot of exciting potential for the Addiction Center at Boston Medical and it's really going to bolster the strong work that's already going on in the community and inpatient and outpatient everywhere that we're touching. I'm looking forward to making addiction less stigmatized and having providers and families and patients who are struggling with addiction get access to top of the line treatment and really get into recovery.
Melanie Cole: Dr. Walley, I would like you to finish up for us with your best advice about addiction itself and if somebody has a loved one that they feel is suffering from addiction, please tell them what you want them to know about seeking help for themselves and for their loved ones?
Dr. Walley: What I want people to know is that people get better as long as we can keep people alive. So, the biggest tragedy for me is when somebody overdoses and dies because that's a lost opportunity for all of us to be able to help that person get better with their addiction and you can't take that death back. So, it's important for us to focus on delivering the best treatment possible. There are good treatments that work. We need to make those treatments more accessible to people. And then, for people who either don't have access to treatment or aren't willing or are ready for treatment, we can't forget about them. We need to figure out how to keep them safe in the meantime. We need to educate them about overdose prevention. We need to support efforts around safer injecting practices. We need to, as Dr. Gray was saying, do everything we can to fight stigma around addiction. For a long time, not just the behaviors of substance use have been stigmatized and criminalized, but the people themselves have been criminalized and that's how we've dealt traditionally with people who use substances. I think we owe it to them and to ourselves to take a more compassionate approach. We need a similar effort to address stigma and invest in the treatment and prevention for addiction.
Melanie Cole: Thank you so much, both of you, for being with us today. You're listening to Boston Med Talks and for more information on the Grayken Center for Addiction Medicine you can go to www.bmc.org/addictionmedicine. That's www.bmc.org/addictionmedicine. This is Melanie Cole. Thanks so much for listening.