1200. That’s how many lives are expected to be claimed from drug overdoses, mainly involving opioids, this year in Philadelphia.
In 2016, there were 907.
Far too high of a number for one city, and ever-increasing throughout each town in the country, “the opioid crisis is going to be a defining public health issue of my generation,” says Mara Gordon, a resident in family medicine at Penn, who graduated from the Perelman School of Medicine in 2015.
An epidemic in every form of the word, 91 Americans die every day from an opioid overdose. A tough challenge with a lot of unanswered questions, addressing this crisis is something Penn is taking head-on, not just behind-the-scenes with research, but on the ground, too.
“We’re on our way, and the potential exists, for Penn to be a big, national leader in fighting this,” says Brian Work, an assistant professor of clinical medicine.
Zachary Meisel, an associate professor of emergency medicine, agrees.
“Penn is leveraging what it does best, which is science, the delivery of unparalleled care, and through education,” he says. “Penn tends to lead the way during major health crises ... so why shouldn’t we be the leader now?”
Empathetic care in a safe space
Work, also a clinical site director at Prevention Point for Penn’s Bridging the Gaps program, steps off the subway at SEPTA’s Somerset Station, clad in his khakis, white button-down, and a bowtie. He walks two blocks to Prevention Point, a multiservice public health organization, which first garnered attention in the 1990s for its syringe exchange program. Today, it’s widely known for its trainings that teach individuals how to use naloxone, a medication that reverses an opioid overdose.
A volunteer at Prevention Point since 2002, Work has served as its board chair for the past two years. Every Wednesday afternoon at the Kensington clinic, which is in an old church refurbished with the help of the city, he sees patients from the community, often who are homeless, lacking insurance, and struggling with health issues, many times including addiction to opioids—specifically heroin.
“These are not so-called ‘junkies,’” says Work, also a senior fellow at the Penn Center for Public Health Initiatives (CPHI). “These are people’s moms, dads, brothers, and sisters.”
Work hugs a former client who’s in the busy “drop-in room,” where people can take shelter from the cold or heat, grab some coffee, eat lunch, and take a snooze or watch TV on a comfortable couch.
Affectionately known simply as “Doc” at Prevention Point, Work says later that the patient was “recovering nicely” after treatment of some severe wounds on his arms that were infected from injecting heroin.
There are eight exam rooms, where Work tends to patients privately, along with Penn, Drexel, Temple, and Jefferson medical residents and students. Nursing, social work, and undergraduate students from various schools at Penn are also often seen working at Prevention Point.
Gordon, who volunteered at Prevention Point as a medical student, and is still involved as a medical resident, says the experience has been one she’ll never forget.
“It’s really powerful for me to see how I can start to gain the skills to be the type of doctor to meet people where they are, and take care of them in a way that makes them feel safe,” she says. “It’s been great exposure to learning how to practice compassionate and non-judgmental medicine, and 100 percent influenced what I want to do in the future.”
Another room at Prevention Point is bustling with social workers. Downstairs, there’s a homeless shelter.
While peering into the basement, where cots are set up with blankets and pillows, Work says they’ll accept anyone who needs a place to stay, whether or not they have an addiction.
The goal of Prevention Point, he says, is harm reduction and education.
“We’re not going to stop everyone from using today,” Work says. “So let’s get them some clean needles, let’s give them Narcan, teach people to not use alone, so they don’t die before they get a chance to recover.”
The rise and fall of prescription opioids
The devastating number of opioid deaths in the United States, which have quadrupled since 1999, has been fueled in large part by prescribing practices of health care providers, due to persuasive drug company ad campaigns and poor studies that ignored opioids’ highly addictive properties.
“It taught an entire generation of medical students to be liberal when prescribing opioids,” explains Jeanmarie Perrone, a professor of emergency medicine, director of Penn Medicine’s Division of Medical Toxicology, and a CPHI fellow. “Now we’re trying to step back and get the horse back into the barn.”
Treating pain in such an expanded way was a noble effort, says Meisel, also a physician in the Hospital of the University of Pennsylvaniaemergency department, “because pain is terrible and it also undermines your health.”
But, unfortunately, he continues, “It may have led to some of these unintended consequences, with patients becoming addicted, and opioids just flooding the market.”
Also, until relatively recently, there wasn’t a way for health care providers to monitor if patients were “doctor shopping,” or going from emergency room to emergency room asking for prescriptions.
Although an issue for the entire nation, the numbers are drastic when it comes to prescription opioids in Philadelphia, says Thomas Farley, the city’s health commissioner. In a recent report by the Department of Public Health, it was estimated that 1 in 3 Philadelphia adults—or about 469,000 people—used a prescription opioid in the past year.
“Many people with pain receive more opioids than they need or use, which increases the risk of addiction,” Farley says.
One of the major related efforts that Meisel, along with M. Kit Delgado, an assistant professor of emergency medicine, are trying to push is changing the default settings on the electronic medical record, which doctors use to prescribe opioids.
“The first thing that pops up when you prescribe something like Percocet might be 20 tabs,” says Delgado, also a senior fellow at the Leonard Davis Institute of Health Economics(LDI). “For almost every prescription, people just pick the first thing that pops up, so if we change the default from, say, 20 to 10 tabs, it might actually make a difference.”
Providing opioid alternatives for minor injuries is ideal, but if opioids must be prescribed, Delgado wants to find clear evidence on the granular: What’s the science behind how many tablets people need to manage pain? For Meisel, also an LDI senior fellow, he’s studying the best communication strategies for physicians to use with patients who might need opioids.
Other researchers navigating the opioid epidemic in a similar capacity run the gamut at Penn, including faculty members such as Peggy Compton, from Nursing; Elliot Hersh, from Dental; Mary Robinson, from Vet; and Jeffery Saven, from the School of Arts & Sciences’ Department of Chemistry. From 2014 to 2016, the CPHI implemented a cutting-edge, evidence-based public health education program about the epidemic of opioid misuse and overdose in Philadelphia.
And, although it’s important to focus on turning the faucet off for people entering into physical dependence, we must also face “the huge ocean of people who already have some dependence,” says Delgado.
Chatting in his office in Blockley Hall, Delgado recalls a story of a recent patient he tended to in Penn Presbyterian Medical Center’s emergency department after she overdosed from heroin—and was revived with naloxone.
“She had back surgery and was being treated with prescription opioids, and it got to a point where her surgeon and primary care doctor said they would no longer continue to prescribe her opioids, appropriately,” he says. “Basically, she was cut off cold turkey and was referred to pain management, but there was a wait. She came to Philadelphia to sightsee, was in a lot of pain and felt a craving, and found someone on the street and snorted heroin and overdosed. It was her first time.”
Indicative of the opioid epidemic right now, this is a story far too common for Philadelphia—a city known for its pure and cheap heroin, which gives a similar but more potent mind-altering experience as a prescription opioid.
Treatable moments in the ER
A lot of times, Meisel says, when a person who overdosed from heroin is saved with naloxone, “they wake up, and they want treatment because they almost died, or they’re with a loved one that’s pushing for them to get their stuff together.”
Having options for these particular patients during these “treatable moments,” as Perrone calls them, is critical.
Often, says Delgado, “these patients have been put into acute withdrawal and are at even higher risk for re-using as soon as they walk out of the ER.”
One of Perrone’s biggest efforts throughout the past year has been advocating for medication-assisted treatments, such as Suboxone, an opioid agonist-antagonist, in Penn’s emergency departments and primary care clinics, as well as the appropriate trainings for doctors who would be able to administer them.
“If we are able to start them immediately on an opioid replacement treatment, they can have a chance at feeling what treatment is like, that they can do it, and they won’t have withdrawal symptoms all the time,” Perrone says.
Perrone, an LDI senior fellow as well, is also helping Penn Presbyterian establish a “Center of Excellence,” which will use state funding for specific space in the hospital for people with opioid addictions, ensuring they stay in treatment, and receive follow-up care and support.
A city-wide effort
Perrone and Meisel brought their ER knowledge and opioid research experience to the table when they served on Philadelphia Mayor Jim Kenney’s Opioid Task Force earlier this year.
The Task Force enlisted several members of the interdisciplinary Penn community, who worked with experts from other academic institutions, city agencies, businesses, community organizations, and health care systems to create a report full of recommendations to address the opioid epidemic in Philadelphia.
Perrone and Meisel, as well as Michael Ashburn, a professor of anesthesiology and critical care, and director of the Penn Pain Medicine Center, served together on the Public Education and Prevention Strategies subcommittee.
An important aspect that the subcommittee discussed was the necessity of the city establishing a one-stop shop—either a phone number, website, or app—that would provide people in need with the available treatment facilities, in real time.
Robert Ashford, who recently graduated with his master’s degree in social work from the School of Social Policy & Practice at Penn, and also a person in long-term recovery, emphasizes the importance of this centralized hub for information.
“Before I went into treatment, I couldn’t imagine being in that frame of mind, dealing with the disease, and trying to find my own care,” he says. “We have to effectively reduce any barriers that exist because the window of opportunity for somebody dealing with a substance use disorder is small. If they are willing to ask for help, we have to get them help right now.”
Ashford, who started the collegiate recovery community, Quaker Peer Recovery, on campus last year, and still conducts research with Brenda Curtis at the Center on the Continuum of Care in the Addictions, served on the Data Analysis and Sharing subcommittee of the Task Force, with David Metzger, a research professor of social policy in psychiatry at Penn Medicine, and Matt Miclette, a master of public health student at Penn.
The subcommittee came up with a variety of recommendations for the city to collect and analyze data around key opioid use and overdose trends, establishing an efficient surveillance program that would, for instance, better monitor the epidemic and establish a rapid response plan.
“The experience was something that was positive overall,” says Ashford. “And the report that was produced in May is a testament to the commitment that Philadelphia has in addressing the overdose crisis and the opioid use disorder problem that exists across the city.”
This summer, Miclette, who co-founded the award-winning prescription take back initiative “Take Back Our City,” worked as a policy associate with LDI and CHERISH, the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV. In addition, he’s been working to make Narcan distribution more efficient, while serving as the policy director of Action Tank, a separate think tank and community service organization he started with fellow military veterans across Philadelphia. This year, Action Tank focused on the opioid crisis by pushing for policies that are evidence based and make large, positive impacts.
First, Miclette says, one of the biggest challenges—for the city and the country—is overcoming stigma, whether it be for the opioid use disorder itself or its treatment.
“I think once the community realizes this isn’t something we can be hush-hush about, that this is something affecting everyone, we’ll see more people working full force toward solving this,” Miclette says. “It’s an epidemic, and that’s not a word that’s used loosely. It’s only going to get worse before it gets better.”
Nobody can hide from the opioid epidemic, says Ashford, and that’s including on Penn’s campus.
“A certain segment of the population, everywhere, is facing this issue,” he says.
In agreement, Ashford and Miclette take comfort knowing the University, and the city, are actively working to bring the brightest minds together to aid the opioid crisis.
“Penn absolutely can be a leader, with its centers and faculty members already leading in the field,” says Ashford. “We’ve got to take a stance that this is something that needs to be talked about, and put our full weight and support behind it as a University.”
Originally published on September 21st, 2017