By R Carter
I tell myself I have a pretty good handle on what it’s like to be an addict, to recover from addiction and what ultimately kills the addict in the long run. My perceptions and informed sense of objectivity come from living with an addict for more than fifteen years, one who ultimately died from an overdose and watching her cross addict from one substance to the next. All the while, ignoring the underlying cause because that cause was the true source of her pain and discomfort, the thing she’s running away from and can’t face. Whether its because they’re arrogant and hard-headed, closed-minded and fearful, untrusting due to some previous betrayal, or all of the above, every addict has a core issue they’re unwilling to face that keeps them addicted and a significant other, who knowingly or unknowingly, enabled them to stay addicted.
Not all addicts become addicts because they’re predisposed to it genetically, more than half of those who die from addiction lack the genetic markers for it. Clearly there is a component to addiction that is based on our psyche and emotions, it’s one of the reasons why 12 Step programs have worked so well. Of those who have more than 10 years of sobriety, as many as 85% of them will claim they have it because they have embraced a 12 Step program on some level, but today there’s a growing number in these ranks which credit Medication-Assisted Treatment (MAT) for their success.
None-the-less I tend to lean in the direction that MAT is of great benefit during the first 1-5 years of recovery, after that you’ve got to do what the Big Book says and change places, playgrounds, and playmates. A combination of MAT and a 12 Step program, IMO, gives the best chances of having a remaining lifetime, free of substance abuse.
I’m also a chronic pain patient, have been for more than eighteen years following a massive back fusion procedure, one where I was told going in, that when I came out, I would be on opioids for the rest of my life. As such my response and reaction to our countries efforts to curb addiction by controlling the supply and redefining who qualifies for pain management is one that ruffles my feathers more than a bit, as you will see from the posts I make here on this forum.
This article from the NIH is one of few I agree with, based on my personal experience from a 30-year career in pain management and in dealing with addicts, so I’m not surprised at the conclusions they draw. And while it is a step in the right direction on informing our perceptions and understanding of the opioid overdose problem, it is by no means an answer for treating those afflicted with addiction and at risk for an overdose. This is not surprising considering the fact that many of the answers to this question have eluded the healthcare profession for more than 100 years.
Of all the ideas tossed around for addressing overdose deaths, the one which has received the most opposition, advocates for forced drug treatment by law; for those diagnosed as addicted to a controlled substance. Fundamentally I remain opposed to this approach, we have no well-defined criteria for what constitutes an addiction which is a threat to the life of the one who’s addicted. Furthermore, such a law left in the hands of ill-defined professional judgment would result in more harm than good. But, in light of this study, I would be willing to reconsider my position if the study were implemented on a larger scale involving several tens of thousands of patients.
Still, if you know someone at risk for an overdose, I highly recommend reading all of this excellent study by Weiner, S.G., Baker, O., Bernson, D., Schuur, J.D., which asked all the right questions before they started.
This study reported:
- About 1 in 20 patients treated for a nonfatal opioid overdose in an emergency department (ED) died within 1 year of their visit, many within 2 days.
- Two-thirds of these deaths were directly attributed to subsequent opioid-related overdoses.
- Immediate treatment for substance use disorder in the ED that continues after discharge is needed to reduce opioid-related deaths.
Every year, emergency departments (EDs) across the country treat thousands of patients for nonfatal opioid overdoses, and this number continues to rise. These patients are typically observed in the ED and then discharged with information about finding outpatient treatment. But what happens to these patients after they leave the ED? A recent study showed that many of these people died within a year, often within the first couple of days after discharge. “Our research demonstrated that about 1 in 20 people who presented to the ED with an overdose and were discharged were dead within a year,” explains Dr. Scott G. Weiner, the study’s first author and a NIDA-funded investigator. “That’s a startlingly high number and perhaps shocking enough to make it clear that simply providing a paper list of detox facilities to these patients at discharge, as we have done for the past several decades, is not sufficient.”
Dr. Weiner and his colleagues from Brigham and Women’s Hospital in Boston partnered with the Massachusetts Department of Health to determine the number of deaths that occurred among 11,557 patients who were treated for a nonfatal opioid overdose and then discharged from Massachusetts EDs. They linked state-wide data on patients who had been treated and discharged from an ED for an opioid overdose between July 2011 and September 2015 with state death records up to September 2016. This allowed them to determine the number of deaths that occurred between 1 day and 1 year after the initial ED visit.
Dr. Weiner and colleagues found that of these patients, 635 (5.5 percent) died within 1 year of their ED visit, including 130 who died within the first 30 days and 29 who died within the first 2 days after discharge. In other words, 1 in 5 patients who died within a year did so within the first month, and particularly within the first 2 days (1 in 25) (see Figure). About two-thirds of the deaths (428 patients) resulted directly from a subsequent opioid-related overdose. Those who died were relatively young (median age 39 years), and almost one-quarter died at a residence, suggesting that they may have died before help arrived.
Figure. Patients Treated and Discharged From an ED for Opioid Overdose Often Die Shortly After Discharge Of patients who died within the first month after receiving treatment in the ED for a nonfatal opioid overdose (n=130), about one in five died within the first 2 days.
The image shows the number of deaths occurring within 30 days among patients treated for opioid overdose and discharged from emergency departments (EDs), overlaid on a background image showing a scene from an emergency room. The horizontal x-axis shows the number of days since ED discharge from 1 to 30; the vertical y-axis shows the number of deaths from 0 to 25. The numbers of deaths were 22 on Day 1, 7 on Day 2, 6 on Day 3, 5 on Day 4, 7 on Day 5, 2 on Day 6, 4 on Day 7, 1 on Day 8, 2 on Day 9, 3 on Day 10, 6 on Day 11, 4 each on Days 12 to 14, 3 on Day 15, 6 on Day 16, 5 on Day 17, 1 on Day 18, 5 on Day 19, 3 on Day 20, 1 on Day 21, 5 on Day 22, 3 on Day 23, 1 each on Days 24 and 25, 4 on Day 26, 5 on Day 27, 3 on Day 28, 5 on Day 29, and 1 on Day 30.
Because the study was limited to EDs in Massachusetts, the results may not be generalizable to other areas. In addition, the data did not include patients who either received treatment for overdose outside of Massachusetts but died in the state, or who had received treatment in a Massachusetts ED but died in another state. Nevertheless, the extremely high mortality rate among these patients, particularly shortly after the ED visit, supports the need for immediate substance use disorder treatment in the ED that continues through discharge and follow-up. “Knowing the high mortality rate of these patients makes the case for EDs to provide buprenorphine to appropriate patients and for health systems to create rapid-access ‘bridge clinics’ for patients who are in desperate need of help,” says Dr. Weiner.
Bridge clinics, which have been established as part of a harm-reduction model in many health systems, including Massachusetts, will see patients on a walk-in basis, regardless of insurance status or current drug use. Dr. Weiner explains, “The model works: About 80 percent of our patients are actively engaged in treatment. Our emergency physicians now know that their buprenorphine prescription is an important link in the survival chain to then get the patient to the bridge clinic.” He adds, “In future studies, I would want to determine how the 1-year mortality rates vary for patients who receive care through these novel approaches to treatment as opposed to the old way of simply providing a ‘detox list’.”
This study was supported by NIDA grant DA044167.
Weiner, S.G., Baker, O., Bernson, D., Schuur, J.D. One-year mortality of patients after emergency department treatment for nonfatal opioid overdose. Ann Emerg Med 2020;5(1):13-17, 2020.