Last week, Gov. Wolf announced a Statewide Disaster Declaration for heroin and opioid abuse. During a 90-day period, representatives from several state agencies will be focused on the public health crisis that has gripped our city, state, and country. While the actions declared by the governor reflect an understanding of the need to remove barriers, I was disappointed to learn that there seems to be no increased support or resources for providers on the very front line of the crisis: emergency departments (EDs).
As an emergency physician I know well the pain and anguish the governor described in talking with family and communities who have lost loved ones to the opioid epidemic. I also know well the deep frustration at attempting the gantlet of getting someone into timely treatment and on the road to recovery. Unfortunately, these feelings are familiar to many emergency physicians — across the city and state and throughout the country.
EDs have been on the front lines from the beginning of the opioid epidemic. Nationally, EDs provide treatment for the majority of nonfatal overdoses and provide care to patients suffering from substance-use disorder or the complications of substance use. The governor notes that there has been an 82 percent increase in ED visits related to opioid overdose in just one year (third quarter 2016 to third quarter 2017). In Philadelphia, there has been a 125 percent increase in ED visits related to opioid use since 2008. Emergency physicians also evaluate and treat acute and chronic pain. In 2011, emergency medicine providers were identified as one of the top five opioid prescribers in all age groups under 40 years. Balancing compassionate pain management without compromising public health has been a challenge.
In 2012, a group of emergency physicians recognized the important role emergency departments played in the health and safety of individuals and the community as it pertained to the emerging opioid epidemic. In developing the Philadelphia Emergency Department Prescription Opioid Misuse Working Group, representatives from almost every area ED, 26 in total, came together to commit to try to limit our role in the problem through safe opioid prescribing, but also work to try to save lives even after our patients leave the ED.
The grassroots approach of the working group predated almost all other citywide efforts. We collaborated across ED and health-system boundaries for the sake of our patients, our departments and staff, our community, and ultimately our city. Yet none of these EDs has received direct city or state government funding or support for our efforts or our reach in supporting the mission of saving the lives of Pennsylvanians amid this crisis.
The outputs of this group read very similarly to the list Gov. Wolf recited as both accomplishments and issues to tackle.
- More than 90 percent of the EDs represented in our working group implemented safe opioid prescribing guidelines as early as 2012. These guidelines went on to inform the state-level guidelines released in 2014. Data from a few show a significant drop in the number of opioid prescriptions. Jefferson EDs alone show more than a 65 percent reduction in opioid prescriptions between 2011 and 2016.
- 86 percent of the group developed educational approaches and curriculum for medical students, emergency medicine residents in training, other emergency physicians, and the larger medical community.
- Five members of the group were called to contribute to the Mayor’s Task Force to Address the Opioid Epidemic.
As the environment changed and the opioid epidemic took on a more ominous face, we pivoted and adapted to the increased needs of our patients and community. Starting as early as 2015, Jefferson and EDs across the city started implementing routine naloxone prescribing with discharge from the emergency department to increase access to life-saving overdose prevention. When we recognized the fleeting moments we have with patients after reversing a near-fatal overdose, some of us worked to develop and advocate for warm hand-off processes to facilitate steps to treatment immediately from the ED.
Others developed processes to start medication-assisted treatment with buprenorphine straight away in the hospital, giving a patient some relief and hope while they take the first steps to recovery.
Our leaders in Philadelphia, including Mayor Kenney and Health Commissioner Thomas Farley, have approached the opioid epidemic by considering the breadth and depth of the issues and have included multiple voices. In these 90 days of the Statewide Disaster Declaration, it is time for our state leaders to recognize the innovative work EDs around the state have been doing with little to no external support. Emergency departments reach those most in need and most vulnerable. There is no question we could be much more effective with financial support and more resources. We are, after all, experts in addressing disasters.
Priya Mammen is an emergency physician and director of public health programs in the department of emergency medicine at Thomas Jefferson University Hospitals and Sidney Kimmel Medical College. She was a member of the Mayor’s Task Force to Combat the Opioid Epidemic as well as a member of the Subcommittee on Service Access, Best Practice and Treatment Providers and was named a 2017-18 Fellow of the Lindy Institute for Urban Innovation at Drexel University.