According to the National Institute on Drug Abuse, overdose deaths involving opioids in the United States rose from 8,048 in 1999 to 47,600 in 2017.
The Midwest has been particularly challenged. As reported by the Centers for Disease Control and Prevention (CDC), between July 2016 and September 2017, opioid overdoses in the region jumped 70 percent, compared to an average national increase of 30 percent. In Wisconsin, emergency department visits for opioid overdose increased 109 percent — among the highest in the nation.
“Further contributing to the need for action and impact in our most vulnerable communities is the fact that 70 percent of rural Wisconsin counties lack any opioid treatment program or licensed buprenorphine prescribers,” notes Randall Brown, MD, PhD ’09, associate professor, Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health. “And rural communities are home to more than 30 percent of our state’s 5.8 million residents.”
Aiming to be part of the solution to this crisis, faculty in several departments and programs dedicate their work toward raising awareness about and reducing the impact of opioid-use disorders and other addictions. A sampling of these programs is described below.
The School of Medicine and Public Health and UW-Madison Division of Extension co-sponsored “A Multifaceted Approach to Addressing the Opioid Crisis in Wisconsin: Catalyzing Opportunities for Engaged Scholarship,” in March 2019 at the Health Sciences Learning Center. Noting that the rise of opioid misuse to epidemic levels is deeply rooted in complex social, economic and medical systems and negatively impacts all sectors of society, speakers and panelists explored myriad factors of this issue.
“A problem as complex, insidious and deadly as the opioid epidemic requires strong collaboration among the full spectrum of diverse scholars, and that was clearly the case among participants,” shares Dean Robert N. Golden, MD, who co-hosted the event with UW-Madison Division of Extension Dean Karl J. Martin, PhD.
Reflecting on the transformation the nation’s first school of medicine and public health in 2005, Golden adds, “We believe that the integration of medicine and public health in all of our missions allows us to tackle the most important, complicated challenges that affect the health and wellbeing of people in our state and beyond.”
He continues, “Clearly the opioid crisis drives this point home. Only by bringing together public policy, population health perspectives and informed clinical practice can we tackle this beast, which has already devoured countless lives.”
Sharing this philosophy, personnel from the UW Population Health Institute’s Evidence-Based Health Policy Project hosted an open house at the State Capitol Assembly Parlor in May 2019 to help Wisconsin legislators, health care professionals and the public learn about opioid- and substance abuse-related work, including research, taking place at UW-Madison, and to give investigators a chance to learn from participants how best to focus their efforts.
Addiction medicine fellowship
In 2010, Brown established and began directing the multidisciplinary Addiction Medicine Fellowship in the DFMCH. Recognized as a National Model Program by the American Board of Addiction Medicine (ABAM), it is among the first programs in the nation created to train physicians to become board-certified in addiction medicine.
Trainees learn strategies to prevent, assess and manage patients with substance-use disorders and related illnesses, focusing on medication-assisted treatment and evidence-based models for integrating addiction treatment into primary care and hospital settings.
As a member of the ABAM Board of Directors and its foundation, Brown advocated nationally for years in support of creating and accrediting addiction medicine fellowships. At the White House in 2016, he explained that it takes 17 years, on average, for evidence-based interventions to make their way into clinical practice and noted that only 11 percent of people with substanceuse issues who require treatment have access to appropriate specialty care.
He told the White House audience, “The combination of research and addiction medicine training … benefits not only our fellows, but residents, medical students, community physicians and other service providers who thirst for the opportunity to examine this illness through a modern lens, with evidence-based interventions.”
Noting that the Addiction Medicine Fellowship was accredited by the Accreditation Council for Graduate Medical Education in 2018, Brown says, “This fellowship has helped us move addiction medicine education more into the mainstream, so we are better able to improve the lives of individuals, families and communities struggling with addiction and related issues.”
Brown, a distinguished fellow of the American Society of Addiction Medicine, also leads the UW-Madison Addiction Consultation Provider Hotline, believed to be a national first, which provides daily on-call support to help Wisconsin primary care providers who seek support and direction to help their patients manage substance-abuse problems. Created through a grant from the Wisconsin Department of Health Services (DHS) and operational support from UW Health, the hotline’s team consults about acute, clinic-based care of the full range of addictions — including alcohol, opioids, stimulants, marijuana and synthetics — and advises on long-term care and follow-up.
“The misuse of substances and the complications that flow from that misuse represent the single largest preventable and treatable contributors to morbidity and mortality in this state and nation,” states Brown. “And research shows that appropriate care for these patients can be effectively delivered in primary care settings.”
Brown’s team worked closely with the Rural Wisconsin Health Cooperative and the Wisconsin Society of Addiction Medicine to launch the program, which has been available since summer 2018 on weekdays, 8 a.m. to 5 p.m., for Wisconsin providers at 800-472-0111.
“We offer real-time support and expertise from specialists in addiction medicine and addiction psychiatry. I am confident that we can reduce the enormous suffering that substance abuse produces,” asserts Brown.
The Department of Surgery launched a pertinent telementoring series in March 2019. Offered for continuing education credits, the Safer Prescribing of Opioids after Trauma and Surgery (SPOTS) program focuses on best practices for physicians, nurses and other health care professionals.
SPOTS organizers note that most opioid naïve patients receive their first dose of opioids in conjunction with a medical procedure, and surgery and traumatic injuries are among the most common indications for a first prescription of opioid pain medications. Their goal is to help address prescribing practices to reduce opioid supply and first exposures.
Ultimately, if we can learn how to identify and support people at risk for opioid misuse, we can reduce the risk of addiction, overdose and death and be one step closer to solving Wisconsin’s opioid crisis.Randall Brown
Participants learn how to implement up-to-date, evidence-based guidelines for opioid prescribing for acute pain; identify and encourage the spread of opioid-related emergency health system innovations; and take part in clinical specialty collaboratives to develop methods for providing feedback to providers on opioid prescribing.
Similarly, the Department of Family Medicine and Community Health offers a free monthly video-conference series called ACCEPT (Addiction and Co-morbid Conditions: Enhancing Prevention and Therapeutics) to connect addiction medicine experts with providers statewide. Led by Brown and funded by the Wisconsin DHS, the series follows the Wisconsin Project ECHO model.
Originally developed by the University of New Mexico Health Sciences Department, the ECHO model helps experts effectively share knowledge at the community level. In the Wisconsin program, each session includes a collaborative, multidisciplinary case discussion and didactic presentation.
As of January 2019, clinicians in 38 locations statewide have participated in the family medicine department’s Project ECHO videoconferences, which provide continuing education credits to physicians, nurses, pharmacists and pharmacy technicians who attend the live session.
“Through these conferences, we train providers, especially those in high-need, underserved areas, on evidence-based practices for opioid treatment and recovery. This improves individual patient outcomes and increases communities’ capacity to support prevention and treatment strategies for opioid-use disorders,” states Brown.
Connections with public health
Participation in community health engagement projects deepens medical students’ understanding of local and regional issues that affect health care, health disparities and awareness of how community organizations work with the School of Medicine and Public Health to address health priorities.
For instance, as part of the ForWard Curriculum, medical students can participate in a 12-week project through Wisconsin Voices for Recovery — a statewide network funded by Wisconsin DHS with support from the Department of Family Medicine and Community Health — that offers education, connections to community resources and an advocacy platform focused on reducing stigma and promoting recovery.
A volunteer-run partner organization, Stop Heroin Now, provides funding for people who otherwise can’t access coaching on recovery and sober living.
At a July 2018 Stop Heroin Now fundraising event — Drop the Needle — in Milwaukee, third-year medical student Bryce Tyler de Venecia conducted video interviews through which he heard stories that drove home the importance of destigmatizing addiction. He met people who had driven for hours to receive addiction treatment and those who had fought for years to get children back after overcoming addiction, and he learned about resources that helped them the most.
“Many people end up in the emergency department secondary to diseases of addiction,” he notes. “As someone who wants to go into emergency medicine, it was great to see what these organizations do for policy and community outreach — all the tiers that it takes to enact public change.”
Membership in Wisconsin Voices for Recovery is free and open to anyone interested in improving recovery support services in Wisconsin, says Aleksandra Zgierska, MD, PhD (PG ’05, ’08), a Department of Family Medicine and Community Health associate professor and the network’s principal investigator (PI).
Its ED2Recovery Program awards seed funding to organizations involved with recovery so they can provide sustainable, peer-to-peer services for individuals with opioid-use disorder who are referred by emergency departments and other health care entities.
Innovative research and implementation
School of Medicine and Public Health faculty members, some of whom also provide addiction-related clinical care, focus on research into prevention, treatment innovations and system-level improvements that can help ease addiction’s impact on individuals, families and communities.
For instance, Zgierska is the principal investigator of a U.S. Department of Justice-funded Madison Addiction Recovery Initiative. This city-wide program, conducted with the City of Madison Police Department, aims to divert individuals who committed a non-violent, minor drug-related crime from criminal justice to treatment.
Zgierska also is the principal investigator on a five-year, multi-site clinical trial supported by the Patient-Centered Outcomes Research Institute to compare the effectiveness of mindfulness meditation with cognitive behavioral therapy in patients who have opioid-treated chronic low back pain.
Although this type of pain is often treated with long-term opioid therapy, it does not work well for many patients and can cause serious side effects, including addiction and the risk of overdose. Many clinicians, patients and their families are interested in complementary and integrative treatments.
“Mindfulness meditation trains the mind to bring nonjudgmental and accepting attention to present-moment experiences, such as pain,” explains Zgierska. “We hypothesize that training in mindfulness meditation will lead to a reduction in pain intensity and to improved function, and will result in better quality of life and help patients decrease opioid use.”
For the trial, patients at UW Health, Brigham and Women’s Hospital/Harvard Medical School and the University of Utah are randomly assigned to one of two eight-week treatment groups, either mindfulness meditation or cognitive behavioral therapy.
Outcomes are being compared over 12-month periods, and investigators interview participants to gather information about the interventions’ effects on pain, function, quality of life and opioid use.
In another study, Zgierska, Brown and Andrew Quanbeck, PhD, an assistant professor in the Department of Family Medicine and Community Health, are collaborating on a National Institutes of Health-funded project aimed at better integrating opioid prescribing guidelines into 38 Wisconsin primary care clinics. This project is building on a pilot study, which determined that distilling clinical guidelines into an implementation guide, along with six months of coaching for clinical teams at four family medicine clinics, resulted in an 11 percent reduction in opioid doses in those clinics.
“Clinical guidelines are often difficult for practitioners to interpret and hard to implement. This is meant to be a model that could be used nationwide,” says Quanbeck.
Further, Brown is the principal investigator for Screening in Trauma for Opioid Misuse Prevention (STOMP), a Wisconsin Partnership Program-funded study to assess the needs of victims of traumatic injury, who often are prescribed opioids for pain. The research team developed a screening tool to predict risk for opioid misuse and related complications after traumatic injury.
As they pilot the tool at University Hospital in Madison and four Wisconsin trauma centers, they are studying the number of procedures the patient had, the severity of pain upon discharge, the patient’s social support network and post-discharge opioid-use patterns, among other factors.
Brown concludes, “Ultimately, if we can learn how to identify and support people at risk for opioid misuse, we can reduce the risk of addiction, overdose and death and be one step closer to solving Wisconsin’s opioid crisis.”
By Andrea Schmick and Kris Whitman
This article appears in Quarterly magazine.