Transcription:

Scott Webb (Host): We have an opioid epidemic in this country and around the world. And many suffering from addiction may feel that there's nowhere to turn for help. That's why I'm glad we are discussing the First Step Program at Summa Health today with Dr. Jason Kolb. He's an Emergency Medicine physician with a special interest in treating addiction at Summa Health.

This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Dr. Kolb, thanks so much for joining me today. We're talking about opioids and the startling numbers that we hear across the country. So, before we get started here, let's just kind of answer a basic one. What exactly are opioids?

Jason Kolb, MD (Guest): Opioids are pain medications from pills that most of us have heard about like Vicodin or Percocet. Also called hydrocodone and oxycodone to what we more think of as street drugs, like heroin and nowadays fentanyl is very popular in this group of patients.

Host: And generally speaking, when we talk about opiates or opioids, how do people become addicted to them?

Dr. Kolb: Yeah, in my experience, and Scott, I treated patients in the office for four years, in addition to my job as an Emergency Medicine physician. The stories were remarkably similar in that most of the patients that became addicted or dependent to opioids, started with a legitimate exposure. And by that, I mean, they had a legitimate injury, a broken bone or a motorcycle accident for which their physician prescribed an opioid pain pill.

I remember one patient in particular didn't become addicted until she was in her thirties, after a C-section, and she was prescribed opioids, which would be very typical. So, that's how most of my patients had their initial exposure. And from there, it spiraled out of control. And once their injury had healed, they liked how they felt on the pain pills. They asked their doctor for more. Eventually, their physician would stop prescribing and they would seek to get pills in an illegitimate way, buying them on the street. And if they couldn't do that, they may progress to heroin or fentanyl. And so it was kind of a very common, but tragic spiral of use in these patients who become dependent on opiates.

Host: One of the things I want to ask you is we hear so much about it and we hear it in the news so much, especially with teenagers. Why is an addiction to opiates or opioids so dangerous? What are the, what can happen when people become addicted?

Dr. Kolb: The problem with the opiates and their danger, is that in the setting of an overdose, they're deadly because the patient stops breathing. So, say in contrast to cocaine or methamphetamine, which are also terrible drugs. An overdose of those two substances, doesn't cause you to stop breathing, but an overdose of opiates will cause a patient to stop breathing and that's why they die. And I want to clarify one thing I said a moment ago about patients liking how they felt. I want to be real careful in that. I don't want this to sound like a moral judgment. I do believe in the disease model of opiate addiction, and so for certain patients, they are hardwired and their DNA is such that when they're exposed to an opiate, they get a rush of dopamine that makes them feel like they've never felt before.

And other patients, most of us, when we take an opiate, that doesn't happen. But with these patients, it does. And so that's what drives them to continue to ask for prescriptions. And when their doctor cuts them off to continue to get them illicitly and illegally, there's something different about their DNA. And I think they certainly have responsibility for their choices too. And we would talk about that all the time in the office, but there's something that these medications and these substances do for these patients that drives the addiction. And it's rooted in their DNA. And I do believe the science backs that up.

Host: The scary thing about addiction, as you say, using that DNA model, that many of us just simply don't know how our bodies are going to react to alcohol, opiates, whatever it might be, until we get started with them. And it's only then that we realize that we have it in our DNA to become addicted. Is that how you see it?

Dr. Kolb: Yeah, I think that's right Scott and opioids are wonderful medications for acute pain, like post-surgical pain or a major injury, and we should be using them. And the medical community has become a lot wiser in the past say five years, that we just need to be more wise in how we use them, and limit the duration of the prescription and limit the dose and use them appropriately. And patients understand that and respond to that. But the medical community is also starting to understand that this is a disease that's rooted in our biology and moving away from this idea of a moral failure. But at the same time, we do need to acknowledge that patients have responsibility for their choices. Just like all of us do in any disease, including diabetes, for instance, we all are responsible for our choices.

Host: Yeah. That sounds right to me. And you're so right. We have responsibility for our choices, but there are things that are maybe beyond our control and that's where we might need assistance. And that's what I want to talk about next is the First Step Program. This is a really a remarkable program. Something unlike people might find at other hospitals or other emergency departments. So, take us through this. What is the First Step Program at Summa Health?

Dr. Kolb: Yeah, so we're really proud of it. And I want to be sure to acknowledge the fact that this was started before I joined Summa. And I'm the champion of it because opiate dependence is an area of interest of mine. But the First Step Program is an Emergency Department based program, where we have a formal treatment process for patients that are addicted or dependent or abusing opiates. And so, when a patient comes to the Emergency Department and either self-identifies as wanting help with their opiate dependence, or maybe we identify them; for instance, we have a lot of patients who come in after they overdose and someone calls 9-1-1 and the medics give them Narcan, which is the antidote for an opiate overdose. And so they present to the emergency department like that.

Once the patient is identified at our two main campuses, which is Akron City Hospital and Barberton Hospital, we have a nurse specialist on duty,12 hours a day who can spend a lot of time with these patients discussing the opiate use, the dependence, and assess their readiness for recovery. One of the bright spots with the opiate epidemic is that there's very effective medication that can treat these patients. And the main one's called Suboxone. Methadone is another one and Vivitrol is another one and they all work slightly differently. But we have a program in the Emergency Department, the First Step Program whereby we actually start patients on Suboxone right there in the Emergency Department. And the nurse specialists, we call them the Addiction Care Coordinator also is able to get a lot of wraparound services around that patient.

And by that, I mean more often than not, we'll get them set up for an appointment with an Addiction Specialist within two to three days. We can get them linked to a Peer Recovery Coach, which is a great service. A Peer Recovery Coach is someone who is in recovery themselves from addiction and has a long history of sobriety and has done specialized training because they want to give back to patients who are struggling.

And so we link them with a Peer Recovery Coach if they want. That person may come to the Emergency Department themselves, help with transportation and just almost like a sponsor from AA. So, that's a great service that we can provide for these patients. We can arrange a Lyft or Uber ride to their appointment because many of these patients lack transportation.

And finally we dispense a kit of Narcan-To-Go. It's a nasal spray. And again, Narcan is the antidote for an opiate overdose and it's been proven to save lives. So, that's really what the First Step Program is. If we can't get the patient an appointment the next day, we invite the patient to come back to the Emergency Department the next day, where we will again, dose them with Suboxone and work on getting them the followup that they need for long-term recovery.

And the program has been very successful. Our show rate at that first appointment is greater than 70%, which is fantastic. In other words, 70% of the patients that we see in the Emergency Department, make it to their first follow-up appointment, which is a big step. And so that's kind of a summary of the First Step Program.

We launched it in 2018 at Barberton Hospital. Over a year ago, we rolled it out at Akron City Hospital. And in the next few months we are going to roll it out to our two free-standing Emergency Departments. One's in Green and one is in Wadsworth and we're going to do that by Telemedicine using iPads and secure technology to do the consults by Telemedicine.

So, yeah, we're really excited about that rollout. We're very proud of the program. We have over a thousand patients a year that we see for opiate dependence. Now the First Step Program Scott, is for anybody who has any substance abuse problem, whether it's opiates, alcohol, cocaine, methamphetamine or any other substance, we will be happy to see you. We will link you to care. But it's the opiates, that are our main substance. And again, it's because of the deadly nature of an overdose with opiates that we really focused on that.

Host: And what an amazing program. And even though it's called First Step Program, I really love, what’s really encouraging about it is really the goal is long-term recovery, right?

Dr. Kolb: Right. So, we're currently studying Scott, our long-term follow-up rates. And I don't have that data in front of me. And again, the program's relatively new, but we're looking at retention rates in recovery at six months and 12 months. And we hope to have that data soon, but you're right, this is a lifelong illness and many patients will need to be on medication for a long period of time.

Some patients may be able to manage their disease without any medication, at some point in the future, and that would be great, but we really try to plant the seed for these patients, that this is a lifelong condition. And I use the analogy a lot that it's like diabetes. And so, let's think longterm, and we all know diabetics that are on pills for their diabetes.

And sometimes with changes in their diet and their exercise, they can come off their medications and manage their diabetes with lifestyle changes alone. That's great. Many patients remain on medication for their diabetes. That's okay, too. Same thing with our opiate dependent patients. Many of them will need to be on medication for long term recovery and that's okay.

Some of them will be able to come off their medication. And again, by medication I'm talking about Suboxone, methadone or Vivitrol, and if they can come off their medication, that's fine too. But what we really want to do allow these patients to have restored functioning in their life and prolonged sobriety.

And that's the goal. And so, yeah, First Step is literally the first step. They're in crisis mode, maybe they overdosed and got rescued with Narcan. Maybe they just were ready for help, and we want to be there for them. And we're there for them, 24 hours a day, seven days a week 365 days a year at Summa. And so that's our program.

Host: And it is a great program. And thank you so much for telling us about it today. Doctor, as we wrap up here, anything else you want to tell people about opioid addiction services at Summa? Anything else when someone clicks play on this that you think can help them?

Dr. Kolb: I'd like anyone to know that I'm most proud of the cultural change I've seen in the Emergency Department. And I've been an Emergency Medicine physician for about 17 years now. And you know, when I first started, opiate addicted patients generally did not fare well in the Emergency Department. There's a lot of shame, a lot of judgment, and that culture is changing really nationwide. And I now specifically see it at Summa and we understand these patients are very sick. And they have a terrible disease and yes, they have responsibility for their choices, but they're sick. Now, Scott, there was a recent study in the leading Emergency Medicine Journal that showed that if a patient received Narcan for an opiate overdose, they had a one in eight chance of being dead within a year.

That is very, very sobering because we see one or two or three patients like this every day. And to think that one in eight of them will be dead within a year, that just speaks to the severe mortality or the deadliness of this disease. And so, I want patients to know they can come to Summa. We're here to help. There's no judgment. We just have all these services that we would love to provide to these patients.

Host: That's so great. And you're so right. The sort of no judging approach is so effective. And I just love the way you took us through this today. You just seem so kind and considerate and measured and recognition that addiction for many people is in their DNA and it needs to be treated that way. And I think a lot of people wouldn't associate an Emergency Department with such comprehensive services in dealing with addiction, with the goal of long-term recovery. So, really amazing stuff, doctor, thank you so much for your time today and you stay well.

Dr. Kolb: Thanks Scott. Same to you.

Host: For more information, visit Summahealth.org/firststep. And if you've this podcast to be helpful and informative, please share it on your social channels. And be sure to check out the entire podcast library for additional topics of interest. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Stay well, and we'll talk again next time.

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