Rowan Medicine takes on the opioid crisis

Rowan Medicine takes on the opioid crisis

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The deadly opioid drug epidemic may seem like an unsolvable problem, too complex and widespread to even begin to fix. While politicians debate public policy and courts weigh whether to treat users of controlled substances as criminals or sufferers, the crisis rages on – and people die. For years, the NeuroMusculoskeletal Institute (NMI) at Rowan Medicine, led by its director, Dr. Richard T. Jermyn, has been on the front lines of this fight.

Jermyn and his team of physicians, residents and medical students have worked in the trenches, helping patients in South Jersey and beyond overcome both chronic pain and substance abuse disorders. The NMI’s most recent efforts, focusing on education and training for doctors nationwide, could do even more.

“The reality is that these training and mentorship programs allow us to train hundreds of people to do what we do. We will help lead the initiative that will save lives in a much bigger and better way,” Jermyn said. 

Delving into addiction medicine

Jermyn didn’t start out working in substance abuse treatment. When he began practicing medicine two decades ago, he worked in palliative care in the HIV community. His interest shifted to pain management because, as treatments for serious medical conditions improved, his patients were living longer – but they were living with chronic pain. He began to worry about the free-for-all prescribing practices doctors had embraced when it came to opioid painkillers – powerful drugs in the same class as heroin. For more than 15 years, he has been educating doctors on proper prescribing.

In an era in which the opioid epidemic claims tens of thousands of American lives every year, it’s hard to imagine a time when no one gave a second thought to prescribing these problematic painkillers. Yet in the late 1990s, these drugs largely were considered unlikely to lead to addiction. In an effort to let no pain go untreated, well-meaning doctors prescribed opioids like oxycodone with unparalleled frequency, Jermyn explained. It took years to become clear that these drugs are highly addictive. By then, for many patients, it was too late.

About 15 years ago, Jermyn started developing opioid prescription guidelines. His efforts helped pain management doctors screen their patients for signs of substance abuse. It was a step in the right direction – but it wasn’t enough.

A new problem arose: what to do with the pain patients – a lot of pain patients – who developed substance use disorder? Their pain, stemming from serious ailments like fibromyalgia, HIV and traumatic brain injuries, was real. So were the negative effects of opioid painkillers on their bodies and their lives.

“I need help. Can you help me?”

Generally, when patients at pain management clinics are discovered to have developed substance use disorder, they are terminated from the practice. It isn’t that their doctors don’t care, but they can’t, in good conscience, enable substance abuse by continuing to prescribe the drugs. Nor do most doctors have the training to help patients get out from under the weight of addiction (a word that, Jermyn said, he doesn’t like to use). To avoid contributing to a drug problem, well-intentioned doctors across the nation turn substance-abusing patients out onto the street.

The wealthiest ones might be able to swing the cost of an inpatient stay in a detoxing hospital, but even then they weren’t out of the woods. As for the patients who couldn’t afford the expense, turning to illegal drugs like heroin or fentanyl became the only option to stave off the terrible symptoms of opioid withdrawal. Powerful, produced without oversight and incredibly dangerous, these drugs can stop withdrawal symptoms in the short term. In the long run, though, they only exacerbate the user’s worsening substance abuse problem, or worse, kill them.

This sad story has played out in pain management offices across the country. In most facilities, it still does. About three years ago, after working with the state to determine what to do with these troubled and troubling patients, Jermyn made the radical decision to stop discharging patients diagnosed with substance use disorder. Instead, he would treat substance abuse patients right alongside the chronic pain patients he had treated for 23 years.

When Jermyn stopped turning patients away for becoming dependent on a drug with known addictive potential, his phone started ringing off the hook. The practice never advertised that it had begun offering ambulatory detox services. Yet new patients eager for help sought him out.

“I need help,” they would say. “Can you help me?”

He could.

“We have a responsibility as doctors to really meet the opioid crisis.”

Part of what makes Jermyn’s work at the NMI so successful is the compassion he shows to patients with a history of substance abuse.

“One reason people don’t get help is the medical community,” Jermyn said. “We had an idea what an ‘addict’ is – the dregs of society – but we were wrong.” Since he started offering outpatient substance use services through the NMI, he feels that he “has grown as a doctor and as a person.” One reality that’s become clear during his decades of practice is that substance abusers aren’t bad people, but rather, patients in pain who have developed a further medical problem.

“This is a disease like none other,” Jermyn acknowledges – and yet it is a disease. Having a substance abuse problem is little different from having diabetes or having high blood pressure. Despite the stigma of drug use, doctors’ approaches to treating this medical problem should be as respectful and sympathetic to substance abuse patients as they are to patients with any chronic medical condition.

“In my waiting room, you can’t tell who is here for substance abuse and who is here for chronic pain,” Jermyn said. The residents and the medical students on clinical rotations don’t know, when they walk into the exam room, which “type” of patient they’re about to see. They only find out once they open the patient’s file. Everyone is on equal footing. No one is judged.

How doctors can end the opioid epidemic

What does it mean to treat pain patients with substance abuse disorder – or, for that matter, substance abuse patients for whom chronic pain isn’t a factor? Ambulatory detox programs don’t force patients to stop opioid use cold-turkey, throwing their body into instability. Rather, they use safe and responsible methods that have more success in long-term addiction recovery.

“We need more doctors to administer Suboxone,” Jermyn said. Suboxone is a combination medication prescribed as a form of maintenance therapy for patients who have struggled with opioid addiction. By minimizing withdrawal symptoms without causing a high, Suboxone can be part of a multifaceted approach to detoxing safely – and it doesn’t have to be given in an inpatient rehab facility.

“Everybody talks about inpatient detox beds, but treating patients in their own community and support systems may be ideal,” Jermyn said. In fact, temporarily getting away from the stressors and environments that lead to drug use can prove even more dangerous. When the recently detoxed person returns to the same environment where the drug use occurred, the risk of relapse is great, and the likelihood of an overdose is higher than ever, especially if the patient is not linked into a community program.

Treatment through Rowan’s NMI takes a different approach: treatment in the community, surrounded by the same support system and the same stressors that make up the patient’s life. For pain patients, detoxing doesn’t mean they are doomed to a life of unmanaged pain. Opioids are far from the only treatment option. The NMI implements an array of other therapies, from nerve block injections to osteopathic manipulative medicine and from conventional physical therapy to music therapy, to give these patients relief without opioids.

A model program for NJ and beyond

The NMI is truly unique, and so is the Rowan University School of Osteopathic Medicine (RowanSOM). “We are the first in the nation with both pain and substance abuse programs,” Jermyn said. “This combination doesn’t exist anywhere but here.”

However, this fact isn’t just a point of pride, but also points to a real problem. “We think every medical school should have a program like this. We want to be a model program of training on how to assess for pain and substance use.” To make that goal a reality, Jermyn is recruiting, mentoring and training community doctors to make the same impact on the lives of those addicted to opioids that the NMI is making already.

New Jersey is looking to Rowan for improvements in training medical professionals statewide. So far, a lot of the opioid training for medical professionals has focused on primary care or specialist physicians, but these efforts aren’t enough to end the crisis. Jermyn is developing training programs for healthcare workers in different functions. For example, the NMI just received a grant funded in conjunction with the state to develop training on dentists’ prescribing of opioid medications.

One educational program currently in development emphasizes training for doctors in hospital emergency departments. When a patient comes to the ER in the middle of the night, in the grip of withdrawal, how physicians treat that patient is crucial. Being turned away for “drug-seeking” behavior only will drive the patient to use again. If emergency department doctors are trained to induce patients on Suboxone – and to do it humanely, not judgmentally – and direct those patients to outpatient substance abuse programs like those at NMI, they may catch substance users at the time they are most open to giving up opioids for good.

Medical students in residency at the emergency department of RowanSOM are ahead of the pack. They already receive training in how to responsibly induce Suboxone treatment in the ER. The challenge is to spread these much-needed skills so that all doctors in all emergency departments across the country can guide substance abuse patients toward the path to recovery.

Despite their many different areas of focus, his research projects with the NMI share common goals. “The beauty of this is that it will eventually save lives in our community,” he said, “and that’s just a big deal.”