Virginia researchers won a $1 million grant to determine if beginning medication-assisted treatment in emergency rooms within hours of an overdose will help people control their addictions.
Despite all the attention, programs and funding centered on the opioid epidemic in Virginia, the overdose rates aren’t budging. Opioids are on pace to claim the lives of nearly 1,200 Virginians this year, according to the state’s chief medical examiner’s office, and the number of overdose cases in emergency rooms has not abated.
“If anything, the number is going up, unfortunately. So far we have not had an impact with the other efforts taking place,” said Dr. Gerald Moeller, director of the Virginia Commonwealth University Institute for Drug and Alcohol Studies.
Moeller is the lead researcher in the collaboration with Virginia Tech, Carilion Clinic and Inova Fairfax Hospital. Starting in March, emergency room patients treated for opioid overdoses will be asked if they want to participate in the project, and before they are discharged they will receive an injection of Sublocade, an extended-release form of a drug known to quell opioid cravings.
The researchers expect to show that immediate enrollment in a medication-assisted therapy will lead to long-term recovery. The funding is coming from Virginia Catalyst, which awards grants to commercial bioscience projects for the state, and pharmaceutical company Indivior, which recently won FDA approval of Sublocade, whose effects are expected to last a month.
The research project aims to reduce the lag between overdose and addiction treatment.
“Treatment as usual, as we are aware, is sub-optimal. People go to the emergency room, they have a crisis, they may get naloxone and they may be referred to a treatment program that will see them — if they are lucky — in a month or two,” said Warren Bickel, director of the Addiction Recovery Research Center at the Virginia Tech Carilion Research Institute. “But they have to shoot up like four to six times a day. So what’s the likelihood they are going to end up in the emergency room again? Substantial.”
That’s why Moeller took the lead in developing the research project.
“I was talking with my colleagues in the emergency room who were very frustrated because they kept seeing patients come in after opioid overdoses, and for those who survived they didn’t have a good place to send them,” Moeller said. “They had difficulty getting them into treatment.”
Moeller said VCU looked at the 400 opioid patients seen in the emergency room in 2015. “Of those who survived, one in 10, within six months, either had a repeat overdose or had died,” he said.
When someone overdoses on an opioid, the standard treatment is naloxone, which negates the effects of opioids. It’s a quick but short-lived remedy.
The longer-term strategy proven most effective is to receive regular doses of methadone or buprenorphine along with counseling. Those programs can be expensive and scarce. Plus, the medication needs to be taken often.
Since patients sever their relationship with emergency room doctors upon discharge, ER physicians generally aren’t certified to prescribe buprenorphine because they cannot comply with the oversight and counseling requirements.
“What we continue to see as a problem on the emergency medicine side is when patients come in with an overdose, we don’t have a successful program to get them right into treatment,” said Dr. John Burton, chair of emergency medicine for Carilion.
“Relapse rates are very high,” he said. “If you could get some long-term, medication-assisted therapy right after their initial point of contact in the emergency department, then it would be a tremendous opportunity to leverage a multi-day or multi-week treatment to get them into recovery.”
Once the trial designs are approved by the FDA, Carilion Roanoke Memorial Hospital ER physicians will be able to ask patients who were revived from overdoses if they want to enroll in the program. If so, they will be given an injection of long-lasting buprenorphine and a quick handoff to Carilion’s psychiatric staff.
Bickel will look at whether the rapid treatment allows people with opioid addictions to think beyond the few hours between highs.
“We’re not testing the medicine, per se. We’re testing the speed and access to treatment and hoping that proves to be a key determiner of people succeeding and improving their life circumstances, and avoiding these overdose deaths and emergency room visits,” he said.
The trial is expected to begin in March. Partner Inova Fairfax Hospital is also enrolling patients and will explore whether there is a genetic component that makes a person more susceptible to addiction and overdoses.
Moeller expects that about 100 people will be enrolled and that it will take about a year to demonstrate a reduction in recidivism.
“We believe it will develop a new paradigm that reduces overdose and death rates,” he said.
Bickel thinks the results will be evident quickly.
“I have a feeling it’s not going to take long to find out there is a different outcome, and I would like to be able to tell the world to start doing something that will stop the large number of mortalities that we are seeing with opioids,” he said.
On the one hand, it makes sense to treat as quickly as possible; cocaine is less addictive than crack because crack works faster. The shorter the interval between use and reward, the more likely repeated behavior will occur. On the other hand, most addicts have used buprenorphone, it’s just their second choice (behind their preferred opioid). However, catching them when they overdose and could have died without intervention also delivers a powerful message at what may be a “teachable moment”.