Addiction Consult Team: Better Care for Patients
Chronic pain afflicts an estimated 100 million Americans. But its treatment, which has long included highly addictive medications, can lead to even more problems for sufferers. The CDC reports that a record 100,306 Americans died from drug overdoses during the 12-month period ended in April 2021 – almost two-thirds from synthetic opioids such as fentanyl.
Although the medical community has taken significant action in recent years to reduce the availability of prescription opioids, it hasn’t done enough to create a comprehensive health care solution to help patients manage their pain while also addressing their problems with addition – until now.
Across the country medical centers including the one I lead, Michigan Medicine, are developing approaches that will make it easier to identify and help patients who are battling addiction and to support their recovery. These efforts include a broad range of strategies, including the use of opioid alternatives and point-of-care counselling, that have been shown to be effective.
These efforts are driven by a fundamental insight expressed by my colleague Dr. Paul Hilliard, a pain specialist. “It’s pretty clear that this country has far more than just an opioid problem,” he explained. “It has a pain management problem.”
This view reflects a profound rethinking of the problem, pushing us to supplement models of care that have tried to limit prescribing of highly addictive medicines to take a more holistic view about how physicians and patients can address the very real pain that is driving the crisis.
Traditionally, if a patient came to the hospital for, say, a hip or knee replacement, we dispensed appropriate amounts of pain medication for their recovery. What we haven’t done on a systematic basis is learn about their history with narcotics. Are they currently struggling with addiction? Are they in recovery so that their sobriety might be threatened by the treatment?
Last summer we established a new inpatient service – similar to ones developed at Johns Hopkins and Massachusetts General Hospital – to provide better care for patients suffering from this medical condition. The core of this approach involves an addiction consult team (ACT) that includes a physician, social worker, pain pharmacist, nurse navigator, and peer recovery coach (who has lived experience with recovery).
It is important to know if patients have a history of addiction, but that isn’t enough because many are often loath to admit dependency for two main reasons. First, is society’s stigmatization of the disease. Second, and perhaps more important, there seemed to be little upside to such disclosure because it wouldn’t result in added care.
The consult team offers such help. The physician and pharmacist work with the patients and their other care givers to consider a broad range of ways to manage pain, including the use of non-opioid treatments such as infusions of ketamine or lidocaine where appropriate. The social worker and peer recovery coach hold meaningful conversations about how and why patients became addicted and their readiness to engage in treatment. The nurse navigator helps ensure they have robust follow-up care once they leave the hospital. It is easy to write an opioid prescription. It is much harder and more effective to explore the emotional pain, which might include the loss of loved ones or job that is amplifying the suffering. This approach begins to unravel these deeper issues.
The team also provides ongoing care, staying in touch with patients, helping monitor and respond to their pain and coordinating follow-up appointments long after their discharge from the hospital.
This approach is providing promising results. In their first 7 months, ACT directly helped about 275 patients, some through multiple hospitalizations or over multiple days. The team started about 70 patients on medications for opioid use disorder and facilitated an expedited hospital discharge for at least 20 patients.
Building on this success, we are working to help every member of the Michigan Medicine community – from doctors and nurses to social workers and physical therapists, to administrators, researchers, patient transporters and community partners – become aware of our efforts around addiction. Our goal is to enable everyone on our team to better help patients deal with the effects of pain and substance use disorder, and inform them about available non pharmacological therapies.
More specifically, we have partnered with Blue Cross Blue Shield of Michigan to build an incentive program to get more caregivers trained and waivered to prescribe buprenorphine which, like methadone, is an opioid that can be effective in the of treatment Opioid Use Disorders. We have also worked to increased capacity at our clinics significantly. Since working with the BCBSM incentives and launching the ACT initiative, we have more than quadrupled the number of primary care providers prescribing buprenorphine and the number of patients benefiting from long term treatment for opioid use disorder as a part of their primary care.
In addition to narcotics – which are often essential to pain management – we hope to include a wide range of effective strategies in our treatment plans, which could include acupuncture and yoga, while recognizing the importance of human support from family members, recovery counselling and religious organizations.
Our addiction consult teams are not a magic bullet for the deadly opioid crisis, which is driven in large part by heroin, fentanyl and other illegal drugs manufactured and sold by criminal networks. But by recognizing pain management as an integral aspect of the care we deliver to patients, it is a difference maker.
Marschall S. Runge, MD, PhD, is Executive Vice President for Medical Affairs and Dean of the Medical School for the University of Michigan. He serves on the Board of Directors for Eli Lilly and Company.
