Glad to read this article–a week old–about Yale New Haven’s effort to bring an Addiction Consult Service to the inpatient floors of the hospital. Happy New Year to all!
The medical director of the hospital’s new Addiction Medicine Consult Service, she comes from Oregon Health and Science University, where she started a similar program in 2015.
As part of her training, Weimer received a fellowship “to look at the overlap between pain and addiction from a medical standpoint,” she said. This was in 2010, “when we were really starting to see more of the problems from overprescribing of opioids.”
According to the Centers for Disease Control and Prevention, 2010 marked the end of the first wave of the addiction crisis and the beginning of the second wave, when heroin use started to become widespread. “We started to rein in prescribing and you started seeing heroin deaths,” Weimer said. People who could no longer feed their addiction with opioids were turning to the dangerous street narcotic.
The third wave began in 2013. “By far worse than the first two waves … is the fentanyl contamination of the drug supply, which is now killing many more people than the first two combined,” Weimer said. “From 2016 to 2017, there was a 45 percent increase in deaths related to fentanyl. … It’s creating unnecessary, preventable death.”
According to the CDC, almost 400,000 people died of opioid overdoses between 1999 and 2017.
Weimer said the psychiatric approach is more aimed at changing behavior, using techniques such as cognitive behavioral therapy, along with medication. In addiction medicine, “the framework is that addiction is a chronic, neurobiological condition of the brain that has biological, genetic, social determinants that affect it,” Weimer said. “So understanding that informs how we approach addiction, recognizing that there are medical treatments that can treat addiction.”
Three major drugs are used to treat what is known as opioid use disorder: methadone, which is itself an opioid, buprenorphine (Suboxone) and naltrexone. The first two are opioid agonists, meaning they activate the opioid receptors in the brain, creating the opioid effect. Naltrexone is an antagonist, “meaning it completely blocks opioids,” she said.
“All have been shown to reduce death, reduce communicable diseases like HIV, hepatitis C, reduce overdoses,” Weimer said. “Methadone and buprenorphine have been shown to reduce crime.”
The Addiction Consult Service is part of the Yale Program in Addiction Medicine that was launched in 2017, with collaboration from the School of Public Health, the medical school’s Departments of Emergency Medicine and Psychiatry and the School of Nursing.
Patients will be referred to Weimer and her team if they’re “admitted to the hospital for a medical condition directly related to the substance use or it’s noted that they have a substance use disorder during their evaluation,” she said.
It makes sense to treat a patient’s addiction while they’re in the hospital, rather than refer the patient to a treatment center after he or she is discharged. “It would be as though you say, ‘I know you need insulin but I’m not going to give it to you until you find a doctor or prescriber in the next two weeks who’s going to give it to you,’” Weimer said. “If someone has that severe of a medical illness, we would not reserve treatment for weeks on end.”
Weimer said the aim of addiction medicine is to “bring it into the forefront, particularly (for) people who are struggling.” Not only will patients’ health improve but doctors will “save a lot of lives in the process,” she said.
There are other physical and financial costs to addiction. “Untreated addiction is linked to increased hospital length of stay and readmission,” Weimer said. “Obviously, from a cost perspective, we want to be able to improve most of the high costs, which in the last decade have quadrupled” since the opioid epidemic exploded.
It is not just the addiction that needs to be treated. People with substance-use disorder, especially those who inject drugs, are more likely to contract other diseases. That’s why New Haven, among other cities, has an active needle-exchange program. “Infective endocarditis is an infection that anyone could get, but people who use IV drugs are more susceptible to it because they’re injecting unclean, unsterile substances into their body,” Weimer said.
Endocarditis is an infection of the inner lining of the heart or heart valves and can be caused by bacteria or other infectious agents that attach to the heart, causing flu-like symptoms, chest pain and other symptoms, according to the Mayo Clinic. Weimer said the disease has increased 12-fold among drug users in the past 10 years, citing a study in the Annals of Internal Medicine.
“It’s difficult to treat, takes a long time to treat and sometimes needs to involve cardiac surgery,” she said. “Before people like myself were involved in their care, those patients would come into the hospital, they would get IV antibiotics for six to eight weeks, they might get cardiac surgery for valve replacement. … They would get all these medical interventions but they would typically … not get medical treatment for their addiction.”
Treatment for such associated diseases threatens to compound the problem of addiction, she said. “They’re having surgery … It’s painful so they’re typically receiving opioids, but not opioids that treat their substance use disorder,” she said. The chances of “relapse and worsening of their condition is very high because they’re not set up to succeed.”
While the opioid epidemic has received much attention, “there are many, many people with alcohol-use disorder than there are people with opioid use disorder,” Weimer said. It is “rising exponentially in middle-aged women for unclear reasons,” as well as among the elderly, she said.
Almost twice as many people die from alcohol addiction or complications such as cirrhosis as from opioid addiction, Weimer said. It is treated with disulfiram (Antabuse), naltrexone (Revia and Vivitrol) and acamprosate (Campral).
Substance-use disorders, including alcohol addiction, are “manageable diseases, not necessarily curable diseases,” Weimer said. “We have counselors on our team who directly link patients with ongoing care” and check in with the patient after 30 days. The service will provide family education, with the patient’s consent.
Weimer’s team, when fully staffed, will comprise two counselors, an addiction medicine fellow and a nurse practitioner.
“We really have only been providing the service for a little over a month, but already we’ve been able to start treatment on many of the patients we’ve seen and we’ve seen that patients are feeling better, (and) staff are feeling better when patients are feeling better,” she said.
Dr. David Fiellin, director of the Yale Program in Addiction Medicine, said Weimer’s service, based at Yale New Haven’s St. Raphael campus, is an important addition to the program. “We had a variety of specialists, but they were not originally in one unit the way they are now,” he said.
Yale New Haven has had addiction treatment services in its clinics and in the Emergency Department, but by adding Weimer’s service to the inpatient floors of the hospital “we can address those issues at the same time as we address their medical reasons for admission,” he said.
“We’re very pleased to have her come join the faculty at Yale and pleased that she has already had experience starting and running a program at an outside institution,” Fiellin said. “I think we’re among a handful of medical centers who are recognizing the importance of addiction medicine for their patients and we’re leading that effort both locally and nationally.”
Dr. Patrick O’Connor, chief of general internal medicine at the medical school, said addiction medicine was only recently made a recognized subspecialty by the American Board of Medical Specialties and its fellowships are accredited by the Accreditation Council for Graduate Medical Education, making them eligible for federal funds.
He said the effort began in 2007. Dr. Gail D’Onofrio, chairwoman of the Department of Emergency Medicine, collaborated in creating the subspecialty. He said hiring Weimer was a coup because the Oregon Health and Science University is “a model for how to provide state-of-the-art addiction care.”
“She’s a rare talent,” O’Connor said of Weimer. “We’re very lucky to have her and she’s already hit the ground running. It’s very exciting and Dr. Weimer’s the perfect person … to get things rolling here at Yale.”
By Ed Stannard, New Haven Register Updated 7:55 pm EST, Saturday, December 22, 2018