Years ago, when someone struggling with opioid dependency would show up in a Colorado emergency room after an overdose or as they were suffering through withdrawal, doctors and nurses would patch them up and send them on their way.
“They came in and we made them feel a little bit better,” said Dr. Jason Hoppe, an associate professor in the emergency medicine department at the University of Colorado School of Medicine. “There wasn’t much we could do.”
What those patients wouldn’t receive is treatment for the underlying condition that brought them to the emergency room: their addiction.
But now, an increasing number of flagship hospitals in the Denver metro area — including ones belonging to the major providers Denver Health, SCL Health, Centura Health and UCHealth — are offering medication-assisted addiction treatment to opioid-dependent patients almost as soon as they walk in the door.
It’s part of a nationwide paradigm and practice shift that is a new first line of defense against an epidemic that killed 543 people last year in Colorado.
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“We in the emergency department have been seeing patients like this for a very long time. It’s frustrating, it’s dispiriting to see people struggling with an illness and not being able to help them or only being able to help them in the short term,” said Dr. Scott Simpson, a psychiatric emergency medicine doctor at Denver Health. “The difference that this makes for the clinician is huge because you feel empowered to treat this patient. The difference this makes for the patient is literally lifesaving.”
The idea is to treat opioid addiction like any other kind of emergency by ushering patients into treatment immediately instead of referring them to services for later.
“It’s a super important thing,” said Dr. Robert Valuck, a professor of clinical pharmacy at the University of Colorado Skaggs School of Pharmacy and head of the Colorado Consortium for Prescription Drug Abuse Prevention. “One of the biggest contributors to overdose deaths is the fact that people can’t get into treatment. If you’re getting a corn removed from your foot you can wait a couple of weeks. If people want addiction treatment, it can be a matter of life or death.”
Hundreds of people have started medication-assisted addiction treatment in emergency rooms since the program launched at Denver Health in 2018 and spread to other hospitals.
Now, doctors are starting to look at ways they might be able to use the on-demand treatment model to help patients addicted to methamphetamine, which is quickly becoming a more prevalent problem in Colorado than opioids.
Anyone who wants treatment gets it
Here’s how the protocol works: A patient comes to the Denver Health emergency room after an overdose or as they are suffering through withdrawal, or simply because they want to treat their addiction.
They are evaluated for opioid dependency and, if they meet the criteria, are then immediately offered medication to reduce their urge to use. That frequently is the drug buprenorphine, known by its brand name Suboxone.
The medication is a pain reliever that reduces a person’s urge to use by blocking receptors that are activated by opioids.
“Anyone who walks up to the Denver Health emergency department — 24/7, 365 — and requests treatment for opioid-use disorder will be evaluated for buprenorphine or methadone treatment,” Simpson said.
From there, the patients are given access or referral to clinical care where they can immediately follow up and get a long-term prescription and treatment plan.
In 2018, the first year Denver Health began offering its on-demand program, it signed up 307 patients. In the first six months of this year, 258 people were brought on.
And there are signs that changes to the program — including more immediate involvement from mental health experts at a patient’s bedise — are keeping people in treatment longer.
In 2018, just 34% of people entering the program were retained in treatment beyond 60 days. Retention has increased to 60% this year.
“While retention beyond that two-month period isn’t where the hospital would like it to be, we’re starting to see some improvements in these domains,” said Lisa Gawenus, who directs outpatient behavioral health services at Denver Health.
Denver Health this year is rolling out the new Center for Addiction Medicine, which seeks to better coordinate all of the hospital’s treatment resources. As part of that, the hospital is conducting more-in-depth evaluations of patients in the emergency room and elsewhere — not just their health needs, but also looking at their housing, transportation and relationships.
The goal is to help patients overcome whatever barriers might keep them from sticking with treatment.
“We’re going to treat addiction like every other disease,” said Dr. Josh Blum, a Denver Health addiction specialist. “That’s the fundamental concept of the Center for Addiction Medicine: no wrong door.”
Gawenus says just getting someone into the funnel that may allow them to kick their dependency is the biggest challenge.
“I’m ever an optimist,” she said. “I believe, fundamentally, that a person in the throes of addiction wants to become well, and an exposure to a (medication-assisted treatment) is that first step into recovery.”
She likens the process to eating healthier, and how it can take time to change behavior.
“Sometimes I start a diet, but it doesn’t last,” Gawenus said. “But then I start a diet again and it lasts a little bit longer. And then finally one day I have a fundamental lifestyle change and I no longer eat chocolate cake forevermore.”
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Getting the word out
While Denver Health appears to be the first in Colorado to have offered the on-demand treatment, other metro-area hospitals have begun similar initiatives.
As more emergency departments sign on, word spreads and plans are in the works to move on-demand treatment into the high country and rural areas.
UCHealth’s University of Colorado Hospital in Aurora has been offering the service for just over a year. SCL Health’s St. Joseph’s Hospital in Denver has also been offering medication-assistance for about 12 months. Centura Health’s St. Anthony North has two emergency rooms in Westminster that have been piloting a similar initiative since October 2018.
“As more and more Centura hospitals across the state have caught wind of our model, they’re interested in adopting it,” said Amber Quartier, a program coordinator overseeing the St. Anthony North program.
Quartier said so far her program has consulted in emergency departments with 120 patients, with about 30% of those receiving medication to treat opioid dependency and getting a handoff to a provider for further treatment.
“We’re universally prescreening all patients at triage,” she said. “So when they come in, they are getting asked additional screening questions to identify whether or not they are currently using opioids in a risky way.”
University of Colorado Hospital has offered about 150 patients access to the on-demand therapy, enrolling 125. About 70% then show up for a first treatment appointment after receiving medication in the emergency department. After a month, 37% were continuing treatment.
“Getting this kind of information disseminated to all the other communities across the state is really important, not just the urban areas,” said Hoppe, the CU medical school professor.
A similar, but not as robust program, is underway at Medical Center of the Rockies in Loveland, another UCHealth hospital. The UCHealth system is also seeking money to expand to Steamboat Springs and working with a group in Colorado Springs to get a program running at that city’s Memorial Hospital.
Cristen Bates, director of communications and policy at Colorado’s Office of Behavioral Health, said studies have shown that people who begin taking medication to treat their opioid dependency in the hospital are more likely to stay in treatment and maintain wellness. That’s why the state has provided $800,000 in grants to UCHealth and Centura to get their on-demand treatment programs underway.
Bates said the state is now working with the Colorado Hospital Association to fund similar initiatives and other opioid-treatment related services at up to 10 other hospitals around the state. The idea is to ensure that when someone going through the throes of dependency enters the medical system, there are providers ready to help.
“Any medical professional that they touch should be able to connect them” to treatment, she said.
Can it be expanded beyond opioids?
With the early successes of the opioid treatment initiatives, doctors are starting to look at how they might be able to expand their serves to handle other drugs — specifically methamphetamine.
Meth use has been rising sharply in Colorado, accounting for more overdose deaths last year than opioids. At Denver Health, of 5,000 hospital admissions in 2018 for a dependency issue, 28% of patients needed medical help because of methamphetamine while 13% had an opioid-use disorder.
“Methamphetamine is coming into our community really hard and fast,” Gawenus said.
There’s never really been anything like the on-demand treatment program for methamphetamine in Colorado before, and there aren’t similar medications to quickly help people like there is for opioids. On top of that, methamphetamine-dependent patients often have psychiatric issues and can be dangerous to themselves or the community.
“We’re increasingly hearing concerns about it from our partners in the city, particularly the police,” Simpson said. “And so we are starting to think about what a treatment program looks like for methamphetamine. We haven’t launched anything yet, but we are thinking about how we can reimagine treatment for methamphetamine.”
Colorado Sun staff writer John Ingold contributed to this report.