With the current Opioid Crisis in the United States, in which patient addiction to prescribed medications is more-than-ever on the rise, changes need to be made to the treatment plan for these patients.  Addiction is multifactorial.  It is not simply a lack of self-control; it involves environment, social issues, family dynamics, physiological factors, housing concerns, peer pressure, physical addition, and family history.  For years, addiction has been treated as more of a personal failure rather than an actual medical condition.  Given the exponential rise in cases of death due to the Opioid Crisis, we felt that this was an issue that needed to be addressed.  We set out to find solutions to the following questions:

• How can we better support these patients?
• How can we improve systems and outcomes?
• How can we serve our community and help save lives?

According to the National Institute on Drug Abuse (NIH) article, Opioid Overdose Crisis (https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis), pharmaceutical companies reassured prescribing opioids would not cause addiction:

In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive. Opioid overdose rates began to increase. In 2015, more than 33,000 Americans died as a result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl, a powerful synthetic opioid.That same year, an estimated 2 million people in the United States suffered from substance use disorders related to prescription opioid pain relievers, and 591,000 suffered from a heroin use disorder (not mutually exclusive).  Here is what we know about the opioid crisis:

This is not to say that pain isn’t individual.  However, for example, after minor surgery, prescribing 30 Vicodin pills is putting people at risk of addiction.  Following a procedure, one could expect pain for 24-48 hours.  After that point, pain is part of the healing process and many times people are not educated enough to understand this. This is not the fault of the patient or the provider. It is in our culture that we do not want to feel pain when pain is a natural part of living.  Addiction does not discriminate.  One can be worth billions of dollars or one can be homeless – addiction does not have an economic barrier.  Educating providers and patients and changing the popular belief that life should be pain free will dramatically improve the environment of addiction treatment.

CCG of Baltimore, Maryland, took the lead to help solve this difficult problem.  They are a progressive treatment center treating over a 1,000 patients a day for addiction.  By combining medication therapy, group therapy, medical treatment, psychological support, laboratory monitoring, housing, job training, and intensive outpatient care, CCG's approach is new and revolutionary in this industry.  This multifactorial treatment has shown significant success in the drug treatment environment.  After few years of success, CCG is expanding to multiple locations to help turn the tide in this most difficult fight against drugs.  The common theme is that patients were not receiving enough support in this fight.  CCG noticed that many of the patients were from difficult backgrounds and needed more treatment than currently being supported by most health systems.  With this in mind, CCG opened up it flagship site in Baltimore to serve a patient base often overlooked.  Seeing that many of these patients were having difficulty, CCG started looking at the underlying issues.  They found that many patients not only needed help with things as simple as getting to the facility, but also with emotional support, housing and job training in order to truly heal.  They also found that addiction is not just affecting those living in poverty, but that it affects every economic subsection of the county.  Therefore, the outcome of our pilot proved that with increased communication between physician, patients, laboratories and therapist combined with increased focus care, patients recover much faster with less risk of relapse.

This interoperability component was important in that the provider directly addressed any variances discovered in the labs.  We found that with better communication between providers, better care was rendered to the patient.  Improved communication was instrumental to their success, regardless of whether the patient was seen by the primary care provider, addictions specialist, or the lab.  The information was available to the primary care providers, the inpatient providers, the outpatient clinic and laboratory. With a revision rate of less than 2%, we found that if more intensive care was given on admission that outcomes were improved.  Furthermore, our study showed that the outcomes greatly improved with increased drug testing, more intensive counseling and better follow up.  Our control group consisted of those in regular outpatient care in comparison with those who were in IOP.  The patients in IOP were 90% more likely to transition to maintenance dosing with less than a 2% chance of relapse.  Then, once they were on a maintenance program, the patients who were in IOP were 96% more likely to be ready to reduce dosing with the possibility of transitioning off methadone.  Our plan included increased frequency in urine testing, group therapy, physiological care, and provider oversight.  In addition to these measures, additional services included Health Home care, housing, and job training.

In addition, our comprehensive success rate of 98% shows how improved communication and services reduce the overall cost of patient care.  With an increased upfront investment in the care of the patients, we found the overall cost was much lower due to the reduction in the revision rate.  Points of reference were frequency of drug testing, number of positive tests after starting the program, frequency of therapy for those who received additional group therapy, additional psychological care, and Health Home care.  Although these differences were key to the success of the care, today they are not all covered in the care plan of most payers.  Therefore, given the national focus on this issue, it is evident that the model CCG practices should be held up as a strong example of successful, innovative care.

Healthcare is ever changing and we believe that with the work being done on the EMDI project, CMS is making great strides in improving outcomes.  It is often against conventional wisdom to increase services upfront, however we found that if we look at the outcomes, we can prove that that is exactly what we need to do.  It may cost more to go electronic and to offer more care upfront, yet with these two increased services, we found that the overall cost of long-term care was drastically decreased.

Topline Healthcare, CCG and Harwood Labs conducted this study with the intention of effecting change in our healthcare system for the better.  Our goal was to prove that even in the health crisis of opioid addiction, if we focus on the illness and not the crisis, then together we can greatly improve the quality care of human beings and their lives.