Overcoming An Epidemic: Opioids In Pennsylvania -- Episode 4: Warm Handoff
A continuum of care is a network of resources to help people enter and stay in treatment. Learn more about how Pennsylvania is managing this process—known as a warm handoff—for treating people with opioid use disorder.
Min Xian - When someone has a heart attack, they get rushed to the emergency room. When they stabilize, they meet with a cardiologist, who can help come up with a treatment plan.
They may be told to start on a medication, eat differently, or plan for a stay in the hospital. They set up an appointment to come back.
A case manager may tell them it’s normal to experience depression or anxiety - so here’s the number for a psychiatrist.
That’s what’s known as continuum of care. Sometimes, it’s called warm handoff.
Corinne - I never had any of that when I when I was in the hospital.
MX - That’s Corinne. She had an overdose a couple of years back. She says, she had no idea what to do, and it would have made a difference if someone was there to catch her.
C - This kind of stuff happens all the time, people overdosing. And you're in such a dark place at that time, to have someone there who's been there, and can help you, give you options. I mean, I just think that's great.
MX - Most researchers and physicians believe opioid use disorder should be treated like any other kind of chronic disease. They say that should start with ensuring warm handoff plans exist. One important step is to get people on medication-assisted treatment, but it’s also the one that faces the most skepticism.
So, what does an ideal scenario for treating opioid use disorder patients look like?
I’m Min Xian. And this is “Overcoming an Epidemic: Opioids in Pennsylvania,” a WPSU podcast looking at what researchers, communities and government agencies are doing to try to prevent and treat opioid addiction.
In this episode, we’ll talk about warm handoff.
Background sound of birds chirping, light traffic
I’m meeting Corinne in the backyard of a coffee house. She arrives in a pair of purple tinted sunglasses, with a green bandana on her head. She apologizes for being late. She commutes by bus to work, and today, it ran behind schedule. Corinne is in recovery from opioid use disorder. We’re only using her first name to protect her privacy.
Corinne tells me she celebrated five years off opiates in May, and that it feels like it’s taken a lifetime to feel okay again.
C - And it's great. I mean, I never thought I would get to this point. I really didn't. I haven't felt like this in a very long time.
MX - Corinne developed severe depression and anxiety in high school. Without a way to cope, she started using cocaine and alcohol.
C - I'm just so shocked that I wanted to keep doing that for so long. I mean, it's just so ridiculous. It wasted so much time, but you don't realize it when you're in your addiction and how, you know, toxic that relationship was and how the friendships I had were not friendships.
MX - She kept using, and later moved on to opioids like heroin and methadone. She says, the choice the first time was hers, but after that, the drug just took over.
Although she continued to work, pay her bills and was, in her words, semi-functional, her life revolved around her addiction. It was a way to not feel the pain of life. When her boyfriend of three years died of an overdose, she went even deeper into opioids - she didn’t know how to deal with it.
C - I didn't want to be around anyone. I was just by myself in my room drinking, smoking weed. I was doing anything I could to get [expletive] up. I mean, that was what I was trying to do was just not to feel anything, and just get through it.
MX - The winter of that year, Corinne overdosed in her home. That was her turning point, she says. She started thinking seriously about getting off drugs. She wasn’t sure how. The hospital pumped her stomach and released her, because she wasn’t suicidal. Her family didn’t know the full extent of her addiction, and more importantly, they didn’t understand addiction.
Eventually, she was sent to an Accelerated Rehabilitative Disposition program because police charged her for having drugs when she overdosed. Corinne was required to go to counseling.
C - I met that counselor who just changed my life. She was awesome. She helped me get through the hardest time. I think the hardest thing for me was learning how to enjoy myself without being high. I never thought I could have fun unless I was high. Well, I'll go here, but I gotta get drugs first.
MX - While Corinne took time to gradually embrace and practice that idea, another change came around.
C - And since I went to the counseling, that's whenever I got the referral to get into the Suboxone program.
MX - Suboxone. It’s one of the medicines used as part of medication-assisted treatment for opioid use disorder. It has two main ingredients, one staves off cravings and the other makes sure that even if someone tries to get high, they can’t. When it’s prescribed, it effectively reduces painful withdrawals.
Corinne is happy she’s taking Suboxone and has a doctor who explains things to her.
C - I feel like my depression’s got a lot better. He's got me on better meds. And he'll talk to me for an hour. Him and I will sit there and chat and talk about everything. And he will explain anything I want to know. And he just seems to care. And it's really nice. He's like you're healthier, you look healthier, you're acting different. You're just when he said when I first came in, I was just pretty much like, “Blah.” But now he's like you're just more vibrant. I can just tell that you're happier that it's really helping and I think he helped me so much.
MX - She gets her prescription once a month. That makes staying on treatment while working and simply having a normal life a realistic goal. Researchers prefer it among the three FDA-approved MAT medications.
Methadone needs to be taken daily, and naltrexone, also known as Vivitrol, requires patients to basically detox before they can start on it. Having different options makes sense, because every addiction is different.
Researchers say, the bottom line is that medication-assisted treatment, coupled with counseling, works. Sarah Kawasaki believes, one way or another, patients should be able to access the treatment. She’s the director of Addiction Services at the Pennsylvania Psychiatric Institute.
Sarah Kawasaki - I think there are still a lot of challenges in Pennsylvania in particular, because there is a big challenge from the treatment communities. So there's not enough legislation that is looking at inpatient detox programs to say to them, “Hey, detoxing people from opioid use disorder, it doesn't work.” People leave and relapse, nine times out of ten. We're in the middle of a crisis. Don't you know? There's fentanyl on the street, [and] people will die. So instead of detoxing patients, you really have to start them on buprenorphine maintenance or methadone maintenance with the focus of transitioning them to a provider in the community.
MX - Suboxone, which combines buprenorphine and naloxone, has been an FDA-approved MAT drug since 2002.
Reporting for this podcast, there’s one thing I’m told again and again: Look at the evidence.
Researchers point to one buprenorphine trial of 40 people based in Sweden. It found that three quarters of the patients treated with the medication continued treatment after one year. Twenty percent of untreated patients died, while all who were on buprenorphine lived.
Similarly, patients who go on methadone treatment test positive for opioids at lower rates.
Kawasaki says, medication-assisted treatment is evidence based and that’s not a matter of argument.
SK - It saves lives.
MX - Here’s another thing that researchers, physicians and people who are affected by the opioid epidemic really want to let you know: medication-assisted treatment is not substituting one drug with another. What it is - is trading addiction for dependence.
SK - Dependence is a state - a physical state - where if you stopped a medication, you would get sick. So you depend on a medicine to stay healthy. Addiction is a series of maladaptive behaviors that primarily revolve around craving.
MX - Kawasaki says, our society doesn’t stigmatize dependence on insulin for people with diabetes. But opioid use disorder, and addiction in general, is viewed as a sin rather than the disease that it is. And, she says, there’s no other illness where the treatment itself is as stigmatized as the disease.
That may be one of the reasons why MAT is still underutilized. The federal government estimates that fewer than one third of people with opioid use disorder in the country received MAT in 2010.
SK - Even if somebody is willing to accept that addiction is an illness, they are less likely to accept methadone and buprenorphine as legitimate treatments for this illness. And those are the two medicines that have been studied for over a decade - in the case of methadone, for 50 years, and for buprenorphine, close to 20 years. So I think that it's a multipronged challenge to get people to both accept addiction as an illness that requires evidence based treatment, and that the evidence based treatment isn't in and of itself dirty in any way.
MAT is one piece of the puzzle. In 2016, Pennsylvania rolled out a new mandate, which required county offices to come up with their own warm handoff plans. The state also established what it called Centers of Excellence, with the goal of keeping opioid use disorder patients in treatment.
One pilot started in Western Pennsylvania. The Addiction Recovery Mobile Outreach Team received nearly 1,000 referrals over three years. Two thirds of those referrals received screening and among them, four out of five got into treatment.
The Clearfield-Jefferson Drug and Alcohol Commission is one of the Centers of Excellence in the state. It’s responsible for both managing the area’s warm handoff protocol and providing case management for patients.
Susan Ford is the executive director of the Commission. She thinks, overall, things are changing for the better.
Susan Ford - When I first started out in the field in 1982, there was nothing like that. It was treatment and that’s it. You got treatment and there was no support services. But anecdotally, people do a lot better now than they did then. Because we would just send them right back to the same environment - doesn’t’ mean to say that we don’t now, but sending them back to that environment with support is a whole lot better than sending them back with nothing.
MX - Their latest plan is to embed a case manager with the emergency department of the local hospital, so patients can receive follow up counseling and treatment as soon as possible.
When it comes to warm handoff, even things as trivial as locating hospital units next to each other make a difference. Inside Penn Highlands’s DuBois hospital, neonatologist Mohamed Hassan shows me around.
[Sound: Electric door open]
Mohamed Hassan - This is the connection between us and the OB-GYN. This is our delivering room. If the baby has any issues, then we go directly to the Neonatal Intensive Care Unit.
MX - Hassan says, the units are set up specifically so that the OB-GYN rooms, the delivery rooms and the Neonatal Intensive Care Unit are all on the same floor.
His unit treats premature babies and babies who were born with Neonatal Abstinence Syndrome. Those babies go through withdrawals because their mothers used opioids during pregnancy.
MH - Five years ago, when we started this program, we were seeing only like 10, 12 babies a year. Now last year, we saw more than 76 babies.
MX - In addition to ensuring these babies receive treatment once they’re born, the hospital also connects the moms with social workers to place them into a continuum of care.
Kawasaki says, closing the gaps in resources is key.
SK - When patients want the treatment, and when they can access the treatment, and having the treatment available are three stars that need to align. We can only do what's in our control. And so if we have the ability to be flexible enough to see them within 24 to 48 hours, we can get patients initiated on medication quicker.
MX - For a long time, people with opioid use disorder didn’t get that warm handoff, and it is still a relatively new idea.
At least for Corinne, getting where she is now took time. She stumbled along the way. But she says, she’s in a good place now.
C - I still get really bad anxiety sometimes in different situations. Or if I have a bad day at work, or if something bad happens, I normally just say, Well, I'm just gonna go get some drugs and not think about this. And I'm finally... I don't think any more like that.
MX - Corinne wants to become a Certified Recovery Specialist, because hers turned her life around.
In the next episode, we'll hear from families about what it means to have a loved one caught up in the opioid crisis.
"It affects a lot of people — brothers, sisters, parents, grandparents. And I think that's overlooked at times."
People left behind... on the next episode of Overcoming an Epidemic: Opioids in Pennsylvania, a production of WPSU.
Thanks for listening. Reporters on the project include Anne Danahy, Emily Reddy, and me, Min Xian. Cheraine Stanford and Frank Christopher edited the episodes. You can find more resources on the opioid crisis and what to do if you or a loved one need help at wpsu.org/opioids. For WPSU’s Overcoming an Epidemic, I’m Min Xian.