Einstein Holds Out ‘Welcome MAT’ for Treatment of Opioid Use Disorder
Tenth in a series
About five years ago, a few doctors practicing primary care and emergency medicine at Einstein Medical Center Philadelphia started looking for a better way to help patients who had become dependent on opioids.
In most cases, the drugs initially had been prescribed by a doctor, for an injury or some other reason.
People would show up in the Emergency Department suffering from an overdose, withdrawal symptoms, or some other condition made worse by addiction.
Others came into offices to get their primary care, but the system wasn’t set up to provide addiction treatment, too, says internist Matthew Behme, MD. Patients referred to outside programs often failed to access appropriate care.
Since then, vast changes directed by a few dedicated doctors have transformed the treatment of opioid use disorder at Einstein Philadelphia.
Meeting Needs in Primary and Emergency Care
A program, led by Dr. Behme, provides medication-assisted treatment (MAT) – in the primary-care offices at the Community Practice Center on Tabor Road – for patients who who are ready to work toward recovery from substance use disorders.
“These beautiful people that had been covered up by their addiction have been uncovered and emerge as just amazing human beings and fierce advocates for helping their peers get help.”Matthew Behme, MD
The program includes two weekly support groups, an increasing number of doctors and other health care professionals qualified to prescribe MAT medications, and participation by residents.
Dr. Behme gives patients his cellphone number so they can always find him.
“We have some people now with four or more years of sobriety,” Dr. Behme says. “These beautiful people that had been covered up by their addiction have been uncovered and emerge as just amazing human beings and fierce advocates for helping their peers get help.”
Meanwhile, patients who appear at the Emergency Department (ED) in crisis get stabilized, referred to addiction treatment, and counseled by a certified recovery specialist – someone who has been there – or a social worker. They learn about what to expect from withdrawal and treatment.
The specialists, Lauren Scarpiello, LMSW, and Tyhearia Carroll, CRS, were hired about two years ago with help from Philadelphia Department of Public Health grants, says Serge-Emile Simpson, MD, director of the Toxicology Fellowship Program in the Einstein Philadelphia ED. He’s looking for another recovery specialist as well.
“I just don’t know how we got along without them,” he says. “They touch so many patients, 30 or 40 each month, and really make all the difference for those people.”
Those who are interested in treatment are seen within days in the Community Practice Center, often by the same doctor they met in the ED. They get appropriate medication, and the primary care staff takes it from there.
Overdose and the Growing Threat of Fentanyl
Unintentional drug overdose deaths increased about 10% in the first six months of 2021 in Philadelphia compared with the same period in 2020, according to the Philadelphia Department of Public Health. The increases were even steeper among African Americans.
Einstein Medical Center Philadelphia typically sees about 17 patients each month with overdoses. An average of 24 others per month show up in the ED with symptoms of opioid withdrawal.
In recent years, at least 80% of the city’s overdose deaths involved some type of opioid drug, mostly illegal ones.
“Even people who have no desire to use an opioid are encountering fentanyl” in other street drugs.Serge-Emile Simpson, MD
Patients tell Einstein doctors that fentanyl, an extremely potent opioid, increasingly is found not only in heroin but even in cocaine and fake street versions of oxycodone and anxiety medications such as Xanax.
“So even people who have no desire to use an opioid are encountering fentanyl,” Dr. Simpson says. “We’ve seen cases here at Einstein where people who get together to use cocaine all overdose because there’s fentanyl in it. One person wakes up and calls the ambulance, but it’s too late for the others.”
The Einstein Philadelphia program to treat opioid addiction, now known as the Einstein Welcome MAT, began in 2017 with one patient.
Dr. Behme was ready. He had received the special training required at that time to prescribe anti-addiction medication. “Then one day somebody walked in and he said he had a problem with Percocet, and I said, let’s try to treat him.”
Program Rebuilt After Pandemic
The program has had its ups and downs, with many patients lost to follow-up, he says. The pandemic was a stumbling block, because the group sessions that form the backbone of patient support had to be moved online. Many people dropped out.
Now, though, the program is back to pre-pandemic strength, with about 70 to 80 patients, he says. Group meetings are voluntary, but everyone needs to come in once a month for a medication renewal.
“Probably half of them cycle in and out, where we’ll see them really frequently for a few weeks and then we don’t see them for a few weeks. The other half we see really pretty regularly,” Dr. Behme says.
Most people in the program are prescribed Suboxone, an oral drug that contains buprenorphine and naloxone.
Buprenorphine is similar to opioids in some ways but is safer and does not produce the same “high.” If someone should take an opioid at the same time as Suboxone, buprenorphine blocks the effects and reduces cravings.
The naloxone component discourages inappropriate use. If someone attempts to inject Suboxone, naloxone will cause severe withdrawal symptoms. (A different version of naloxone, known as Narcan, is used to reverse an opioid overdose.)
A few Einstein patients who have been in recovery for some time use a monthly injection of naltrexone (a drug similar to naloxone). This medication blocks the effects of any opioid a person may take and is an alternative to Suboxone for some patients, Dr. Behme says.
“We’re integrated within a primary care practice, so you don’t have to go to any other doctor…. We try to reduce as much of the stigma as possible to really open the door to allow people in for treatment.”Matthew Behme, MD
Research shows that people taking buprenorphine are three to four times as likely to stay sober as those who withdraw from opioids without medication.
Buprenorphine is not as effective as methadone for addiction treatment, but is prescribed for at-home use. Patients who prefer methadone can be referred to a clinic that administers this medication daily.
“We’re integrated within a primary care practice, so you don’t have to go to any other doctor,” Dr. Behme notes. “You sit in the same waiting room with people who are here for high blood pressure, and we try to reduce as much of the stigma as possible to really open the door to allow people in for treatment.”
About 30 Einstein doctors, mostly in primary care and the ED, now have the “X waiver” required to prescribe opioid-addiction medications, a substantial increase in recent years, he says.
Training Residents to Treat Opioid Abuse Disorder
“Our treatment of opioid use disorder has become commonplace,” Dr. Behme says. “And the internal medicine residents who graduated this year are the first group that’s regularly taken part in treating opioid use disorder with medicines throughout the whole course of their residency. And that’s very encouraging to me.”
Emergency medicine residents also are being trained to meet the needs of patients with opioid use disorder. Thanks to a grant from the Albert Einstein Society, they have Narcan kits they can carry everywhere to administer prompt treatment to someone having an overdose, Dr. Simpson says.
Patients with opioid use disorder most often come to the ED in crisis – overdose or withdrawal. Dr. Simpson says that recovery specialists also visit ED patients who are admitted for some other medical condition related to their addiction.
Everyone who’s willing gets information about addiction treatment – at a recovery center, a methadone program or the Community Practice Center. Those who want to try the CPC are scheduled for the first available appointment.
At least one ED doctor works in the center every Tuesday morning in order to get former ED patients started with medication for their addiction. They also sit in on support group sessions, Dr. Simpson says.
“Not everybody shows up for their appointment, but the ones that do they’re really grateful. We are able to quickly capitalize on their interest and get them into treatment.”
For more information about the Welcome MAT program, call 215-456-6500.
Alternatives to Opioids: Read the series