A Minnesota Critical Access Hospital Uses Medication-assisted Therapy to Tackle the Opioid Crisis

Leaders at a critical access hospital in Little Falls, MN, were moved to create and implement an opioid community task force to address opioid use disorders in their community after they noticed that narcotic refills, emergency department visits and overdoses were spiking. 

In 2014, Lee Boyles, president and CEO of CHI St. Gabriel's Health, and two of the organization's physicians - Kurt DeVine and Heather Bell - collaborated with the local police department, social workers, schools and public health alliances to target the social factors around opioid substance use disorders in their community. 

As a result, St. Gabriel's has reduced prescription opioid use for more than 350 patients. Boyles said that community collaboration and communication are key to the effort. 

"You have to have the utmost transparency with that information sharing if you're going to have success," he said at the AHA's 2018 Rural Health Care Leadership Conference.

St. Gabriel's program, which included clinical approaches such as avoiding early refills, incorporating prescription drug management programs, reviewing patient charts in a more coordinated fashion and conducting urine screens, received a 2017 AHA Nova Award. 

Bell also emphasized the advantage of medication-assisted therapy (MAT) over abstinence-based treatment. 

Initially, Bell and others resisted MAT. But cutting off opioid use abruptly can be fatal, she said. Because opioids damage the frontal lobe of the brain, where executive decision-making is done, it is difficult for those with substance use disorders to override their impulses. 

Bell suggested the brain takes at least three months to recover from opioid abuse, and it takes approximately five years for brain chemistry to completely regulate. Because opioids are so powerful, it's common for an addicted person to relapse and overdose within that period, she said. 

Narcotic cravings are like other cravings, Bell said. "It's actually the brain telling you, 'you need that medication to function normally.'" This is why abstinence efforts often fail, she said, because patients can lose basic cognitive functioning in the years it takes to recover after withdrawal.

With that in mind, physicians at CHI St. Gabriel's Health began prescribing Suboxone to patients going through opiate withdrawal. Unlike Methadone, which also can be used to taper patients off opioids, Suboxone isn't addictive, and prevents opioid overdoses, Bell said. It also can be prescribed in larger doses than Methadone, requiring fewer patient trips to the hospital to obtain it. 

With MAT, patients are able to "function normally" again, Bell said, a feat when considering how vulnerable they otherwise would be for the five-year period following opiate withdrawal. Bell noted that patients who stop using Suboxone within five years have an 86 percent chance of relapsing. "We tell these patients, 'this is your insulin. This is your blood pressure medication. This is helping your brain function,'" she said.

Because Suboxone has been so critical to recovery, Bell and others have been working with the Little Falls police department to allow incarcerated patients to use it. Since January 2015, the total number of days patients spent incarcerated prior to their use of Suboxone was 616. After using the drug, most patients stopped seeking out illegal narcotics such as heroin - which some of the patients used when they had difficulty obtaining opioids - and the number of days the same group spent in jail fell to just three, Bell said. 

To bolster their MAT efforts, Bell and her team instituted a process through which nurses and social workers begin immediate treatment for patients who come to the emergency department (ED) in withdrawal or who have overdosed. Simply giving these patients Narcan - a drug that can reverse the effects of an opioid overdose - and sending them home can be fatal, Bell said. 

"That person has a higher chance of dying than a person who is having a stroke," she said. Educating ED physicians about this and advocating for MAT has been instrumental, Bell said.

Bell encouraged other hospital leaders to adopt the same approaches in their organizations and she has published a manual to assist them in their efforts.

"This is actually doable process no matter who you are," she said. "You can really do this in your community and it can be done with very little money."