Facing Addiction: The Opioid Epidemic | PCOM Digest Magazine
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Facing Addiction

May 15, 2018

Osteopathic physician Bradley Miller, DO '98, FAAFP, speaks on addiction in rural communities and an obligation to teach future physicians.

by Janice Fisher

Having spared no corner of the nation, no demographic category, the opioid epidemic has reshaped the interests and energies of practitioners and programs in every medical specialty. The faculty and alumni of Philadelphia College of Osteopathic Medicine are no exception. Here, a dozen faculty members and alumni share their professional stories and personal viewpoints about dealing with what has been called the worst public health crisis in American history.

In the Trenches: Working in Addiction Medicine

Richard Gold, DO ’91, who began his career in HIV medicine and then became interested in how HIV and addiction intersect, is medical director of Cornerstone Treatment Facilities Network. With two detox and rehab facilities, one in New York City in Queens and the other in Rhinebeck, New York, and a total of 265 detox and rehab beds, it is one of the largest such facilities in the state. A team of 24 physicians and nurse practitioners provides medically supervised inpatient withdrawal and stabilization and inpatient rehab.

“Perhaps only 15 to 20 percent of our patients,” says Dr. Gold, “are using one substance—just opiates, for example. Many people who turn to benzodiazepines—Xanax, Klonopin—are self medicating for anxiety. Benzos work well for the short-term treatment of anxiety, but people get on them for years. Young people who have no psychiatric diagnosis can be addicted to benzos, which they buy on the street. Some take a huge amount—if I took that many, I’d probably stop breathing.

“Fentanyl is a super-powerful opiate. But some people don’t even realize they’re using it. They’re buying counterfeit Xanax that’s actually fentanyl. They take what they think is one Xanax, and they die of a fentanyl overdose.

“We see people using a large quantity of pills. They are prescribed strong narcotics for pain, but then the doctor cuts them off. They wind up turning to heroin, which is much cheaper than buying narcotic pills on the street.”

A 2017 New York law guarantees all patients up to 14 days of addiction treatment, with no insurance authorization required. “In terms of detox,” which typically lasts five days, says Dr. Gold, “that’s great, because we used to have to call the insurance company and wait hours for them to call us back. And now we don’t need authorization for detox, and the patient does not have to wait for treatment, or possibly be denied. Prior to 2017, when we’d have to get authorization, a lot of people wouldn’t get any rehab services. 

“But rehab is intended to be a 28-day program. And now, insurance companies generally don’t allow us to extend it much beyond 14 days.” Cornerstone’s average length of stay for rehab decreased from 13.5 days in 2016 to 10.5 days after the new state law took effect. (The numbers include patients who left against medical advice or whose stays were shortened for any other reason.) “Unfortunately,” says Dr. Gold, “even 14 days isn’t very long to teach somebody new behaviors.”

Photograph of heroine, syringe and spoon on a table.

“We see people using a large quantity of pills. They are prescribed strong narcotics for pain, but then the doctor cuts them off. They wind up turning to heroin, which is much cheaper than buying narcotic pills on the street.”

Another unintended consequence can be seen with Suboxone. “Probably 20 percent of our patients,” says Dr. Gold, “test positive for Suboxone, but they haven’t been prescribed it. Doctors are prescribing it for other patients, but some of those patients are selling it to buy illicit drugs.

“On the other hand, a lot of doctors just don’t want to deal with Suboxone patients. In New York State, some certified Suboxone prescribers have zero patients. In rural areas, patients may have no options for obtaining Suboxone. Even upstate in Rhinebeck, there are many fewer options than in New York City.”

Dr. Gold maintains, “You have to be a certain kind of person, have the right mindset, to want to do this work. Somebody who comes in and is withdrawing isn’t in their best state of mind, and you have to be able to let their behavior go. The reason I went to medical school was to help others. It is very rewarding to be able to save a life and help some people get their lives back.”

The Psychology of Addiction Treatment

When David Festinger, PhD, professor of psychology and director of substance abuse research and education, PCOM, started publishing in the early 1990s, use of crack cocaine was epidemic. “I thought it was the most insidious addiction imaginable,” he says. Now he studies opioids. “If you had to set this up as a behavioral experiment, you couldn’t create a more efficient substance to facilitate and sustain an addictive disorder.”

Dr. Festinger, past president of the American Psychological Association’s Division of Psycho-pharmacology and Substance Abuse, explains that “opioids stimulate the reward centers in our brain very effectively. They mimic very closely the natural endorphins in our body that dull pain and encourage our engagement in behaviors that are essential for survival. When ingested, opioids compete powerfully with and eventually diminish the availability and impact of those natural endorphins. That’s why opioids have a very high addiction potential. For some people, a chronic compulsion develops—an inability to stop using even when it’s causing harm, destroying their lives. A person has to use increasingly larger doses of the drug to get the same high.”

After tolerance, individuals who chronically use opioids typically develop physical dependence. “The body enters withdrawal when the individual stops taking the drug, so now it’s a negative reinforcer,” Dr. Festinger explains. “You’re taking the drug to avoid being punished by the withdrawal symptoms.”

Dr. Festinger’s current research evaluates medication-assisted treatment (MAT) in drug courts, a setting he has been studying for more than 15 years. “Only recently,” he says, “have drug courts begun to evaluate the use of medication in helping individuals graduate from drug courts sooner, maintain abstinence and demonstrate reduced criminal recidivism. Methadone has shown a lot of efficacy, mostly as a replacement substance and as a way of reducing criminality and the spread of infectious diseases.” More recently, the full antagonist naltrexone, which completely blocks opioid receptors, has become available in a longer acting form, Vivitrol. “An intramuscular injection completely blocks opioid receptors for 30 days. That means the user can’t overdose, can’t get high. The hope is that after a long enough time, they’ll learn it’s not working.

“Among incarcerated individuals who are addicted to opioids, researchers have begun to examine administering the first dose of naltrexone before they leave prison. But the best behavioral approaches,” according to Dr. Festinger, “haven’t been tested yet. For example, individuals could be released earlier or receive reduced sentences on the condition that they continue to obtain and take their monthly doses of naltrexone. That’s where we run into ethical stickiness. Could you give a person a fair option to choose—to say, ‘OK, I know this is a condition of my release, just like paying fines, getting a job, not breaking parole’?

“The criminal justice system is almost entirely opposed to using anything but the full antagonist naltrexone in MAT. There’s a stigma associated with medications that have a potential euphoric effect. But that’s a very black and white way of thinking.” A very few courts, and some parole and probation officers, are starting to look at Suboxone, the partial agonist whose active ingredients are buprenorphine and naloxone. “As more and more research shows that Suboxone may be an effective strategy,” says Dr. Festinger, “it’s going to be important to educate the criminal justice stakeholders about the utility of this method.

“Naltrexone and Suboxone are really our first-line treatments now, but there’s no shortage of need for psychology in this arena,” he says. “Cognitive behavioral therapy, contingency management, and other evidence-based behavioral strategies that we are so strongly aligned with here in our department of psychology can be very useful not only on their own but also as a way to increase compliance and adherence with the medications.

“There’s not a student that goes through our doctoral program who’s not going to come up against this in their future clinical work.”

Neonatal Medicine

In North Carolina, where Stephen D. DeMeo, DO ’08, MEd, is a neonatologist at WakeMed Health & Hospitals in Raleigh, the number of infants hospitalized for opioid withdrawal at birth, or neonatal abstinence syndrome (NAS), is up almost 900 percent since 2005. That increase, he says, correlates directly with the numbers of child-bearing-age women who are addicted to or abusing opioids in the state. “We’re the downstream effect of the problem.”

There are 48 neonatal beds at WakeMed, with five or six infants being treated for NAS at any given time. “The average length of hospital stay for those babies is 20 days, compared to two to four days for a normal baby,” says Dr. DeMeo.

“As with everything else in health care, we tend to focus on the crisis moment, when a baby is admitted to the NICU,” Dr. DeMeo says. “But hospitals are having more success when they partner with treatment programs in the prenatal period. Our best bet is to identify at-risk women as early as we can, and partner with their obstetricians, psychologists, and treatment programs, and in this way become a part of their lives.

“I have an appreciation,” says Dr. DeMeo, “for all the non-pharmacologic things we do—thinking about external stimuli, swaddling, infant positioning and feeding. We’ve learned that non-separation of infant and mother is really important; those babies get out of the hospital faster. And you can encourage moms to continue breastfeeding, which has been shown to decrease length of stay. Part of the osteopathic orientation is toward care of the whole patient, and in pediatrics that sphere is a little wider—you really have to take care of the whole family.

“About 60 to 70 percent of the moms we care for are in a supervised treatment program. Others are women who don’t realize the impact of having taken narcotics or prescription drugs off the street. I have to build trust, so I’ll say, ‘Look, I’m here to take care of everybody. It’s in the best interests of your baby to have a good understanding of what’s been in your body for the last couple of months.’ We are very much against states’ decisions for punitive action against mothers who are abusing opioids, because all that does is drive mothers away from care.

“We need to be asking,” says Dr. DeMeo, “whether the NICU is the best place to take care of babies that are withdrawing. I would love to have a dedicated care area where we could have access to the developmental team, our pediatric pharmacist, our social workers, to give moms and babies their own space. But that obviously runs into lots of capacity issues.

“Right now, babies have to get off methadone before they are discharged, and there’s a multitude of reasons for that. But some hospital systems have gotten grants for home visitation of nurses to evaluate how an infant is doing. We could still take care of this infant—maybe under the supervision of a neonatologist, but out of the NICU itself—and then, once the infant is controlled on medicine, create a transition to home that’s safe, where you decrease time in the hospital but you still provide moms and dads with what they need.”

Personally Touched by the Epidemic

As an attending emergency room physician for 12 years, Rachel Mallalieu, DO ’02, has seen “a lot of families that were not whole.” She and her husband, Jared Mallalieu, DO ’03, already the parents of four sons, became licensed foster parents in the fall of 2015, taking care of children who have suffered from neonatal abuse syndrome.

They adopted a daughter from foster care, Mila, in 2017. “I have a good relationship with Mila’s mom,” Dr. Mallalieu says. “She was a foster child herself and never had any resources.”

Earlier in her career, says Dr. Mallalieu, who currently works two nights a week, she rarely saw deaths result from opioid abuse. But at Baltimore Washington Medical Center–Glen Burnie, Maryland’s second busiest ER, “in my first two shifts in 2014, I had two heroin overdoses, and both patients ultimately died. A 21 year-old man, released that day from prison, shot up, was administered Narcan, and his heart started beating again. But he was declared brain dead the next day. A few days later, a 55-year-old man died of a heroin overdose; I had to break the news to his adult daughter. Now people dying is a fairly regular occurrence for me. In the last four years, so many have died that I can’t remember.”

Dr. Mallalieu has seen that “the common denominator among so many foster placements is a parent with a drug addiction. This problem took years to create, and it will take years to fix. But through foster care, I can affect one child at a time, one family, and that’s what gives me hope. I’ve brought along at least three families to also be foster parents—sometimes until the child’s parents can take them back—or to adopt. The hope is that the child can break the cycle and learn a different way of living. If illness is dormant in them, they’ll have tools to handle it.”

Treating Military Personnel and Veterans

“In the pain world,” says Ron Paolini, DO ’85, an addiction psychiatrist and addiction medicine and brain injury specialist at Eisenhower Army Medical Center, Neuroscience and Rehabilitation Center, Fort Gordon, Georgia, “chronic pain and acute injury are like apples and oranges. With acute injury, opioids are effective. But we know that chronic pain is not a clear indication for the use of opioids.

“What helps,” Dr. Paolini says, “is what DOs are really good at—treating the whole person. The Army uses acupuncture, including ‘battlefield acupuncture,’ in the management of pain. They use restorative exercise, which teaches you how to exercise and keep moving without further injury. They use regenerative medicine to work on joints; they use yoga. It’s a comprehensive approach, along with cognitive behavioral therapy.

“In Eisenhower’s Interdisciplinary Pain Management Center [IPMC],” Dr. Paolini continues, “we have a chiropractor, acupuncturist, occupational therapist and social worker, as well as a physician assistant and nurses, neurologist, and physical medicine and rehabilitation specialists. Everyone works together in the management of the patient. The providers offer radiofrequency ablation, nerve block, spinal cord stimulators, lumbar discography, and injections. And the Traumatic Brain Injury [TBI] clinic draws on brain injury specialists in physical medicine and rehabilitation medicine, and psychiatry, along with neurology, neuropsychology, clinical psychology, clinical social work, psychometry, physical therapy, speech language pathology/cognitive therapy, occupational therapy, recreational therapy and case management.”

Both the IPMC and the TBI clinic offer intensive, three-week outpatient programs utilizing group integrative therapies. Both are designed to focus on functional recovery for service members, with the IPMC’s Intensive Outpatient Program (IOP) more specific for motivated service members wanting to overcome chronic pain to return to full physical readiness for duty, and the TBI Functional Recovery Program (FRP) more specific for cognitive and behavioral health consequences of injuries but mindful of pain issues and effects as well.

The IOP comprehensive program aims to reduce and eliminate the use of opioids. Treatment includes restorative physical training and aquatic therapy along with integrative modalities such as chiropractic care, acupuncture, massage therapy and yoga, and cognitive behavioral therapy. The FRP utilizes a modified physical training approach, adding more extensive spiritual recovery through chaplaincy interventions coupled with a family program to involve spouses. Working in harmony along with the comprehensive services and support of Eisenhower Army Medical Center, Dr. Paolini says, “These programs make a difference. It’s amazing to hear people describe how these programs have changed their lives.”

Prison Systems and Opioids

Donald Lewis, DO ’00, is chief psychiatrist for the Federal Bureau of Prisons, overseeing the mental illness and substance abuse treatment of approximately 183,000 inmates in the nation’s 122 federal prisons. Approximately 40 percent of the inmates have a substance abuse disorder, many involving opiates.

Like his colleagues in other settings, Dr. Lewis, who has served in his role since 2009, sees an increase in the acuity of substance abuse–related problems as well as increased polypharmacy among inmates. Resources are spread thin, he says.

Yet here is the irony: Substance abuse treatment is better in prison than what inmates would receive in the community. “Many of our patients don’t want to leave to go back to a community that doesn’t support them and where their only avenue is selling and using drugs,” says Dr. Lewis. Because prison is such a highly controlled environment, no one can hide their drug use, as they can in the community.

“I love taking care of these guys,” says Dr. Lewis. “They are generally getting regular psychiatric care for the first time in their lives, and 95 percent are extremely appreciative. And I love to see them change. In the community, regardless of what I recommend, I have zero control. Here I know they are compliant. We can sometimes clear up four or five concomitant psychiatric diagnoses. We don’t have to worry about insurance; there are no reimbursement issues. We are available same day for emergencies and have nationwide access to charts, psychiatric records, and lab work.

“Most of the time I have no idea what their crimes are; that doesn’t affect management. You just treat them.”

Opioid Abuse in Rural America

The small fishing town of Lubec, in Washington County, Maine, is where Bethany Pinkham Day, MS/PA-C ’12, spent five years in her first job as a physician assistant at Regional Medical Center, a federally qualified health center.

Mosaic image of opioid dust over a rural farmland landscape photoThe closest hospital was about 45 minutes away; specialists, two and a half hours. “So you got really good at handling complicated patients,” says Ms. Day.

Tourists arrived in the summer, with split knees or twisted ankles, and there were retirees—“people from away”—attracted by Lubec’s 11 miles of coastline. But commercial fishing is Lubec’s business—and fishing, says Ms. Day, “is a pretty grueling job physically; it takes its toll on backs and knees. Fishermen who were suffering from joint issues were used to getting their pain pills. All of a sudden there was a clampdown on the prescription of opiates, with strict law in place by July 2017. Then we started seeing an influx of heroin.”

A fisherman told Ms. Day that he’d go down to the boats in the morning and see people “shooting up heroin in their trucks, because it gave them the energy to get through the day.” When they were paid at the end of the day, they purchased more heroin. It often came from out of state—New York, Philadelphia, New Jersey. “You had a lot of people with easy cash. Smart businessmen from away recognized that there was a growing opiate problem and then started flooding the area.”

Those seeking medication-assisted treatment could turn to a methadone clinic in Calais, 45 miles from Lubec, or to a handful of providers within the county who prescribe Suboxone. But detox centers were hundreds of miles away. Those seeking a quick detox had few choices; some went to the ER or the jail. The police, says Ms. Day, “struggled with funding and having resources to deal with the problem. There was a lot of demand, and not a lot of supply.”

Up to 80 percent of the opioid abusers Ms. Day saw came from a residential treatment program staffed by volunteers—some formerly addicted themselves—in Machias, the next closest town. Ms. Day had to deem these patients “medically appropriate—without any benzo use or multiple substances, without heavy drinking.”

The Clinical Opiate Withdrawal Scale is typically used to categorize mild, moderate, or severe withdrawal. Depending on where a detox patient fell, says Ms. Day, “you could sometimes get away with just doing symptomatic treatment—something like clonidine to help with the agitation and the heart rate issues, and trazodone to help with sleeplessness. If people needed a little bit more, you could give them Bentyl [dicyclomine] for the abdominal cramping. Sometimes all people needed was a little bit of Benadryl. Typically, depending on what was in their system, they could be feeling a little better in 48 to 72 hours.”

The residential program’s founder was from Camden, New Jersey, and many people in the program were from New Jersey and Philadelphia. “They would bring people up to this program to get them out of their environment, and vice-versa; they took people from Maine down there,” says Ms. Day. “Swapping the environments helps at least initially, but the difficult thing is when people return.”

Ms. Day lived in downtown Lubec—“more of a main street area, right on the border of Canada.” The hours were long, with a lot weekend and afterhours care. “I didn’t have any friends or family within a three- or four-hour drive,” she says, “and it was hard getting away because the demand was so high. But my work gave me purpose.”

The Role of Pharmacists

Shari Allen, PharmD, BCPP, assistant professor, pharmacy practice, GA–PCOM, regularly faces concerned veterans in her work at the Atlanta Veterans Affairs Medical Center in Decatur, Georgia. “They say to me, ‘I’ve been on these meds for so long’—opioids, benzodiazepines—and my doc wants to take me off them, out of nowhere.’ They don’t see that they shouldn’t have been on those meds long-term to begin with.”

Dr. Allen tells them, “They’re taking you off benzos, but then you’re going to be put on a medication such as an anti-depressant, which is the recommended way to treat anxiety. The honest truth is that anti-depressants do not work overnight. Here’s what’s you can expect.”

As a community pharmacist, Dr. Allen must make constant judgments when presented with a prescription for opioids or other controlled substances. “Do they need that drug? Why is the script from another state?” She can check the Georgia Prescription Drug Monitoring Program, an electronic database, to see whether someone appears to have been “shopping” for the drug at other pharmacies. “I might tell them, ‘I can’t fill this today unless I can talk to your doctor.’ Some will say, ‘Never mind.’ ”

Dr. Allen, who is also a preceptor for PCOM School of Pharmacy students, teaches a third-year substance abuse elective. Last year, every week the class reviewed “a new substance—what it looks like, what addiction to it looks like. We had guest speakers, including a pharmacist who had become addicted to opioids. We had someone come in from the Drug Enforcement Administration. I made students go to a Narcotics Anonymous meeting just to open their eyes to what they’re going to see as pharmacists.”

Osteopathic Manipulative Medicine as an Approach to Pain Management

“You can’t overestimate the power of human touch,” says Walter Ehrenfeuchter, DO ’79, FAAO, professor and director of neuromusculoskeletal medicine and osteopathic manipulative medicine, GA–PCOM. “The professional touch involved in manipulative treatment tends to break down communication barriers between physician and patient. So patients end up telling me things on the treatment table that they won’t tell their own psychologist or psychiatrist on the couch.”

Dr. Ehrenfeuchter describes the multistep process of using OMM to treat an opioid-dependent patient: “The first thing we do is to find out why they are on the opiate to begin with. Most of the people we see are in pain, but pain is not a diagnosis. The next step is to see if somatic dysfunction is present. Then manipulative treatment does a number of things. First, it removes somatic dysfunction and reduces pain levels almost regardless of the cause. Second, it demonstrates to patients that they can move. So many have been told to rest, to avoid this or that activity. That sets up a vicious cycle—more atrophy, more pain. Once we demonstrate that they can move without dying, the next step is to start to reintroduce exercise into their lives, perhaps just moving their own body against gravity. Sometimes there is a co-diagnosis—whether it’s degenerative disc disease, osteoarthritis, muscle tears and sprains that didn’t heal well and the exercise has to progress really slowly or they fail. And the one thing you don’t want them to do psychologically is to fail.

“Generally, as you get the pain under better control, patients often taper or discontinue pain medicines on their own. Most people don’t want to be on them.”

A Place for Opiates When Prescribed and Used Properly

Samvid Dwivedi, DO ’09 (GA–PCOM), an interventional pain physician and anesthesiologist at Henry Ford Health System in Detroit, works to manage the pain of “people who otherwise have a long healthy life ahead of them, and that’s where using opioids becomes a problem.”

In the pain clinic, Dr. Dwivedi deals with “a lot of post-surgical pain as well as chronic pain from non-surgical sources—like chronic arthritic knee pain, back pain, neck pain, pain from cancer. People have neuropathies from poorly controlled diabetes or chemotherapy, fibromyalgia, complex regional pain syndrome, chronic headaches and facial pain.

“We shoot for a multimodal approach to pain management,” Dr. Dwivedi says. “We typically don’t even approach the opioid option until there’s no other option left. We use a mix of medication—muscle-relaxing medication, nerve pain medication, anti-inflammatories, various intravenous infusions; we do a lot of spine, joint, and other nerve injections under X-ray and ultrasound guidance to see if we can calm down the source of pain. We work closely with PT to improve patients’ range of motion, flexibility, muscle strength, and conditioning, and employ behavioral health specialists to address the depression and frustration that is comorbid with chronic pain.

“As this opioid epidemic continues to unwind,” Dr. Dwivedi says, “we have to make sure that the pendulum doesn’t swing too far. There’ll always be patients who do benefit from opioid management. Everyone is trying to tout various other modalities as opioid-free ways of pain control: stem-cell therapy, implantable devices, TENS units, peripheral nerve stimulators, various creams and lotions. We want to make sure we don’t send patients down the wrong path where they could truly get hurt from treatments not backed by good evidence.”

Dr. Dwivedi points out that in other specialties, “you can do objective tests and tell what someone’s heart function is or what their gut function is. With pain, that’s difficult to do. We try to be as objective as we can in treating a very subjective problem.

“And I think that was part of what became the opiate problem: physicians always wanting to help people, and if someone comes in and they’re suffering, our first instinct is to try to do what we can as quickly as we can. Unfortunately, I think we lost control of that train when it left the station.”

Advocacy Efforts

George K. Avetian, DO ’80, FCPP, a family practitioner in Upper Darby, Pennsylvania, is president-elect of the Delaware County Medical Society, as well as co chairman of the Delaware County Health Advisory Board and chairman of the Medical Subcommittee of the Delaware County Heroin Task Force. In these roles and others, he welcomes the opportunity as a PCP to have both a voice in and impact on the opioid crisis, an epidemic that he stresses “has no boundaries or borders.”

The Medical Society’s activities include educating physicians on proper opioid prescribing, providing information about programs for patients who may require rehabilitation; updates on the governor’s declaration of emergency regarding the opioid crisis; and instructing on how to dispose of unneeded and unused pharmaceutical products.

Photograph of pill bottles on a medicine cabine shelf

"The medical community wasn’t always aware that drug-seeking was driven by our giving the drugs in massive quantities."

Dr. Avetian is proud that Delaware County was the first entity worldwide after FDA approval to purchase Narcan Nasal Spray, which reverses heroin and prescription painkiller overdoses, for use by police officers who suspect an overdose. “We have instructed every officer in use of the product,” says Dr. Avetian. The district attorney recruited police chiefs, he says, who “realized the problem wouldn’t be solved through the legal system. All counties in Pennsylvania now participate.” Delaware County has also hired certified recovery specialists, who are another resource at every ER to counsel patients and their families about resources. A local drug collection van and drug drop boxes are available—”no questions asked, we just collect and dispose.”

James F. Baird, IV, DO ‘09, an attending emergency physician and assistant medical director of the Emergency Department, Jefferson Washington Township Hospital, Turnersville, New Jersey, was honored by the Philadelphia Business Journal as a 2017 Extraordinary Doctor for launching a tracking program at Kennedy’s emergency departments that he hopes could lead to the creation of a national database of opioid-seeking patients.  “In the emergency department,” Dr. Baird says, “patients come through very fast. They may have been in other EDs in other systems, but we don’t have that data. Health information exchanges are a bit archaic. If we could log in patient information and keep track of people who OD or exhibit signs of drug abuse behavior, we could get people more help.

“Right now, we rely on the Prescription Drug Monitoring Program, which lets us see whether people have been prescribed controlled substances. But if someone ODs and gets reversal agents, we don’t have access to that information unless they’ve been in our healthcare system.” Dr. Baird is frustrated that in 2018, “we still can’t get electronic health records to share data. I can get records from another system, but by faxing. I know patients are going 20 minutes to another ED, and then 30 miles north—going all around South Jersey. A regional databank is my long-term dream.

“If a patient is exhibiting drug-seeking behavior, the old way was to say ‘no, get out.’ ” Dr. Baird knows from his senior colleagues “that the medical community wasn’t always aware that drug-seeking was driven by our giving the drugs in massive quantities. Our mindset must change from cynicism to empathy. I try, both within and outside the hospital, to teach people to look past how someone may be acting in the volatile ER. It’s a real opportunity to talk with this individual, and then you have an opportunity for intervention.

“Every day, 175 people die from a drug overdose in America. I think that number is way under-reported, and about 60 percent of it is from opioids. The numbers are always behind the trends we see firsthand.

“So the database is important, but we’re trying to educate the public on the epidemic through town halls, high school meetings, partnering with law enforcement. We are showing the community that we’re here to help with your addiction.

“It begins with a conversation, and the conversation is being had. If you bring people to the table, someone will have an idea.”