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Welcome to Public Health

0:02

on Call, a podcast from

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the Johns Hopkins Bloomberg

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School of Public Health,

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where we bring evidence,

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experience, and perspective to

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make sense of today's leading

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health challenges. If you have

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Public Health Question at JHU.EDU.

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That's Public Health Question at

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JHU. EDU. for future podcast

0:28

episodes. This is Lindsay Smith

0:30

Rogers. Today, the importance of

0:32

starting treatment for opioid addiction

0:34

in the emergency department. Arianna

0:36

Campbell is an emergency department

0:39

and addiction medicine physician assistant

0:41

at Marshall Medical Center in

0:43

Placerville, California. She's also the

0:45

co-founder of the Bridge Center

0:47

at the Public Health Institute,

0:49

a program that helps emergency

0:51

departments around the country build

0:53

addiction treatment programs. She speaks

0:55

to Dr. Josh Sharfstein about

0:57

how this work has evolved

0:59

over the last decade to

1:01

become the standard of care. Let's listen.

1:04

Ariana Campbell, thank you so much

1:06

for joining me today on Public Health

1:08

on call. How are you? I'm doing great.

1:10

Thank you so much for having me. I want

1:12

to talk to you about an effort

1:15

that I know you have personally

1:17

been deeply involved with, which is

1:19

getting emergency departments to provide more

1:22

treatment for people with opioid addiction.

1:24

Yeah, I mean this has been a big

1:26

goal for a long time, just to

1:29

have treatment for opioid use disorder as

1:31

a tool in my toolkit. And a

1:33

lot of this stems from feeling somewhat

1:36

helpless or just not having those tools

1:38

for... 17 years of my 25-year career,

1:40

and then making practice change, which I

1:42

mean, quite frankly, wasn't that challenging and

1:45

providing this as just a part of

1:47

practice. My daily routine when I see

1:49

a patient, just as if they had

1:51

high blood pressure, and I would address

1:54

that, if there's any indications of opioid

1:56

use disorder, or if that person feels

1:58

safe to disclose that. me, it's

2:00

something that I can help them

2:03

with. So take me back before

2:05

you started offering treatment. What was

2:07

that like? They came to see

2:09

you for something else, and how

2:11

did you experience that? You know,

2:13

there was a lot of unsaid

2:15

things, so there would be, I

2:17

think, on my part, a suspicion.

2:19

And then a feeling that this

2:21

person wasn't disclosing something to me.

2:23

In fact, I think it's always,

2:25

oh, they're lying to me. They're

2:27

not telling me that they're using

2:29

opioids in a non-prescribed way. Or

2:32

they're falling asleep and they told

2:34

me they don't use drugs. And

2:36

feeling this disconnect, actually, with a

2:38

patient, which actually makes me feel

2:40

uncomfortable. In the emergency department, I

2:42

need to make... really quick connections

2:44

with people and establish rapport and

2:46

trust rapidly. And when you get

2:48

that disconnect from the start, it's

2:50

uncomfortable and you feel like you're

2:52

not addressing the elephant in the

2:54

room. And how did that begin

2:56

to change for you? I was

2:58

asked to attend a meeting, you

3:01

know, as I think a lot

3:03

of us, you know, you attend

3:05

a meeting and I had a

3:07

moment of self-reflection where somebody was

3:09

asking if I would start a

3:11

medication, bupenorphan, if somebody was in

3:13

opioid withdrawal. I had a lot

3:15

of misinformed ideas actually. I just

3:17

didn't have a lot of training

3:19

in this. And when somebody proposed

3:21

that to me, I actually didn't

3:23

even think it was legal. And

3:25

of course it was. It's the

3:27

standard of care. It's a recommended

3:29

treatment. And once I took a

3:32

step back and looked at the

3:34

overall picture, which was, what am

3:36

I doing right now? for people

3:38

with opioid use disorder that I

3:40

am so proud of that I

3:42

wouldn't make a practice change. And

3:44

of course, that was nothing. I

3:46

was sending people to non-evidence-based treatment.

3:48

I was sending people to places

3:50

that wanted them to pay a

3:52

lot of money to stay for

3:54

three months and may not have

3:56

been prescribing medications and may have

3:58

been putting them at risk of

4:01

overdose when they left. I live

4:03

and work in a small community

4:05

and I would actually get feedback.

4:07

that the information I was giving

4:09

people wasn't helpful, that they were

4:11

having trouble accessing the kind of

4:13

care that I was trying to

4:15

connect them to. So you go

4:17

to this meeting and you hear,

4:19

well actually there's a treatment you

4:21

can provide in the emergency department

4:23

and you begin to offer that

4:25

treatment. You get trained, you begin

4:27

to offer that. How does that

4:30

change the dynamic that we were

4:32

talking about before for patients who

4:34

are showing up? I mean, I

4:36

had a moment of humility in

4:38

practice and that I thought, how

4:40

did I not know that this

4:42

existed? And then it really changed

4:44

my interaction with people who use

4:46

drugs. I started, it's like I

4:48

opened a small door into what's

4:50

possible when you make this, you

4:52

know, practice change. And my patients

4:54

started talking to me about a

4:56

lot of things. In fact, many

4:59

people disclosed that they had never

5:01

talked to a health care professional

5:03

about their substance use. They didn't

5:05

feel comfortable. telling somebody because they

5:07

thought they would be mistreated. And

5:09

once they realized that as part

5:11

of their visit in the emergency

5:13

department, we could talk about this

5:15

and provide a reasonable set of

5:17

options, it just completely changed, not

5:19

just my practice, but it changed,

5:21

I think, the view of our

5:23

emergency department even in the community.

5:25

Did it change the view of

5:28

the staff towards the patients? That's

5:30

a great question. That happened through

5:32

time. So initially, I'll admit, I

5:34

didn't tell many nurses that we

5:36

were doing this or our staff.

5:38

I was actually afraid somebody would

5:40

tell us we couldn't do it

5:42

and I knew it was the

5:44

right thing to do. And that

5:46

was a mistake because I put

5:48

signage in the emergency department in

5:50

like the lobby in the waiting

5:52

room. And when I did that,

5:54

a nurse came to me and

5:57

said, wait, what are we doing?

5:59

And I explained it and there

6:01

was also, I mean, coming from

6:03

the same place, there was a

6:05

lot of misinformation that, you know,

6:07

people thought, are we just substituting

6:09

one opioid for another? Are we

6:11

enabling this behavior? And this is

6:13

from just an antiquated set of

6:15

ideas. that wasn't based in medicine,

6:17

and I knew I had a

6:19

lot of work to do, actually.

6:21

We did a stigma intervention in

6:23

our hospital that made a massive

6:26

difference in people's understanding of what

6:28

we could offer, what we could

6:30

do, and why it mattered. So

6:32

you're now treating patients, and you

6:34

realize that what you've gone through,

6:36

the process you've gone through, can

6:38

actually help other emergency departments change

6:40

too. Yeah, I think, you know,

6:42

I stood this program up in

6:44

a rural hospital, community hospital, single

6:46

hospital system, and I don't think

6:48

I realized it was supposed to

6:50

be really hard. So then when

6:52

I realized that there was a

6:55

lot of pushback, there was a

6:57

lot of people saying that this

6:59

can't happen anywhere, I think I

7:01

took that as a challenge maybe

7:03

that I actually thought this could

7:05

happen anywhere. You know, we started

7:07

this. prescribing in a matter of

7:09

four to six weeks of just

7:11

learning about what we could do

7:13

and how we could change that.

7:15

And now it's on a quality

7:17

improvement spectrum. We're always looking to

7:19

improve our program. But we started

7:21

working in other hospitals and realized

7:24

maybe there's some resources that can

7:26

be helpful. We realize that we

7:28

could teach people how to do

7:30

this. We could create champions who

7:32

can lead these efforts and that

7:34

it would work. And then we

7:36

worked with urgency realizing, you know,

7:38

really the massive scale of the

7:40

overdose epidemic, and that if we

7:42

worked with urgency, we could create

7:44

a whole system, and this is

7:46

the dream, that you see an

7:48

H on the freeway, and you,

7:50

just like if you're experiencing chest

7:52

pain, and you would say, I

7:55

should go to a hospital because

7:57

I'm really worried that I'm having

7:59

a heart attack, that you could

8:01

see an H on the freeway,

8:03

and you could go to that

8:05

hospital and have a reasonable expectation

8:07

of receiving... high quality evidence based

8:09

care for opioid use disorder and

8:11

opioid patrol. Since you started doing

8:13

this work with other hospitals, how

8:15

many hospitals have you been engaged

8:17

with? 276 in California, now that's

8:19

more than, we've worked deeply in

8:21

more than 17 states, and that

8:24

those numbers continue to grow. So

8:26

more than 300 hospitals total and

8:28

growing. That is a large number

8:30

of hospitals. That must mean thousands

8:32

of patients. Yeah, hundreds of thousands

8:34

of patients actually. It can be

8:36

done. It can be done rapidly.

8:38

And, you know, emergency clinicians, I

8:40

think, are natural to make practice

8:42

change quickly. We're asked to do

8:44

that often because the work that

8:46

we do, you know, there's life

8:48

and death consequences as with what

8:50

many of us do, but in

8:53

real time. And so I think

8:55

we are able to make change

8:57

pretty rapidly to meet. the standards

8:59

that are set in communities and

9:01

to to really meet the demands

9:03

of high-risk patients you know people

9:05

who are experiencing high-risk conditions. So

9:07

when you go into a hospital

9:09

that is just signed up to

9:11

start to do this you you

9:13

must run into some resistance sometimes?

9:15

Yeah a lot of the resistance

9:17

is that we're too busy you

9:19

know and we are we're all

9:22

too busy. I am too busy.

9:24

I am seeing people in the

9:26

waiting room, I am seeing people

9:28

in triage, I am making up

9:30

rooms to see my patients, and

9:32

what I think is really important

9:34

is that When you do this,

9:36

and you start adopting this practice,

9:38

you're actually addressing some underlying conditions

9:40

that make a difference for people

9:42

so that they don't need to

9:44

come back over and over again

9:46

for the same reason. You know,

9:48

we're addressing sort of a root

9:51

cause of many of the medical

9:53

challenges that people face. And at

9:55

the same time, we are kind

9:57

of putting the underlying issue on

9:59

the table. We're making it safe

10:01

for people to disclose. a highly

10:03

stigmatized condition. And so where you

10:05

may, to me, may come in

10:07

saying they have abdominal pain, and

10:09

that means I'm going to do

10:11

a lot of things that you

10:13

know, include. a CT scan, you

10:15

know, something that is a lot

10:17

of radiation, right? And if they

10:20

feel safe just telling me that

10:22

they're an opioid withdrawal, I can

10:24

very easily treat that with a

10:26

medication that dissolves under their tongue,

10:28

and they don't need a lot

10:30

of these other interventions because we

10:32

just created a safe space to

10:34

have a therapeutic relationship and to

10:36

discuss what's really going on. So

10:38

it's actually the opposite. When people

10:40

say, but I'm too busy not.

10:42

to make this practice change actually.

10:44

And that's what we found. Let

10:46

me ask you about evidence. You

10:49

know, you have worked in all

10:51

these different hospitals. How can you

10:53

tell you're making a difference? Well,

10:55

we track it, you know, as

10:57

any good public health professional. We

10:59

look at the data. So this

11:01

is what was really surprising to

11:03

me. You only know the data

11:05

that you are looking at and

11:07

collect. And we were never looking

11:09

at or collecting data on opioid

11:11

use disorder. And... We actually weren't

11:13

doing that because people weren't making

11:15

the diagnosis, and we just didn't

11:18

know to look at this. So,

11:20

you know, in terms of what

11:22

we've done in the state of

11:24

California, we've been looking at overall

11:26

data, and you can do this

11:28

from your local hospital to like

11:30

a statewide initiative, right? So, let

11:32

me describe this in my local

11:34

hospital. We just look at how

11:36

much pupanorphan are we prescribing? Because

11:38

if we take a drop in

11:40

bupenorphine prescribing, this is a medication

11:42

to treat opioid use disorder, then

11:44

we know that there may be

11:47

some barriers, there may be some

11:49

gaps in education, because we know

11:51

that there are a lot of

11:53

people out there with opioid use

11:55

disorder. So we start looking at

11:57

why. We also look at the

11:59

variability, who is getting bupenorphine. Are

12:01

there people who are invisible in

12:03

our communities? And then we look

12:05

at other things like how we

12:07

can affect... For example, readmissions. Are

12:09

people leaving without finishing treatment? Are

12:11

people needing to be readmitted because

12:13

we didn't provide them the right

12:15

medication at the right time? So

12:18

we've really put this into a

12:20

category like other high-risk conditions on

12:22

a local level. And we look

12:24

at our data, we look at

12:26

it monthly, and then we look

12:28

for any change that means our

12:30

system could be better. We also

12:32

look at follow-up rates. You know,

12:34

are people making it to treatment

12:36

from our emergency department? We've maintained

12:38

very high follow-up rates. And then

12:40

on a statewide level, we had

12:42

ways people were reporting it for

12:44

a long time, but we found

12:47

out good objective data, watching... our

12:49

PDMP, you know, watching how much

12:51

pupanorphin is being prescribed and by

12:53

who, I think is really important

12:55

on a statewide level. That's great.

12:57

A lot of different measures. You

12:59

recently had a major study published.

13:01

Yeah, we just published some some

13:03

great researchers published on our program

13:05

in JAMA a few weeks ago

13:07

that was led by Annette Decker.

13:09

And that paper showed that just

13:11

Emergency department clinicians giving prescriptions for

13:13

a buponorphin makes a big difference.

13:16

So we found that one in

13:18

three people who were given a

13:20

prescription for a buponorphin from the

13:22

emergency department received a second prescription,

13:24

right? So this is a big

13:26

deal because this medication can, you

13:28

know, over a period of time

13:30

can cut a person's risk of

13:32

dying in half. So, you know,

13:34

any period of time in treatment

13:36

with medications for opioid use disorder

13:38

is... a really good thing, and

13:40

that one in nine of those

13:42

people actually had continuous treatment for

13:45

six months. I mean, that's a

13:47

really good number. If you think

13:49

of, I mean, I initiate treatment

13:51

for asthma, for emphysema, for diabetes,

13:53

for, I mean, hypertension, high blood

13:55

pressure, you know, all sorts of

13:57

medical conditions, and often people do

13:59

face disruptions in treatment for a

14:01

variety of factors. So these are

14:03

pretty astounding numbers, actually. providing this

14:05

treatment yourself for many years to

14:07

providing it for your patients in

14:09

a small emergency department to sharing

14:11

your knowledge. with hundreds of other

14:14

hospitals to finding evidence that it's

14:16

making a difference at a large

14:18

scale. That's really remarkable. Yeah, I

14:20

would say it's of course my

14:22

proudest work in medicine. If you

14:24

asked me 10 years ago, if

14:26

I would be doing this, I

14:28

could have never predicted that. But

14:30

I think I saw a massive

14:32

gap in medicine, you know, this

14:34

massive gap where we could be

14:36

doing so much more. And then

14:38

as the overdose crisis escalated, there's

14:40

urgency associated with that. Why aren't

14:43

we doing more when we have

14:45

answers and we have tools? And

14:47

then working through all of the

14:49

challenges, you had mentioned, you know,

14:51

different emergency departments come to us

14:53

with different challenges of why this

14:55

may be, you know, why this

14:57

is hard in their setting, working

14:59

through that and figuring out ways

15:01

and doing it. with urgency and

15:03

doing it with creativity. I think

15:05

that that is, that's the proudest

15:07

work I've ever done in medicine.

15:09

It's really been important and can

15:12

impact whole populations in that, you

15:14

know, I started thinking about things

15:16

more from that public health population

15:18

health perspective and I think this

15:20

program, this project opened my eyes

15:22

up to the impact we can

15:24

have when you see a wrong

15:26

and you work to write that

15:28

wrong in medicine. Thank you so

15:30

much for having me. This has

15:32

been fun. I appreciate you. Public

15:34

Health on Call is a podcast

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15:38

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