The date was Aug. 25, 2018.

My older son, Forrest, was supposed to go to his mother’s house that day and help his brother, Parker, pack and leave for college. I went into Forrest’s bedroom in our apartment around 10 a.m. and tried to awaken him.

The first attempt was in a low voice. The second time, a little louder. The third time, I tapped his foot.

“Come on. Get up, bud.”

There was no response. I shook him a bit. His head rolled off the pillow, but he didn’t open his eyes. My heart and brain immediately raced. I felt a sharp pain in my chest and my legs weakened. I reached down and moved the bed sheet back.

There was the needle and syringe. Forrest’s feet were cold.

He was dead three months before his 25th birthday.

After dialing 911 and screaming at the top of my lungs, part of me was gone forever as well.

Unfortunately, the memory of that Saturday morning will always be part of my life.

Addiction affects everyone in the family, not just the addict.

That’s the first thing everyone should know about this opioid crisis. The second is a high percentage of addicts truly want to quit, but can’t for a number of reasons. The third thing is that addiction doesn’t discriminate.

It might be your son, daughter, brother or mother. Addicts aren’t bad people. They’re just sick.

When Forrest was young, his mother and I never dreamed anything like this was possible. No parent does.

He was a gifted student in Newark City Schools. He was reading two or three grades above his grade level in elementary school. In middle school, his poetry was so good, his gifted teacher took him to The Poetry Forum in Columbus and Forrest recited his work.

He also was athletic and fast. He was talented in baseball and above average in soccer. He was funny. He was loved by his classmates. He loved music, playing violin then acoustic guitar, electric guitar, harmonica, ukulele and anything he could find. He taught himself how to play several instruments and he wrote, sang and recorded his own songs.

Forrest also was a class clown due to having attentiondeficit hyperactivity disorder. He didn’t like taking his ADHD medication because, as he would say, it “curbs my personality,” so there was no way to foresee him addicted to pills and eventually heroin.

By the time he was a freshman in high school, he was obtaining pills from the medicine cabinets of his friends’ homes. We spent several nights with him in emergency rooms the following summer.

By then, he also was smoking marijuana.

In the fall of his sophomore year, his mother and I sought help and argued about rehabilitation. We finally settled on a center near Shelby, about 65 miles north of Newark. Between September 2009 and February 2010, we drove to see him once every weekend. When Forrest was released, he had changed. He was mean and angry that he spent his birthday, Christmas and New Year’s away from home.

His problems continued to drive a wedge between my wife and me over the next few years. Before he graduated in 2012, my wife allowed him to have a live-in girlfriend. By then, my wife and I were constantly arguing and she left me and took both boys with her that March.

Around that time, Forrest scored a 32 on his ACT with no preparation and received college scholarship offers. He was barely speaking with either parent and was trying to stay out of our situation. We got divorced in 2013.

Forrest also opted not to attend college. Not that he achieved great grades in school, despite his brilliance. He aced most tests, but refused to hand in any “stupid homework.” Still, he had a superior memory and knowledge and likely would’ve succeeded in college without homework requirements.

In September 2017, my ex-wife moved out of town with her boyfriend and Forrest was not allowed to live with them. He had no driver’s license or transportation and he moved into my apartment.

We butted heads. He had worked a string of part-time jobs at numerous fast-food establishments and factories, but was never serious about creating his future.

In late December 2017, I saw him with needles for the first time. We fought and the police were called. He spent days away at his friends’ places.

There were lies, lies and more lies. There also were constant fights for three or four weeks and I even had to hide the spare change I had been accumulating for years.

In mid-January 2018, he hit rock bottom. I picked him up from his friend’s house and I was pulled over by police on the way home. Forrest had been at a “drug house” and he had used needles in his possession.

I made every effort trying to help his recovery. By June, he was doing well and we moved from Newark to Lewis Center. I wanted to get him away from some of his friends.

I helped him create a résumé, canceled my vacation and took him to interviews.

It was a success. He found a job and loved it, earning a good wage at a smaller factory where the employer cared about its employees. I purchased a used car for him.

It all seemed to be life-changing.

“It’s not like I’m a number anymore,” he said. “I have a life, a car, a new phone and everything.”

He told me several times that he was “lucky” to have a father like me who “didn’t give up on him.” He even texted his friends, “I didn’t think I could ever be this happy again.”

He bragged to me, Parker and his mother about how great he felt.

Aug. 25, 2018, came about six weeks later.

He was high on life. Apparently, he felt it was time to celebrate, thinking he could handle heroin. He had done it before and stopped.

Not this time.

Forrest touched everyone he met. Several of his friends told loving stories about my son at his funeral and how he’d give you his last dollar if he had it. I was filled with guilt. I had judged many of those friends.

I always saw troubled kids and thought, “Where are the parents? What are they doing? Why can’t they help?”

But until you’ve been there, you don’t understand what the addict’s family goes through.

You don’t know how it harms a family, marital status or relationships with friends. You don’t know how hard a parent or sibling has tried or how hard the addict has tried.

Let me tell you, counseling helps you compartmentalize your feelings, but nothing can ease the pain.

I hope you never feel that pain.

bemerine@thisweeknews.com

@Brad_ThisWeek

Editor’s note: Brad Emerine is a sports writer for ThisWeek Community News. His son, Forrest, died of an overdose Aug. 25, 2018.

As the number of drug-related overdoses in central Ohio emergency departments began to rise sharply several years ago, OhioHealth practitioners realized a new course of action was required.

A pilot program, started in April 2017, provided naloxone kits to patients treated for an opiate overdose at four OhioHealth facilities: Grant Medical Center, Pickerington Medical Campus, Westerville Medical Campus and Marion General Hospital.

Naloxone is a nasal spray commonly known by its brand name, Narcan. When naloxone is directly administered into the nose of a person who has overdosed, it reverses the dangerous effects of the opiate the person has taken.

“It saves lives and gives a person a chance for treatment and successful recovery,” said Paula Kobelt, a nurse and outcomes manager at Grant Medical Center. “We started this project to provide naloxone to high-risk emergency department patients [who overdose] in response to the opiate crisis in central Ohio and as part of an initiative to create a community standard in the emergency department.”

But putting naloxone in the hands of at-risk patients and their family members or caregivers is just one prong of OhioHealth’s program. It also includes education and encouragement to seek the professional intervention required to treat and recover from a substance use disorder.

Currently, there is no formal follow-up but these patients are connected to treatment or sent home with a number of resources to get help when they are ready, including contact information for treatment programs, said Wendi Hayes, a clinical nurse manager at Grant Medical Center.

The kits include two doses of naloxone and instructions on how to administer the medication.

“There is a stigma and a bias associated with substance abuse [and] we work diligently to address it,” Hayes said. “It’s getting better, but there are still some people who we cannot convince that [substance abuse] is not a choice. They cannot stop without treatment.” The opiate, whether it’s a prescription drug such as Oxycodone or an illegal drug such as heroin, “hijacks the brain,” said Grant Walliser, a pharmacist at Grant Medical Center.

“It tricks the brain into thinking the only way to achieve euphoria is to use the drug,” he said, but soon the user is taking the drug not for the euphoria but to avoid the symptoms of withdrawal.

Substance use disorder develops for several reasons, Kobelt said, including early exposure, individual environment and possibly genetics.

The brain of a developing adolescent is much more susceptible than a fully developed adult exposed for the first time to an opiate, Kobelt said.

“Adverse childhood experiences and exposure to any of a variety of drugs at home or among peers adds to the propensity and prevalence of addiction,” she said.

Walliser said that while there might be an initial choice by a first-time opiate user, substance use disorder “is truly a disease.”

“Recovery is like any other chronic disease, something a person with substance use disorder must  be vigilant about the rest of their lives,” Hayes said.

Erasing the stigma associated with substance use disorder is an important first step toward the success of the naloxone program.

“We want to make people feel it’s OK to get treatment [and] words matter,” Kobelt said. “Our patients aren’t addicts or junkies; they are people with a substance use disorder.”

It is a treatable medical condition that knows no bounds and has no limits like other medical conditions, Kobelt said.

“It doesn’t matter how rich you are, how poor you are, how pretty you are, or your culture or religion. Denying that is a danger. We need to create awareness and emphasize prevention factors,” said Kobelt. Hayes recalled providing care to an emergency patient who died just shy of her 18th birthday from a heroin overdose, the result of a dependency rooted in the prescription drugs she received after a sports-related injury.

For Hayes, the epidemic hit much closer to home.

Her 41-year-old brother died in October from an opiate overdose and another brother is battling with substance use disorder, she said.

“I silently worked on [the naloxone] project for a while and it was hard to hear what other people said about the overdose patients seen in the ED,” Hayes said. “I fought bias at work for staff to give the Narcan that could save these lives.”

The logic behind doing so is to give patients the opportunity to seek the help they need, Kobelt said.

“Some people say, ‘Why give it to a person if they are going to use again?’ And they probably will to prevent going into withdrawal unless they opt into a treatment program,” she said. “But with [our naloxone program] they are alive for us to offer treatment. That’s the essential part of the program, to prevent death.”

OhioHealth’s program to provide naloxone kits extends to its facility in Marion, about 50 miles north of Columbus.

“We currently distribute the kits to high-risk patients and family members due to elicit opioid use, misused or highdosage prescriptions, or following an overdose,” said Dr. Matthew White, who is medical director of emergency services at Marion General Hospital. “For us, the key to success has been identifying high-risk patients and working closely with our physicians, pharmacists, EMS teams and nursing staff to formalize processes and educate about the use and benefits of the kits.

“The more Narcan in the community, the more we can save or change a life.”

kcorvo@thisweeknews.com

@ThisWeekCorvo

Photography: Lorrie Cecil/ThisWeek News

Dr. Bruce Vanderhoff, OhioHealth’s senior vice president and chief medical officer, remembers a time when opioids were thought to be a necessary evil.

When he was a younger doctor, Vanderhoff recalls the commonly accepted side effects of surgeries, including a variety of digestive issues. One culprit, he now knows, was the opioids prescribed for recovery.

“Most of us were trained to interpret much of the constipation after abdominal surgery as an inevitable result of the surgery invading the abdominal cavity,” he said. “What we’re discovering is that the opiate medicines we prescribed with the best of intentions were more the culprit than we imagined.”

That paradigm shift is a microcosm of the larger conversation happening within OhioHealth regarding the use of opiates.

It’s not realistic to end opioid use entirely, especially for patients with unbearable pain. But for Vanderhoff, one of OhioHealth’s most important projects is fine-tuning the use of those opioids and changing how healthcare providers think of the drugs.

“The advent of this opiate epidemic really prompted what I can only describe as a sea change in the practice of medicine,” he said. “For many, many years before we recognized this epidemic, pain had evolved to be viewed as a so-called ‘fifth vital sign.’ Physicians were expected and held accountable for working to eliminate patients’ pain and the goal was to be completely pain free. This was reflected in national quality surveys, national benchmarks and measures.

“Today, we realize that eliminating pain is not the appropriate goal, but rather helping our patients be comfortable and functional is the right goal. Because some degree of discomfort may actually be an important signal the body is giving about what is going on in the healing process.”

For Vanderhoff and OhioHealth, “that’s a very different goal,” and one that they’re trying to achieve through education, policy changes and having physicians more “heavily involved” in teaching their co-workers.

“We’ve had to ask, ‘How do we make this change? How do we make this paradigm shift in clinical practice?’” Vanderhoff said. “We realize it begins with education and awareness. It begins with working with patients and communities to make people more aware of the dangers of opiate medications and recognizes their real risks, setting goals that are more appropriate when it relates to pain management and care.”

Part of this new implementation is giving young doctors the right frame of mind for the start of their careers and advancing those who understand the importance of drug management.

Dr. Krisanna Deppen, who specializes in addiction medicine and family medicine at OhioHealth Family Medicine Grant, said the system is “training people to do better” than what came before.

She said OhioHealth has been holding surveys regarding the stigma of addiction and communities’ attitudes toward it. It’s holding monthly substanceabuse seminars and trying to spread the word about what addiction is and how it can be handled.

Perhaps more importantly, Deppen and other specialists now have a voice within OhioHealth and beyond.

She said addiction medicine only has been recognized by the American Board of Medical Specialties since 2016, which hasn’t given them long to catch up.

But now, OhioHealth has a special addiction medicine fellowship, which gives two young doctors an extra year of on-the-job training beginning this August.

“We’re grown up; we have a seat at the table,” Deppen said. “So we’re training doctors to do this work and to put it into the healthcare system so that it’s part of what we do.”

And for Vanderhoff, that training from younger generations is an important part of changing the culture.

He said he hopes, with the new knowledge and specialists available, that the “sea change” becomes widespread.

“Physicians and other care providers rely on their training; they rely on the education,” he said. “And it’s always based on the best observations available at the time. But the common use of opiates in the perioperative period, frankly, scientifically blinded us to their impact. Now, that impact is far better understood.”

aking@thisweeknews.com

@ThisWeekAndrew

When Dr. Ryan Squier first became an emergency department physician, he envisioned that he’d need to be proficient in dealing with things such as strokes, heart attacks and physical trauma.

The opioid epidemic has broadened Squier’s perspective significantly regarding the knowledge that medical professionals must have.

Originally from Toledo, and with a background of training at the first community-based emergency medicine residency program in the country, at Akron General Medical Center, Squier has served with Mid-Ohio Emergency Services in Columbus for about six years, working in many emergency departments throughout the OhioHealth system.

“In the past decade, and it’s mirrored in the news, what we’ve really seen on a daily basis is complications that have arisen from the opioid epidemic,” Squier said. “Whether it’s been the infectious causes, the psychiatric consequences, the consequences of overdoses of opioid dependents … there’s no real easy answer to get out of the rut we’re in right now.”

Squier has tried to become a part of the solution.

In 2016, he helped launch a campaign through the Ohio Chapter of the American College of Emergency Physicians called NIX Opiates to help fight teen opioid abuse in Ohio.

Squier made his first NIX Opiates presentation that year to administrators in the Olentangy Local School District, where he and his wife, Amy, and their four children reside.

Since that time, he’s visited middle schools and high schools throughout central Ohio.

“He spoke at a staff professionaldevelopment day back in September of 2016 and also spoke to our students that same month,” Olentangy Orange High School principal Trond Smith said. “I remember most of the feedback surrounded how easy opiates were to obtain, certainly easier than alcohol. In addition, his perspective from the frontlines in providing treatment of overdose victims was painful to hear, but necessary. The NIX Opiates initiative has been imperative in reaching those who need this education the most — young people who either recently have or may be faced with a decision regarding whether or not to use opioids.”

Misconceptions

Since launching NIX Opiates, it’s become clear to Squier that “everyone” has a connection to opioid addiction, whether it’s a family member, friend or neighbor.

Despite that fact, among the misconceptions many have about opioid addiction is it’s not going on in their community.

“Even when we use medicine, we always caution people that it can be addictive and that you have to be very careful about utilizing it,” Squier said. “It’s common that I’ll have patients say, ‘You don’t have to worry about me, it’s not going to be me.’ The truth of the matter is we don’t know who it’s going to be.

“There are currently scientists looking to see if there is some sort of genetic trait that pre-disposes people to that addictive potential. Right now, we don’t know. We don’t know if it’s the 16-year-old who got in a car accident or the elderly 90-year-old who broke their hip who could potentially become addicted or dependent on an opioid. We want to understand that potential.”

Opiate addiction is what Squier calls a “common story,” and combating it requires educating people and not being judgmental.

“They started using thinking it wasn’t going to be them,” Squier said. “They didn’t decide they were going to start using heroin. They typically started by purchasing pills off the street, which got too expensive. Some began abusing them thinking it was a safe drug because it was a pill and it led to the pathway of more and more expense, and they inevitably began heroin, which is cheaper. Commonly those patients tell me, ‘I’m just using now so I can feel normal again.’ If they could turn back the clock and stop using and never have used it, they would, but they can’t function, they can’t get out of bed without using because of what happens to their body with this drug.”

Viewing pain as a necessary part of healing is something patients must understand when they’re first prescribed opiates.

“The thing is that it happens every day and it happens every day in central Ohio,” Squier said. “It’s not happening because they’re bad people. That’s the misconception. It’s important to educate because it’s important [in treating] the patient.”

Things are getting better

Other central Ohio physicians, such as Dr. John Leff, a trauma surgeon from OhioHealth Riverside Methodist Hospital, have been at the forefront of helping to educate people on the dangers of opioid abuse.

Leff is a member of The Stand Project, a community coalition formed in Upper Arlington focused on the prevention of substance abuse and providing a resource for students and families to easily find information, help and support.

Leff said his eye-opening moment came a few years ago when he was treating a young college student for an abscess on his arm. It quickly became obvious that the infection came from injecting drugs. The patient was well-dressed and had graduated from a suburban high school with a 3.9 grade-point average.

“As I was talking to this kid, I realize this nice young man was a heroin addict,” Leff said. ” That changed my whole point of view about drugs. I realize now there are no boundaries.”

He encourages parents to “be suspicious” of their children no matter how uncomfortable it is. ”Follow where they go. See who they’re hanging out with. Educate yourself, and be prepared.”

Initiatives such as The Stand Project and NIX Opiates appear to be working.

According to a report published in May by the U.S. Centers for Disease Control and Prevention, Ohio saw its number of heroin overdose treatments in emergency departments decline by more than 50 percent from 2017 to 2018.

Other states, including Kentucky and Pennsylvania, also had significant declines in hospital-treated heroin overdoses.

Others, though, such as Indiana and Illinois, saw increases in ED-treated heroin overdoses during that time frame.

Education, according to Squier, is one of the key steps in continuing to improve those numbers.

The reality of the situation, he said, is the average person goes through rehabilitation several times before breaking away from opioid addiction.

“Really, when we talk about NIX Opiates, we wanted to focus not on dealing with the legal aspect but on the, ‘Hey, we care,’” Squier said. “We’re doctors and we tell families horrible news in the emergency department and take care of devastating injuries. This is something we see and it breaks our hearts and it wears on us, knowing there’s got to be some way to stop this. There was research published in U.S. News & World Report that says that Ohio is actually on a decline, which is fantastic. It shows that we’re making some headway. This is not a solution that we’re going to ‘Narcan’ our way out of. We’ve got to be thinking of the people who are ready for treatment and get them access to the treatment.”

When a person experiences an overdose, reversal medications such as Narcan Nasal Spray can be used to reverse and block the effects of the opioid, but that doesn’t necessarily get to the heart of the problem, according to Squier.

With each of his four children ranging from 6 to 9 years old, his first step in teaching them about the effects of pills is that only the adults have access to medicine bottles at their house.

Programs such as NIX Opiates become appropriate when students begin heading into their teen years and throughout high school.

Seeing the effects of this crisis first-hand as a trauma surgeon, Leff says, “I don’t think this is a problem that will ever stop. I look at drugs as dream killers.”

julrey@thisweeknews.com

@UlreyThisWeek

Photography: Shane Flanigan/ThisWeek News

For healthcare providers, one of the most important battles in the opioid epidemic is the struggle to overcome stigma, misconception and judgment.

Dr. Krisanna Deppen, an addiction and family medicine specialist with OhioHealth Family Medicine Grant, is no stranger to treating patients with addictions to opioids or other substances. She said a key part of her job is relaying to patients, colleagues and the public that there is no “typical” opiate user.

“I think anyone can be affected by the opioid epidemic, and I think there are a lot of stereotypes around what that looks like,” she said.

That battle is waging even within hospitals, where Deppen said caregivers can sometimes slip into the same thinking as those outside the profession.

“One of the biggest barriers within healthcare is how even we, as healthcare providers, still come with a lot of stigma and even discrimination as it relates to addiction and treatment,” she said. “If you had a heart attack and came into the emergency department, we wouldn’t tell you, ‘Gosh, you really need to see a nutritionist before we talk to you because you need to stop eating all those hamburgers. ’ We’re just going togive you a list of providers and you can follow up later.”

When people imagine a person with addiction, it’s unlikely that they think of pregnant women. But one of Deppen’s specialties is caring for women with addictions while pregnant, and that population alone is a reminder of how diverse the face of addiction can be.

“I do a lot of caring for pregnant women with addiction and I think there’s this idea that they’re young, minority, teenage moms, but it’s actually quite the opposite most of the time,” she said. “It’s women who have been moms before — they’re in their 30s, they’re usually white and they come from lots of different backgrounds.”

In Athens, Ohio, at OhioHealth Physician Group Heritage College Obstetrics & Gynecology, Dr. Jody Gerome said she and her colleagues have seen a significant increase in the number of women entering prenatal care while using or abusing opioids. They had to come up with a solution on the fly.

“We really weren’t sure what to do with it, but we identified this as a risk in our region,” she said.

Along with other doctors and hospitals, Gerome helped form a “collaborative approach” between caregivers in a five-county region that brought “likeminded people to the table who wanted to make a difference and make change.”

That collaboration is important, she said, because of how “complex” caregiving can be for a pregnant woman with an addiction.

“We have a wide range of different types of women we care for at our practice, but the majority of women we care for who suffer from addiction disorder also tend to have a lot of poverty associated with them,” she said. “Not only do they have an opiate addiction, but they lack resources for basic things … that you take for granted, like food on the table, transportation or a place to live.”

Deppen and Gerome both said the goal is to provide what each patient needs, rather than a onesize-fits-all approach.

Deppen has experience with women across the addiction spectrum. Some, she said, became addicted to pain medicine, while others started with heroin. She said 20 years ago about 5 percent of addicted pregnant women started by using heroin. In a recent study, she said, that number has risen to about 30 percent.

“The majority of people, by the time they get to me, are using heroin and injecting,” she said. “So that’s different — they’re not just misusing pills anymore, they’re misusing something different.”

And while it would seem that a pregnancy would provide more chances for addiction to be caught by healthcare providers, Deppen said the combination of addiction, outside stigma and the patient’s own guilt can mean they often avoid treatment.

“There are plenty of patients who show up without any prenatal care and have a baby in labor and delivery,” she said. “It’s a barrier to care, when they’re using. So sometimes they don’t get care. We have to make sure that when they reach out and get help — whether that’s in labor and delivery or in their office — that people know how to help that patient. We still want them getting care, regardless.”

That’s why Deppen and others, such as OhioHealth Senior Vice President and Chief Medical Officer Dr. Bruce Vanderhoff, are trying to eliminate that stigma at the healthcare level by introducing more addiction specialists and fewer barriers to treatment.

“There’s always this fear, especially in a health system, that we don’t want those patients,” Deppen said. “But the truth is, those patients are right here. Right now, we’re just not treating them. This gives us an opportunity to address those patients.”

And the ultimate goal, she said, should be the same for all doctors: to “bring hope to our patients.”

“Addiction is a chronic medical disease,” she said.

“People can get better; I think we forget that in the hospital. I try to remind my residents that healthy people don’t come to a hospital. Well-controlled diabetics don’t come to the hospital; people who are using their inhalers as prescribed don’t come to a hospital; and people who are in recovery from addiction also don’t come to a hospital.

“So we get a skewed view, and it’s important to remember that people do get better.”

aking@thisweeknews.com

@ThisWeekAndrew

Photography: Lorrie Cecil/ThisWeek News

She continues to double down on this sentiment as a growing chorus of voices and change-makers across OhioHealth join the fight against the opioid epidemic. What is emerging are new and thoughtful ways to better address pain management, and ultimately, avoid the unintended consequences of opioid addiction.

The Naloxone Pilot, Addiction Fellowship and Project ECHO

Dr. Deppen is using her experience to drive change — both in perception and programming — to combat opioid addiction.

"The Naloxone pilot we established in the Grant emergency department is working, but we still need data for clinical validation," said Dr. Deppen. "It's saving the lives of people who have accidentally overdosed."

The pilot, which also is established at OhioHealth Marion General Hospital, OhioHealth Pickerington Medical Campus and OhioHealth Westerville Medical Campus, provides lifesaving Naloxone to reverse the effects of an opioid overdose. It has also opened a pathway for real change, particularly the Addiction Fellowship at Grant. The fellowship is not about opiates, it's about treating addiction as a whole. Every year, two fellows will receive an additional year of training that's specific to substance use disorder.

"There is momentum in the hospital setting that we can no longer view addiction and mental health as someone else's problem, that it will get solved in a different silo of care," said Dr. Deppen. "We need to address it as we would any other chronic disease. With the right treatment, people get better."

Another initiative, Project ECHO, virtually connects patients with primary care doctors in areas where there aren't enough resources or expertise. Dr. Deppen said OhioHealth is leveraging the Project ECHO approach to bring primary care doctors together with pharmacists, pain management specialists and addiction experts to create a virtual team that can collaborate and learn from one another with regard to opioids, pain management and addiction.

"We are at a tipping point and there have been disconnects when it comes to addiction, medicine and treatment," said Dr. Deppen. "Communities are watching to see how we're handling this."

Grant Substance Use Disorder Education Program

Fueled by the epidemic, her involvement in the Franklin County Opioid Action Plan, and the Naloxone ED pilot, Paula Kobelt, DNP, RN-BC, clinical outcomes manager in Quality and Patient Safety at OhioHealth Grant Medical Center, was tasked as part of a process improvement initiative to lead her team to develop substance use disorder (SUD) education for the hospital.

"We learned a lot of healthcare professionals don't fully understand substance use disorder because it isn't part of their training or education," said Kobelt. "We want to improve knowledge and reduce stigma around this medical condition."

Kobelt and her team surveyed hospital staff in late 2017 to identify knowledge and attitude gaps and what people wanted to know. They learned there was an appetite for greater understanding and a need for clinical resources on substance use disorder and treatment.

They developed a three-pronged approach to address these gaps including:

•  
•  
• An online learning series "Understanding Addiction" produced by Harvard Medical School Global Academy, which provides eight, free CME credits.
• Monthly "Lunch and CME" sessions featuring presentations and group discussion on a topic covered in the online series.
• A dedicated Addiction/Substance Use Disorder for associates with educational resources, like training videos and more.

"We received feedback that the series helped our healthcare team view addiction as a medical condition that is treatable, with recovery as an outcome," said Kobelt.

"The language we use matters," said Kobelt. "Replacing the terms drug addict or drug abuse that labels people and is demeaning with a person with a substance use disorder is an example of person-first language. People with heart disease or diabetes don't feel shame or judgment about their medical condition and individuals with substance use disorder shouldn't either. More importantly, stigma prevents people with SUD from seeking treatment. We want them to seek treatment just as anyone else would."

It Takes a Village: The Dreamland Effect

In and around Athens, Ohio, the opioid epidemic has taken its toll.

"We were seeing a lot of work happening, but really didn't know how to bring people together as a community in a way that shared best practices and didn't duplicate efforts," said Brittany Jarvis, MHA, BSN, RN, nurse manager, cardiac catheterization lab, pain management program and cancer services at OhioHealth O'Bleness Hospital.

Jarvis met with her co-founding member of Athens HOPE, Rebecca Robison-Miller, who serves as senior director of community relations for Ohio University's College of Health Science and Professions, and learned of college dean's desire to do something about the opioid epidemic. Jarvis and Robison-Miller decided to reach out to Sam Quinones, author of Dreamland: The True Tale of America's Opiate Epidemic, inviting him to speak on how the community could work together.

When the author agreed, a three-day series of talks was scheduled, including community events with opioid awareness and discussion for medical staff and forums in Nelsonville and Athens for frontline professionals. The events, co-sponsored by OhioHealth O'Bleness Hospital, Ohio University's College of Health Science and Professions, and the OhioHealth Foundation, reached more than 1,500 individuals and was recently named the Prism System Award Winner for Stewardship in the team category.

"We were dreaming big, but this was bigger than we imagined," said Jarvis. "These events brought medical professionals, educators, police, firefighters, family members affected by opioids, social workers and counselors together. It's been really positive."

"This was a spark for our physician group to take deliberate action," said Brett Kim, vice president of OhioHealth Physician Group's south region. "There is a greater understanding now and our providers think deliberately about pain, addiction and patients who could be prescribed opioids."

Kim said physicians in his region helped initiate four key actions:

• Identifying and sharing best practices for weaning patients from opioids across all practices.
• Securing support for PastRx, a prescription drug monitoring program to help providers understand a patient's history with controlled substances.
• Stocking Naloxone in all clinical offices in the southeast Ohio region and providing training on how to use it.
• Securing grant funding for the first-ever substance and addiction patient navigator.

"For people wanting to know more or who are in a crisis, the navigator will work with providers and help patients get on the right path," said Jarvis. "They also will do important follow-up and step in earlier to help prevent substance issues before they begin."

A New Era for Postsurgical Recovery

For decades, the protocol for patients before and after surgery has been clear — no eating in advance of surgery, ask for pain medication as needed and stay in bed during recovery. But recent research and concern about opioid addiction has paved the way for an Enhanced Recovery After Surgery (ERAS) program.

"Dreamland was an eye-opening read and it motivated me to think about how we use narcotics in our pre-operation, in-hospital and post-operation phases," says Anand Satyapriya, MD, quality medical director of anesthesia at OhioHealth Riverside Methodist Hospital. "I believed we could cherry-pick the best of what was out there in practice and customize it for OhioHealth. I also believed it would reduce the length of stay, provide cost-savings and dramatically reduce narcotic use."

This became Dr. Satyapriya's process improvement project, although it took significant time to present evidence and educate a team on how to employ an ERAS program. He admits it was challenging.

"It goes against what everyone has been taught and trained to do," said Dr. Satyapriya. "The ERAS approach advocates that a carbohydrate-loaded drink before surgery helps with wound healing and insulin resistance after surgery, and that getting up and walking speeds up recovery."

Dr. Satyapriya also said that specific anesthesia techniques are affecting postsurgical need for narcotics.

"Asking, 'What is your pain level?' meant that pain was viewed as a vital sign and treated with narcotics," said Dr. Satyapriya. "Previously, doctors wouldn't want to see you again for six weeks and would prescribe medication to last as long. We need to ask how they feel and exhaust all alternatives to opioids first."

Preparing for ERAS took six to nine months. A group of 30 to 40 colorectal surgery patients without chronic pain were selected during the program's first three months in 2017.

The results were convincing and worth the effort.

"We saw length of stay drop from 3.3 days to 2.9 days with a financial analysis suggesting a quarter million dollar savings across 150 patients," said Dr. Satyapriya. "And among our first 40 patients, only two took an IV of narcotics."

ERAS has already been used with more than 250 colorectal, orthopedic and gynecology patients, and Dr. Satyapriya looks to share the approach across the OhioHealth system.

"We are trying to innovate and use everything in our toolbox to avoid narcotics," said Dr. Satyapriya. "The risk is real. ERAS is making a difference."

This story was originally published in an internal OhioHealth associate publication.