State of addiction, state of healing

By Krystle Dodge ’11, M’11

The deadly opioid drug epidemic may seem an unsolvable problem, too complex and widespread to fix. But that hasn’t deterred the NeuroMusculoskeletal Institute (NMI) at the School of Osteopathic Medicine, led by Richard T. Jermyn, D.O., from coming up with practical solutions to the problem.

Jermyn and his team of physicians, residents and medical students have helped patients in South Jersey and beyond overcome both chronic pain and substance-abuse disorders. The NMI’s most recent efforts, focusing on education and training for doctors nationwide, could accomplish even more.

“The reality is that these training and mentorship programs allow us to train hundreds of people to do what we do. We will help lead the initiative that will save lives in a much bigger and better way,” Jermyn said.

Delving into addiction medicine

Jermyn didn’t start out working in substance-abuse treatment when he began practicing medicine two decades ago. He worked in palliative care in the HIV community. His interest shifted to pain management because, as treatments for serious medical conditions improved, his patients were living longer—but they were living with chronic pain. He began to worry about the free-for-all prescribing practices doctors had embraced when it came to opioid painkillers—powerful drugs in the same class as heroin. And for more than 15 years, he has been educating doctors on proper prescribing.

In an era in which the opioid epidemic claims tens of thousands of American lives every year, it’s hard to imagine a time when no one gave a second thought to prescribing these problematic painkillers. Yet, in the late 1990s, these drugs largely were considered unlikely to lead to addiction. Intent on letting no pain go untreated, doctors prescribed opioids like oxycodone with unparalleled frequency, Jermyn explained. It took years to become clear that these drugs are highly addictive. By then, for many patients, it was too late.

By developing opioid prescription guidelines, Jermyn helped pain management doctors screen patients for substance abuse signs. It was the right approach—but it wasn’t enough.

A new problem arose: what to do with patients—a lot of patients—who developed substance use disorder? Their pain, stemming from serious ailments like fibromyalgia, HIV and traumatic brain injuries, was real. But so were the negative effects of opioid painkillers on their bodies and their lives.

“I need help. Can you help me?”

Generally, pain management clinics terminate from the practice patients who develop substance use disorder. It isn’t that these doctors don’t care, but they can’t enable substance abuse by continuing to prescribe the drugs and aren’t trained to help patients end their addiction (a word that, Jermyn said, he doesn’t like to use). To avoid contributing to a drug problem, well-intentioned doctors across the nation turn substance abusers out onto the street.

Many of these patients turn to illegal drugs like heroin or fentanyl to stave off the symptoms of opioid withdrawal. Powerful and incredibly dangerous, these drugs can stop withdrawal symptoms in the short-term. In the long run, though, they exacerbate users’ worsening substance-abuse problem, or worse, end their lives.

This sad story occurs in pain management offices across the country. About three years ago, after working with the state to determine what to do with these troubled and troubling patients, Jermyn made the radical decision to stop discharging patients diagnosed with substance-use disorder. Instead, he would treat substance abusers the same way he had treated chronic pain patients for 23 years.

When Jermyn stopped turning patients away for dependency, his phone started ringing off the hook. The practice never advertised that it offered ambulatory detox services. Yet patients eager for help sought him out.

“I need help,” they would say. “Can you help me?”

He could.

“We have a responsibility as doctors to really meet the opioid crisis.”

Part of what makes Jermyn’s work at the NMI so successful is the compassion he shows to patients with a substance-abuse history.

“One reason people don’t get help is the medical community,” Jermyn said. “We had an idea what an ‘addict’ is—the dregs of society—but we were wrong.”

“It comes as a surprise to people that opioid addictions affect every ‘type’ of person in every aspect of life,” said Dr. Danielle Cooley, a Rowan Medicine physician who performs osteopathic manipulative medicine at the NMI. “Despite preconceived notions, addiction affects everybody.”

Since Jermyn started offering outpatient services through the NMI, he “has grown as a doctor and as a person.” One reality that’s become clear during his decades of practice is that substance abusers aren’t bad people. Rather, they’re patients in pain who have developed a further medical problem.

“This is a disease like none other,” Jermyn acknowledged—and yet it is a disease. Having a substance-abuse problem is little different from having diabetes or high blood pressure. Doctors’ approaches to treating this medical problem should be as respectful to substance-abuse patients as they are to patients with any chronic medical condition, Jermyn believes.

“In my waiting room, you can’t tell who is here for substance abuse and who is here for chronic pain,” Jermyn said. The residents and medical students on clinical rotations don’t know when they walk into the exam room which “type” of patient they’re about to see. They only find out once they open the patient’s file. Everyone is on equal footing. No one is judged.

“It was a surreal experience to see how candid patients were,” said Aaron Wu, a fourth-year SOM student planning a career in emergency or internal medicine. “Patients ranged from the very hopeful, who have started a new chapter of their lives after having come to the NMI, to those who have an extensive pain/substance-abuse history and saw the NMI as their last hope. It was a sobering experience to listen to their stories.”

“It’s great to have someone in your home institution who cares so much about something I care about,” said Neil Kalpesh, a fourth-year SOM student who calls tackling the opioid crisis “a personal goal of mine as a medical student.” Kalpesh, whose advocacy contributed to the American Medical Association’s recent decision to incorporate training in naloxone use into the Basic Life Support Certification Program, noted, “We come out to be well-rounded physicians. No matter our specialty, we have in our arsenal knowledge of how to manage patient pain.”

How doctors can end the opioid epidemic

What does it mean to treat patients with substance-abuse disorder? Ambulatory detox programs don’t force patients to quit cold, throwing their body into instability. Rather, they use safe and responsible methods that have more success in long-term addiction recovery.

“We need more doctors to administer Suboxone,” Jermyn said. Suboxone is a combination medication prescribed as a form of maintenance therapy for patients who have struggled with opioid addiction. By minimizing withdrawal symptoms without causing a high, Suboxone can be part of a multifaceted approach to detoxing safely—and it doesn’t have to be given in an inpatient rehab facility.

“Everybody talks about inpatient detox beds, but treating patients in their own community and support systems may be ideal,” Jermyn said. In fact, temporarily getting away from the stressors and environments that lead to drug use can prove even more dangerous. When the recently detoxed person returns to the same environment where drug use occurred, the relapse risk is great, and the likelihood of an overdose is higher than ever, especially if the patient is not linked into a community program.

Treatment through Rowan’s NMI takes a different approach: treatment in the community, surrounded by the same support system and the same stressors that make up the patient’s life.

For pain patients, detoxing doesn’t mean being doomed to a life of unmanaged pain. The NMI implements an array of therapies, from nerve block injections to osteopathic manipulative medicine and from physical therapy to music therapy, to give patients relief.

“Prior to medical school, I was intimidated by the opioid crisis,” said SOM student Duwayne Campbell. “My greatest concern was, what are the alternatives, and how do I give opioids responsibly?”

What calmed Campbell’s concern was discovering “the vast amount of options before getting to opioids,” as well as seeing responsible prescribing practices in action. NMI doctors make sure patients who are on opioids have the overdose reversal medication Naloxone and teach family members to identify overdose signs and administer the drug.

A big part of preventing addiction is changing the way pain is dealt with in the first place. “A lot of patients addicted to opioids—probably 75 percent—were first prescribed medications by a doctor,” said Cooley.

“My goal in primary care is to prevent them from getting that prescription. When a patient is in pain, I focus on hands-on treatment through osteopathic manipulation, not pain meds. If it doesn’t work, that’s when I refer a patient to the NMI.”

Cooley, who graduated in 2007, was a student before the opioid crisis emerged. “Doctors were using opiates a lot but still developing protocols,” she remembered. Now, she said, the medical community sees a “need for treatment—for addiction and rehab programs that incorporate medication, psychiatric care and counseling.” To help fill this need, she recently underwent advanced training. “Not all of us could prescribe Suboxone, so I figured, why not get that extra training so I can?”

Every day, SOM alumnus Dr. James Huber ’14, draws on what he learned from his rotation at the NMI as he practices physical medicine and rehabilitation at the Physician’s Clinic of Iowa in Cedar Rapids. “Pain underlies everything I do. We have to treat pain, or we can’t treat function.”

“The education I got on prescribing and tapering off opioids was invaluable,” Huber said. Over the course of his career, he has noted a “paradigm shift” in how doctors prescribe opioids—“from treating pain as the fifth vital sign to prescribing nothing stronger than Tylenol.” Despite the best intentions, this shift can have negative ramifications when doctors shy away from helping patients on opioids adjust the doses. “The training I received sets the groundwork for how we navigate through this system as the paradigm has shifted,” he said.

For chronic pain, opioids are the last resort. “You have to treat the whole person, including psychological and other factors that feed into the pain cycle,” said Huber. “Treating people with pain takes a team approach, and I don’t think that’s stressed enough across the continuum to help these patients.”

A model program for NJ and beyond

The NMI is truly unique, and so is SOM. “We are the first in the nation with both pain and substance-abuse programs,” Jermyn said. “This combination doesn’t exist anywhere but here.”

“I get to brag that my school is at the forefront,” said Campbell, who plans to specialize in emergency medicine. “I’ll know what kind of outpatient services are available. Most medical students don’t know where to start.”

This fact isn’t just a point of pride. It also points to a real problem. “We think every medical school should have a program like this,” said Jermyn. “We want to be a model program of training on how to assess for pain and substance use.” To make that goal a reality, Jermyn is recruiting, mentoring and training community doctors to make the same impact on the lives of those addicted to opioids that the NMI is making already.

New Jersey is looking to Rowan for improvements in training medical professionals statewide. So far, a lot of the opioid training for medical professionals has focused on primary care or specialist physicians, but these efforts aren’t enough to end the crisis. Jermyn is developing training programs for health care workers in different functions. For example, the NMI received a grant funded in conjunction with the state to develop training for dentists’ prescribing of opioid medications.

One developing educational program emphasizes training for doctors in hospital emergency departments. When a patient comes to the ER in the middle of the night, in the grip of withdrawal, how physicians treat that patient is crucial. Being turned away for “drug-seeking” behavior will only drive the patient to use again. If emergency department doctors are trained to induce patients on Suboxone—and to do it humanely, not judgmentally—and direct those patients to outpatient substance-abuse programs like those at the NMI, they may catch substance users at the time they are most open to giving up opioids for good.

Residents in the SOM emergency department already receive training in how to responsibly induce Suboxone treatment in the ER. The challenge is to spread these much-needed skills so that all doctors in all emergency departments across the country can guide substance-abuse patients to the recovery path.

Despite their many areas of focus, his research projects with the NMI share common goals. “The beauty of this is that it will eventually save lives in our community,” Jermyn said, “and that’s just a big deal.” ■

Krystle Dodge B’11, M’11 wanted to be a writer since she was old enough to hold a pencil. She just
celebrated the first anniversary of committing to freelance life full-time.