When it came time to choose the topic for the 4th Annual Addiction Medicine Symposium, there was no debate.

Terry Horton, M.D., FACP
Terry Horton, M.D., FACP

“We wanted to learn about heroin,” said Terry Horton, M.D., FACP, chief of the Division of Addiction Medicine. “Our friends and our families are affected by this epidemic in ways that surprise even those who have been in the field. I’m startled by the extent and magnitude with which heroin affects our patients and family members. It’s an extraordinarily important topic.”

Titled “The Heroin Epidemic,” the daylong conference on Aug. 30 drew 185 professionals to the John H. Ammon Medical Education Center at Christiana Hospital, the largest crowd to date for the annual event. The forum was sponsored by Christiana Care Health System, Central East Addiction Technology Transfer Center Network (ATTC) and two dozen community providers that were on hand to distribute literature.

The symposium also featured a training session in administering Narcan, a drug used in an emergency to counteract a narcotic overdose.

The five speakers, including Rita Landgraf, secretary of the Delaware Department of Health and Social Services, addressed the history of the current heroin epidemic, debated effective treatment options and examined the efforts Delaware is making to combat addiction.

Opioid addiction is a disease, they stressed, and should be treated as such. It does not discriminate by gender, class or ethnicity.

Dr. Horton recalled a range of patients: a 20-year-old admitted with “horrific endocarditis,” a 26-year-old man bound for graduate school before he died and was revived in the emergency room, and a 58-year-old woman who awoke from an angioplasty in heroin withdrawal.

How did we get here?

Matthew Ellis, MPE, CGE, of the Department of Psychiatry at Washington University in St. Louis, provided an overview of the perfect storm that exploded into an opioid epidemic. He harkened to the early 2000s, when the Joint Commission on Accreditation of Healthcare Organizations referred to pain as the “fifth vital sign,” which could be treated with opioids.

At that time, the potential for abuse of extended-release oxycodone was considered low. That is, until snorting and injection became common, Ellis said. That led to the development of abuse-deterrent formulations that could not be crushed into small enough particles to snort and would turn into a gel, unable to be injected, if liquefied. Then entered drug cartels, which understood how lucrative the heroin trade was.

As supply-side efforts cut down on the availability — and upped the cost — of prescription opioids, more and more users turned to heroin. It was cheaper and easier to get, and the stigma of using heroin began to fade.

Ellis cited quotes from users who participated in research studies. Said one, “Every single person I know now that used pills now uses heroin. … Also every person I know that now uses heroin uses it intravenously. More people than I can count who I never thought would ever even try heroin are now shooting it up.”

So far this year, through Aug. 21, Delaware has seen 136 suspected overdose deaths, Landgraf said. The state ranked ninth in the nation in 2014 for the rate of fatal overdoses — 20.9 people per 100,000, compared with the U.S. average of 14.7. The problem is particularly prevalent in the southern part of the state.

“It’s the most horrific disease impacting Delaware,” she said.

The state’s system for combating the disease is fragmented. “Individuals face gaps in services and support,” she said. The answer lies in a partnership approach among prevention education, treatment and recovery, and law enforcement.

The state is working to develop more withdrawal management centers for addicts, she said, and pushing for Narcan to be available in pharmacies.

“I want to really make Delaware a state that dealers are afraid to come to,” she said.

Adam Brooks, Ph.D., and David Gastfriend, M.D., of the Treatment Research Institute in Philadelphia, spoke of the benefit of medication-assisted treatment along with counseling to help addicts get clean.

Drug-free treatment models have a higher relapse rate, Brooks said. However, he noted the stigma among some recovery groups that won’t accept a participant who is on medication, and the high cost of the medication, as hurdles to the medication-assisted approach.

“Cost is not a medical consideration,” Dr. Gastfriend said, projecting charts showing that spending upfront on treatment reduces providers’ costs in the long run. “We need pharma-therapy available for all patients. … Without medication, you’re building a house on quicksand.”

Lex Remillard, MSW, LCSW, who practices in West Chester, Pennsylvania, and sees mostly young adults, was more leery of using medication in treatment.

“I have never seen Suboxone work in a long-term fashion,” he said. Suboxone, made up of buprenorphine and naloxone, is one of the medications used to treat people in withdrawal.

Many of the patients he sees began using painkillers as teens, after a surgery or swiped from a family member, and spiraled into addiction, he said.

“My job often is to just plant a seed” for recovery, he said. “Because if not, the addiction is going to take you.”

The audience, comprised of a wide range of professionals who interact with people struggling with addiction, came away with more than continuing medical education credits. They learned best practices for treating addicted patients with evidence-based approaches, how to administer a life-saving drug, the difference between the myths and realities of heroin addiction and, finally, the role they each can play attacking the addiction in partnership with each other and the state.