Chapter 5 — We Need to Talk:
Training health providers to ask the right questions
Sprawling 70 miles east of the five boroughs, Long Island’s Nassau and Suffolk counties are home to over 2.5 million people. Although opioid addiction was hardly a widespread health concern in suburban Long Island before 2005, this economically diverse stretch of communities is now the newest battlefield in New York’s war with opioids.
Prescription painkillers, which flooded the market in the early 2000s, paved the way for heroin and, more recently, the cheaper, deadlier synthetic fentanyl, which was involved in over 80 percent of overdose deaths in New York State. In Suffolk County specifically, the fentanyl-related death rate has quintupled since 2014. Doctors on Long Island found themselves ill-equipped to deal with the opioid epidemic that grew out of rampant overprescribing.
Mike (last name withheld) is a 32-year-old lawyer from Oakdale, a small waterfront hamlet on Long Island’s South Shore. After a severe neck injury in 2009, Mike developed an addiction to prescription painkillers that sparked a five-year cycle of substance abuse, rehabilitation and relapse.
Even though he sought help from multiple psychiatrists and checked himself into rehab facilities in several different states, Mike couldn’t break his addiction. Every time he would successfully get off pills, his neck pain would lead him right back to the doctor for more.
For two years, Mike saw a doctor willing to prescribe him hundreds of opioids and Xanax a month. The doctor, a pain specialist named Carmine Mandarano, lost his license in 2014 after his office was raided by federal investigators. But by then, Mike was addicted and his life had unraveled. He wasn’t alone in his addiction. During the years he struggled, overdoses took more than 2,000 lives on Long Island, mostly from synthetic opioids. As the prescribing went up, so did the death toll.
“As prescription opiate medication was more widely prescribed and more people received it, the percent of people who were getting it who were more vulnerable to becoming addicted grew. It’s almost like a numbers game,” said Dr. Jonathan Morgenstern, head of addiction services at Northwell Health. Northwell is New York state’s largest healthcare provider, and it’s based on Long Island.
Morgenstern says that despite the medical industry’s role in the problem, as recently as 10 years ago – during the prescription painkiller boom – substance abuse wasn’t really treated like a medical problem.
“Now is an important juncture where we look at this organization, the largest in the state, and ask, ‘What do we do for individuals who were left to fend for their own and try to figure out what’s the next step?’ said Northwell’s Dr. Sandeep Kapoor. “Either it’s street drugs mixed with so many other things … fentanyl, bleach … or it’s to come to us for some kind of support. And that’s what we’re trying to stand up.”
In order to stop people from dying, doctors on Long Island are working toward to change the culture of addiction and substance abuse treatment. That means identifying a patient’s “substance use status” in places like the emergency room or in primary care office, and if necessary, referring the patient to substance abuse counseling or treatment, in some cases on-site. To effectively do this, every single healthcare professional in the system must be trained to recognize the signs of substance abuse – which often starts with identifying patients who are at risk. According to Kapoor, simply asking patients who are seeking medical help – for any reason – about their substance use history is a great place to start.
But this type of conversation isn’t part of most clinicians’ training. In fact, according to Kapoor, even though primary care visits account for more than half of all doctor’s visits nationwide, many early-stage substance abuse disorders go unnoticed by doctors, sometimes for years. Most physicians received less than one hour of addiction training in medical school, and many never become comfortable addressing substance use with their patients.
Although these doctors were encouraged to prescribe opioid painkillers for over a decade, many weren’t properly trained to identify or address the dependence the drugs would cause with long-time users.
Many patients ultimately suffered for it. Mike himself fell victim to the liberal prescribing practice, and his various doctors’ lack of understanding of the real danger of the problem perpetuated it. He had been in and out of treatment in Florida, New York and Connecticut, and was still able to receive opioids for pain, no questions asked, he says. He got them from several different doctors over the years. If a doctor didn’t ask, he didn’t talk about it.
“The onus was definitely on me to speak up, but I didn’t,” Mike said. “If he would’ve said ‘have you ever been addicted to Vicodin before,’ I would’ve said ‘yes.’”
Many doctors don’t have clinical experience asking about substance use. That’s why Dr. Kapoor and Northwell Health are working to do more than train their current staff in early addiction identification; they’ve also helped implement a new substance use screening program as part of the curriculum at Hofstra Northwell School of Medicine.
The goal is for every student at Hofstra Northwell to become comfortable discussing and diagnosing substance misuse in a clinical setting – no matter what discipline they plan to enter – while at the same time every medical provider within the Northwell system, starting with primary and emergency care, will be retrained to screen for substance abuse through a process called SBIRT: Screening, Brief Intervention, and Referral to Treatment.
Under the guidance of Doctors Kapoor and Morgenstern, Northwell Health has taken cues from other progressive healthcare facilities. Several of New York’s teaching hospitals and emergency facilities provide on-site substance use screening, intervention and referral to treatment.
“We’re not the first ones. Montefiore, SUNY Downstate … everyone now is starting to understand that the best way to make something sustainable is start off with the folks that can disseminate this naturally,” said Dr. Kapoor. “And who better to start off with than our students. They’re going to hit health systems throughout this country. They’re the folks who can make a long term impact.”
While Northwell is New York State’s largest healthcare system, its doctors aren’t just working within Northwell facilities. Kapoor and his team helped install Stonybrook’s SBIRT training program out in Suffolk County. But because of its size, Northwell Health stands to make a huge difference in the effort to combat addiction-related deaths on Long Island, even within its own organization. Northwell operates 21 hospitals and has hundreds of facilities all over Long Island. The organization employs more than 18,000 doctors and nurses, and has the capacity to treat 8 million patients statewide.
Mike is one of those patients. His family eventually connected him with Dr. Robert Galak, a 30-year veteran of addiction psychiatry, who runs a practice in Nassau County. Every six weeks, Geppetti visits Galak’s office, which is tucked away inside the Northwell Health hospital complex most people know as Long Island Jewish Medical Center.
Galak was the first doctor to successfully manage Mike’s recovery. Galak, who worked at a methadone clinic in California after serving in Vietnam, believes in medically-assisted treatment, but says he doesn’t prescribe opioids himself. He’s also no stranger to the stigma associated with addiction.
“It’s a chronic disease, it’s an addiction and we’re trying to treat it. And you try to destigmatize it,” said Galak. “The same way that psychiatry used to have a stigma. You couldn’t get patients to see a psychiatrist because – ‘I should be able to handle this on my own.’ Well, if you’re schizophrenic or bipolar or depressed you really can’t. Sometimes you need medication, sometimes you need therapy, sometimes you need all of it. I’m not a cop, I’m a psychiatrist. I’m here to help.”
While addiction psychiatrists like Galak frequently ask patients about their substance use history, Northwell is rolling out this approach in its primary care facilities. In a little over two years, primary care and emergency providers at Northwell’s SBIRT pilot sites have completed over 200,000 screenings, and have helped to identify more than 3,000 patients who need treatment. In 2016 alone, Northwell Health admitted 6,240 people to inpatient substance abuse treatment, and connected thousands more with outpatient care.
Effective beginning in 2017, New York State allocated $200 million to combat the heroin and opioid epidemic – an 82 percent increase in state spending since 2011. While some of that money will increase Northwell’s capacity to treat addiction, they’ve already begun network-wide campaigns to monitor and reduce opioid prescribing, increase the availability of buprenorphine treatment and train families and communities in the use of naloxone. Morgenstern says that despite their previous attitudes toward addiction, the medical community’s approach to substance abuse is beginning to shift.
“We are making important progress overall in treating addiction. There’s a much more sophisticated progressive understanding of the issue and the need for the field of health and the medical profession to do something about that. The fact that you have a health system as large Northwell saying ‘we need to do something about this. This is our responsibility as a health system.’ That’s new.’”