Led by doctors Comilla
Sasson and Jason Smith, two teams set out on a
journey to Los Angeles, California, to investigate a new program at the West LA VA.
Comilla's team was looking for an innovation to spur an infant
addiction service in the Denver Emergency Department.
Jason's team was looking and
trying to find a formula for providers to be successful with their patients.
Doctors Neil Patel, Jonie Hsiao, Manuel Celedon,
and Larissa Mooney are innovators, rethinking how and where
Veterans receive care for opioid use disorder.
If we were going to learn anything about how West LA
was successful, we would need to go to the source.
Dr. Manny Celedon is the youngest staff physician in the ED, and one of the
best. Manny, explain to us why he became a physician. The reason I became an emergency doctor
is because, my idea of a doctor is somebody knows the whole scope of medicine.
And, from you know, acute care to ambulatory, non-acute care.
This was crucial.
It paints a picture of the type of physician for which the VA has come to be known.
It would also be key to the origination and formation of an
opioid use disorder treatment program in the Emergency Department. The first of its
kind in the VA. Our question to Manny, was was why he thought he
could treat addiction without any formal training.
The world as it is now, is a lot of patients get their care in the Emergency Room. And I do a lot Primary Care in the Emergency Room, I do that with my training.
Regardless of whether this is helping them for their diabetes, because they're
hyperglycemic, and helping them get connected to Endocrine
clinic, and starting them on insulin or metformin, or whether it's asymptomatic hypertension,
and they're not on any blood pressure medications, and helping them get started, follow-up. Opioid use disorder, to me, is the same thing.
Understanding this attitude was very important, but it
wasn't the only step to treating this disease. A catalyst was needed.
Manny turned to his colleague and friend, Dr. Jonie Hsaio,
Associate Chief of the Emergency Department
in LA. Off-camera, she shared her secret to success.
I'm not a talker though, I get things done. But how do you get things done?
I ask a lot of questions, I pick things in my mailbox, I don't throw away anything, until it's done.
Dr. Hsiao had been at the West LA VA for many years before she was
approached by Dr. Celedon to innovate a new practice.
When asked what she thought of Manny's idea,
her candor demonstrated a willingness to change.
To work on this issue? I think the interesting thing is, maybe a year ago, I was in the same kind of
group where 'oh, opioid withdrawal, it's not a life-threatening illness, we just need
to give them symptoms control and that's that,' and,
I think what increasingly we realized is that this is an opportunity to really help the Veteran,
help the patient overcome the withdrawal if they're ready and willing.
And that, realizing what MAT can do, and the different drugs out there, there's a better way to
do it, and better way to make patients, you know,
stay sober from their addiction.
We worked with Dr. Mooney, in particular, the Chief of
our Substance Abuse clinic, who basically,
explained to us that the drug, specifically Suboxone, or
buprenorphine, and understanding how safe it was, and how relatively easy
it would be to try to induce someone in the ED.
It seemed like a perfect opportunity to really, again, engage the veteran in their care long-term, and
something that we could, honestly relatively easily do in the ED with no support from different ancillary staff.
Her attitude changed when she witnessed what she described as miraculous.
And that's when we've seen veterans, patients, realize,
'Wow, there is an alternative to what I'm doing here that will work for me, and this is a way
out of my addiction." And that's what really really miraculous and wonderful to see.
Dr. Sasson and Smith needed confirmation that the role for addiction specialists would remain
a critical part of how providers would expand their Emergency Departments.
Specifically, they wanted to know care would be provided to patients
who would most likely benefit from timely intervention. Comilla and Jason
turned to Dr. Larissa Mooney, Chief of Addiction Services at GLA.
Well, the Emergency Department is a point of entry for treatment.
Many times, people with addiction aren't necessarily in that moment seeking
treatment for their addiction, but they may come
to primary care, or an Emergency Department for a medical problem or
medical consequence. So, if at the same time as
they're receiving treatment for medical condition, they can be identified as having
opioid use disorder, that's an ideal place to start treatment if it's available, and if it's appropriate.
GLA had, in part, realized success
from a collaborative environment with specialists like Dr. Mooney,
who felt strongly that all providers could have critical discussions
with veterans, and treat opioid use disorder.
Dr. Sasson and Dr. Smith pushed her on the issue.
It's everyone's responsibility because
addiction is a chronic illness, and we are right now facing
an opioid epidemic where we need a lot of creative solutions and rapid solutions.
And in fact, the number of cases of opioid use disorder in this country cannot
readily be handled by specialty clinics. The volume is too high.
So, we need to remove barriers to treatment, work together, work as a team,
to provide continuity of care and
really bridging that continuum of care across specialties, moving from
ED to outpatient, sometimes ED to inpatient. Residential treatment to after care
in outpatient. These are depending on the needs of the Veteran, of the patient, they need
more structure, they may need less, they may stabilize very quickly.
But, if we all think about, 'What is our role?'
'What can we do?' 'Is there a small part we play?' Even if it's just initiating
that treatment and then linking them with longer-term treatment. That can be very meaningful.
It was then clear that everyone at the GLA VAMC had a
stake in treating OUD. Their teamwork was infectious.
We asked Dr. Sasson
what had inspired her about this campaign?
Why should Emergency Department providers be
thinking about naloxone? I had a case of a Veteran, who
he had a MAT response in the parking lot in our facility, and
I responded to it. And I realized, myself and the two techs and a nurse
that had come with me. We actually ended up pulling a Veteran out of the car physically, and his friend
who had brought him to the VA, had said, "You know, I think might've overdosed on opioids."
So we, put him on the stretchers as fast as we could, we bring him down the
hallway, and it was far! The whole time I was thinking to myself ,'Oh my gosh, this is a patient
who truly needs naloxone. And we may not be able to get to him in time.'
We were able to run as fast as we could, we got to the Emergency Department. We called ahead and said, "Hey, can you guys
grab the naloxone? I think this is an opioid overdose." And
fortunately, we were able to give him the medication right away,
didn't have to intubate him, he responded within seconds
of administration of that medication. And as a provider, there's very
few things that are so gratifying, in terms of being able to truly have that
person who you're helping, save from that brink of life-and-death. And to me, that was one of those things
where I kept saying to his friend, "Look, if you had waited three more minutes
to call us, your friend would have died." We do a lot of things that sometimes you wonder, 'Am I making a difference?'
'Am I gonna make an impact?' And I really do think that has made an impact, not just on him, but more importantly, on me.
Our team had stumbled upon something unexpected. We captured
in Los Angeles just what we were hoping to find.
Doctors that were dedicated to the mission, and doctors
that had personal responsibility for every veteran they
encountered.
It would now be our responsibility to
bring this spirit back, and share it with is many people as possible.
When asked to offer a statement as to how they were able to create a program like this
with little resources, and no additional staffing?
Each provider answered the same:
"It's our job."
The Academic Detailing service from VISN 19 would like to say thank you
to the providers that participated in this unique event.
It was our pleasure to be of service.