Breaking the Cycle of Opioid Dependence

Breaking the Cycle of Opioid Dependence

Even before Michael Fingerhood arrived for his residency at Johns Hopkins Bayview Medical Center (then Francis Scott Key Medical Center) in 1986, he knew that he wanted to devote his career to caring for people with opioid use disorders.

As a medical student in the Bronx, Fingerhood often witnessed patients who happened to be heroin users. “They’d be admitted for fevers or for local infections at their injection sites, and once that problem was solved, we’d discharge them and say, ‘See you later,’” he recalls. “We didn’t seem to address why they were injecting drugs. I thought: Why can’t we do something about this?”

In 1993, when he was just a few years out of residency, Fingerhood persuaded the Johns Hopkins Bayview Medical Center board of trustees to invest in a small outpatient clinic dedicated to providing primary care to patients with addiction. In the years since then, Fingerhood has built one of the country’s most respected chemical dependence clinics. One of the clinic’s central tools is buprenorphine, an under-the-tongue medication that blocks cravings for opioids. That treatment model is not new – buprenorphine was synthesized more than 40 years ago – but until recently, federal regulations made it difficult for outpatient practices to treat more than a handful of patients at a time.

Now Fingerhood and his colleagues are demonstrating that it can be done at scale: As of October 2017, they have more than 600 patients being treated for opioid use disorder with the use of buprenorphine. The need for this kind of simple treatment is obvious, Fingerhood says: The national crisis has grown worse each year, with more than 52,000 lives lost to opioid-related overdoses in 2016. Maryland has not been immune: During the first three months of 2017, there were 473 opioid-related deaths in the state, up from 132 during the comparable period a decade earlier.

But Fingerhood’s clinic is about much more than buprenorphine. He and his colleagues are trying to redesign opioid-related care delivery from top to bottom. Fingerhood hasn’t forgotten the questions that first bothered him in the Bronx in the 1980s: What do you do with an opioid-dependent person when he or she is discharged from the hospital? In a severely fragmented health care system, how can we help people find their way to the treatment they need?

“When you screen someone and find that they’re using opioids, there’s usually a lot of emotion in that conversation,” says Fingerhood. “You can tell someone, ‘I can help your tomorrow be better than today, if you’d like to try.’”

To that end, Fingerhood has worked with colleagues across the Bayview campus to design new models of care for opioid disorders. Together with other attending physicians in his service, Fingerhood has tightened protocols to help keep patients from getting lost after they’re discharged from Bayview’s inpatient chemical dependence unit. They’ve de-ployed community health workers to stay in contact with patients in their homes. They’ve developed interventions for formerly opioid-dependent people who’ve just been released from jail – a point when the risk of overdose is high. Most ambitiously, they’ve built new systems for screening all patients in Bayview’s Emergency Department for opioid- use disorders.

“We put the new screening protocol into place at the end of June,” says Carol Sylvester, vice president for care management services at Bayview. “When patients are identified as opioid-dependent, they’re referred to Dr. Fingerhood’s clinic and others in Baltimore City for follow-up. In the month of August, 43 percent of patients who received referrals for treatment showed up for the follow-up visit with treatment programs.”

Fingerhood would like to push this model even further, and to train emergency department doctors not only to offer referrals but actually to initiate treatment on the spot.

“When you refer someone out, you’ve often lost them,” he says. “You’ve lost the moment of impact. When you screen someone and find that they’re using opioids, there’s usually a lot of emotion in that conversation. You can tell someone, ‘I can help your tomorrow be better than today, if you’d like to try.’” Giving an initial dose of buprenorphine during that very first encounter, Fingerhood says, can be a powerful tool. When a patient experiences a day without cravings, the idea of recovery suddenly seems more tangible.

Sylvester agrees that this approach is worth trying. “We know that we need to have the capacity to offer buprenorphine at the time of the visit to truly help these patients,” she says.

The care delivery integration in Fingerhood’s clinic works in both directions: He also strives to weave together opioid disorder treatment with all the other kinds of medical treatment that his patients receive at Bayview.

“The fact that we’re seeing our patients so frequently for their buprenorphine treatment means that we’re also keeping an eye on everything else,” he says. “If they have hypertension, we’re looking at that. If they have diabetes, I say, ‘Bring in your meter and we’ll look at your numbers.’ If they have HIV, we can check on their medication adherence.”

All of this work has been supported in part by the Center for Innovative Medicine. With future support from CIM donors, Fingerhood says, even greater gains will be possible.

Reducing overdose deaths, Fingerhood says, could be a powerful way of meeting the center’s goal of increasing life spans in the neighborhoods surrounding the Johns Hopkins hospitals.

Some of the patients at Fingerhood’s clinic have been through many cycles of detox, but many others had never previously received any treatment for their addictions. In 2017, opioid-dependent patients come from the full spectrum of society: urban, suburban, affluent, marginalized. Whatever the patient’s background, Fingerhood trains his staff members and residents to offer a maximum of comfort and a minimum of stigma. He never delivers fire-and-brimstone sermons about the risk of fatal overdose. Instead, he offers respect and hope.

Even if patients don’t enroll during the initial consult, he says, “We’ve planted a seed. About a year ago, I saw a woman with diabetes who was clearly terribly abusing prescribed opioids. I said,
‘What about trying buprenorphine?’ And she said, ‘No, no, no. You don’t understand. This is for pain.’ And she walked out without making a follow-up appointment. But six or eight months later, I came in one day and there she was on my schedule. She’s on buprenorphine now and doing very well.”

Buprenorphine was originally synthesized by chemists who hoped to create an opioid painkiller with a diminished risk for overdose. A few years later, in 1978, Donald Jasinski, the founder of Johns Hopkins’ chemical dependency program, co-authored the first paper to identify buprenorphine as a potential aid in treating people with existing opioid addictions. It was not until 2000, however, that the federal government began to permit primary care physicians to prescribe the drug for that purpose. There were originally tight strings on the therapy, but the rules have recently become more flexible. Fingerhood believes primary care doctors across the country should embrace the practice.

“If you regularly prescribe oxycodone, if you regularly prescribe morphine,” Fingerhood says,
“you may not realize it, but eventually you’re going to create someone with an addiction. And that means you should feel an obligation to help that person get out of their mess.”

But even as the tide of overdose deaths continues to rise, few primary care doctors feel comfortable offering treatment for opioid dependence. Kelly Dunn, an associate professor of psychiatry and behavioral sciences at Johns Hopkins, co-authored a 2017 study that explored why so few primary care physicians – even those who have been through the training – prescribe buprenorphine. One of the primary reasons offered by doctors is that they didn’t feel they had time available to take on new patients or to do this work adequately. “Quite a few more resources are being mobilized to deal with the opioid crisis,” Dunn says, “but we still haven’t found a model that primary care doctors feel fully comfortable with.”

Sylvester agrees. Even with buprenorphine therapy, patients fighting addiction still need counseling to help them make behavioral changes. “And if as a doctor you’re only being scheduled for a 15-minute appointment,” Sylvester says, “you may feel that you just don’t have the time. Maybe primary care practices with robust support from allied health professionals can do it, but many don’t have that resource.”

Fingerhood acknowledges that those structural barriers are real. But he also believes some primary care doctors avoid opioid use disorder treatment because of sheer ignorance and stigma. “Some doctors think, ‘I don’t want to have that kind of person in my waiting room,’ he says. “But those patients are already in your waiting room, and you’re not treating them.”

Don Willett November 11th, 2017

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Celebrating 10 Years of the Aliki Initiative

Celebrating 10 Years of the Aliki Initiative

Ten years ago, thanks to a generous and visionary gift from philanthropist Aliki Perroti, the Aliki Initiative was launched at Johns Hopkins Bayview Medical Center by the Center for Innovative Medicine, creating a new model for the way young doctors today should be trained.

The goal of the Aliki Initiative is beautiful in its simplicity: to give medical trainees the time they need to get to know their patients as people. By talking with patients and their families, by calling and making home visits once these patients are discharged from the hospital, Aliki trainees and medical students can see just how patients are doing – and make it more likely for them to get and stay well.

In the decade since it was launched, the Aliki Initiative has flourished, and its impact has come to be felt well beyond Johns Hopkins Bayview. To celebrate the program’s anniversary, we bring you 10 highlights of the Aliki Initiative’s first 10 years:

1. More than 100,000 patients have been touched
Each member of the internal medicine house staff at Bayview (about 15 to 20 doctors per year) participates at some point in his or her training in the Aliki Initiative. These medical residents then carry what they learn to all other experiences, including the other general medical services and intensive care units.

“So basically, the Aliki experience touches every internal medicine house officer here at Bayview,” says cardiologist Roy Ziegelstein, who is co-director of the program. “If you think about it that way, the Aliki Initiative has permeated the entire teaching service and affected all patients admitted to the Department of Medicine over the past 10 years.”

And Ziegelstein doesn’t stop there: “I would say the impact is even greater than 100,000 patients,” he says. “Because the graduates who leave our residency programs take with them what they’ve learned to other institutions and practice settings. So the true number of patients impacted is almost impossible to estimate.”

2. New collaborations have broadened the Aliki Initiative’s impact on medical education
“An important part of knowing a patient as an individual is understanding his or her spiritual needs as well,” notes Cynthia Rand, a professor of medicine and also co-director of the Aliki Initiative. Toward that end, members of the chaplaincy trainee program at Bayview have begun serving on the Aliki team, together with medical residents. “It’s a natural alliance for a program that is focused on the whole patient,” says Rand, since chaplaincy trainees – who talk closely with patients about their spiritual concerns – gain insights into a patient’s life that can then be shared with the medical team.

More recently, components of the Aliki model were applied in the training program for medical house staff in the ICU and cardiac ICU. When patients are critically ill and often unable to communicate, their stories can get lost. Through this new initiative, trainees learn the importance of including family members when discussing the patient’s goals of care, Rand explains. Just as important, she says, “the trainees learn to document that information in the medical record so that it doesn’t get lost as the patient moves to the next point of care.”

Nursing, too, has been drawn into the Aliki program, with the addition of a “nurse attending” on the patient care team during medical rounds. Because nurses are on the front lines of patient care, “nursing has a great deal to teach the medical team,” says Rand.

3. Aliki faculty have become leaders across Johns Hopkins Medicine
Faculty members who train young doctors in the Aliki Initiative curriculum also hold important leadership positions across Johns Hopkins. Consider the case of Laura Hanyok, who completed her residency training at Bayview and now directs the faculty development program of the Aliki Initiative. She was recently appointed assistant dean for graduate medical education. She is just one of many faculty members who are extending the reach and impact of the patient-centered Aliki mission across Johns Hopkins.

“Whenever people become leaders in medical education or clinical care, they have the potential to influence how medicine is practiced and how it’s taught to the next generation of doctors,” says Ziegelstein, who himself is the vice dean for education at the school of medicine.

4. The Aliki Initiative has gained honor in Greece
Earlier this year, the prestigious Pro Bono Humanum Award was bestowed upon Aliki Perroti “for her domestic and international contribution in the fields of Health, Social Medicine and Education.” The humanitarian award, which comes under the auspices of Prix Galien Greece (an international awards program that promotes significant advances in pharmaceutical research), recognized Mrs. Perroti’s important contributions in her home country, where her philanthropy made possible the Konstantopoulio General Hospital N. Ionia and the expansion of the American Farm School.

The award also praised Mrs. Perroti for her humanitarian work abroad, specifically mentioning the Aliki Initiative at Johns Hopkins Bayview, “which places the patient at the center of medical education, research and care.”

5. The Aliki Initiative has garnered notice in leading scholarly journals
Johns Hopkins faculty members have written many articles about the initiative, which have appeared in a wide variety of important publications – including the New England Journal of Medicine. Perhaps mostly notably, Roy Ziegelstein, the Sarah Miller Coulson and Frank L. Coulson, Jr. Professor of Medicine, coined the term “personomics” in a viewpoint piece he wrote for the Journal of the American Medical Association. Noting that “precision medicine” is the leading force in medicine today, with its reliance on genomics, proteomics and other so-called “-omics”, along with big data and cutting-edge technology, he emphasized the importance of adding “personomics” to the precision medicine toolkit – the study of the unique person at the heart of the data.

“Physicians-in-training must learn all aspects of precision medicine, and they must be provided the time, opportunity and resources needed to master personomics and to understand and appreciate its importance to patient care,” he wrote.

The personomics concept has caught on well beyond strictly medical circles. In fact, Johns Hopkins University President Ronald Daniels was so taken with it that he cited personomics and Roy Ziegelstein in his universitywide commencement address last spring. While it’s important to understand the “collective evidence” in all that you examine, Daniels told the Class of 2017, “you must never lose sight of the incredible richness of the human story.”

6. The Aliki Initiative was featured in an influential book by a prize-winning author
When Kenneth Ludmerer, M.D. ’73, set out to write a prescription for fixing the system for graduate medical education, the noted medical historian turned to the Aliki Initiative as a model. As Ludmerer has written: “The Aliki Initiative is the most important innovation in graduate medical education in a generation.”

In his book, Let Me Heal: The Opportunity to Preserve Excellence in American Medical Education, Ludmerer discusses how improving resident training in the United State is key to improving our broken health care system. Key to that training, he argues, is giving young doctors the time they need to get to know their patients as people. When discussing Let Me Heal at national meetings, says Cynthia Rand, “Dr. Ludmerer has said without any hesitation that the Aliki Initiative should be adopted by every hospital and medical school in the country.”

7. Hospitals and programs across the country have adopted elements of the Aliki Initiative
The Aliki curriculum is publicly available online through the MedEd Portal, making it widely accessible to medical training programs everywhere. In addition, Aliki faculty leaders and alumni are frequently called upon to give talks at leading medical conferences. Among those institutions that have already incorporated parts of the Aliki curriculum are the University of Virginia and Brown University. Aliki concepts have also been presented (or will soon be presented) at Grand Rounds at New York University, Yale University, Stanford University, Brown University, the University of Virginia and at Johns Hopkins All Children’s Hospital in Florida.

8. The Aliki Initiative has achieved a global reach with patients
Over the 10 years of the program, Aliki graduates have gone on to serve as doctors at hospitals and academic medical centers across the country – from Maine to California – and around the globe: in far-flung locations, including Nepal, South Africa and Thailand. Wherever they go, Aliki alumni take the patient-centric model they trained under with them to share with colleagues and to call upon in their care of patients.

9. Numbers speak to the success of the Aliki Initiative
Medical students, residents and patients uniformly give high evaluations to the program. In addition:

•  99 percent of graduates report that the lessons of Aliki last for years beyond training.
• Patients with heart failure who were treated on the Aliki Initiative team were 71 percent less likely to be readmitted within 30 days of discharge than their counterparts.

10. Aliki Scholars are pushing to advance and broaden the impact of the Aliki Initiative
Aliki Scholars are an integral part of the Aliki mission – a cadre of 18 doctors serve as attending physicians on the Aliki Service at Bayview. In addition to overseeing training and education for medical residents and medical students, the Aliki Scholars also meet four times a year to discuss and brainstorm ideas for new innovations in patient-centered care. Thanks to the fresh thinking, commitment and energy of the Aliki Scholars, we can rest assured that the Aliki Initiative will reach new and even greater heights over the next 10 years.

Don Willett November 11th, 2017

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Building Resiliency as We Age

Building Resiliency as We Age

We all know older friends or family members who find themselves in need of a serious medical procedure. For some, it’s a hip replacement. For others, it’s cardiac surgery or a cancer-related treatment.

Most sail through these procedures and make a quick and resilient recovery. For others, recovery is slow and they don’t bounce back. Sometimes a cascade of complications follows.

Why are some older people more resilient than others? That’s the question that geriatrician Jeremy Walston, the Raymond and Anna Lublin Professor of Geriatric Medicine, and his team at Johns Hopkins Bayview Medical Center have set out to explore, under a new five-year $11.5 million grant from the National Institutes of Health (NIH).

“This grant will allow us to identify the biological underpinnings of resilience, which we believe are related to the stress response systems in the body,” explains Walston, who co-directs the Biology of Healthy Aging program at Bayview. “Someone who is resilient is more likely to have more stable and less easily broken down stress responses during a stressful period.”

Walston and his team will soon be recruiting older patients who are undergoing one of three medical procedures: hip replacement, hemodialysis (for chronic kidney disease) or bone marrow transplant (for hematological cancer).

“Some of these patients will do very well, while others will suffer many complications. We aim to study both groups and identify subsets of biological differences between them,” says Walston.

If the researchers can identify biological markers for resiliency, doctors will be able to figure out in advance which patients might be more susceptible to complications – and take preventive measures to ward off those problems.

Walston believes that an overactive inflammatory system may be involved. “If we do find the inflammatory system is over-responsive in those who are less resilient, we could potentially develop methods to modify that response in susceptible patients before they undergo the medical procedure,” he says.

He is in fact already working toward that goal of developing a suitable treatment for chronic inflammation – thanks in part through funding from philanthropist Charles H. Salisbury, Jr., a Center for Innovative Medicine International Advisory Board Member, and his wife Bunny Salisbury (see sidebar).

Ultimately, identifying the biological underpinnings of resilience could have a dramatic impact on improving the quality of life for all older people. The long-term goal, says Walston, is to keep these stress response systems intact and operating normally as we age. “Through this research, we hope to help people live longer, healthier lives – and to help them bounce back quickly if and when a medical problem does crop up.”

Don Willett November 11th, 2017

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Making Space for Big Ideas

Making Space for Big Ideas

Folly Farm is just 22 miles from downtown Baltimore, but with its rolling green fields and lush trees, the 100-acre rural villa feels worlds away. And that’s precisely why Stephanie Cooper Greenberg and husband Erwin L. Greenberg graciously opened their home on August 31 to host the Center for Innovative Medicine’s third annual retreat.

“We’re able to offer a rural setting that’s beautiful and calming, where you can breathe the country air. That’s when the ideas can start to flow!” says Cooper Greenberg, who is chair of CIM’s International Advisory Board.

Indeed, with more than 70 people participating from across Johns Hopkins’ vast enterprise – representing the fields of medicine, nursing, public health and more – the retreat offered an unparalleled opportunity to trade ideas and share thoughts about how Johns Hopkins can achieve greatness as a public trust over the next several years.

“In our busy lives, we tend to go from meeting to meeting, sticking to our own departments and staying in our own silos,” says Johns Hopkins Hospital President Redonda G. Miller, who led the retreat this year. “To have people from different schools and different disciplines, all sitting together in the same room thinking and talking about key issues … that was absolutely invaluable.”

The Greenbergs first hosted the CIM retreat in summer 2015. There were 50 people on the guest list, Cooper Greenberg recalls. “It took our breath away – to see people from so many Johns Hopkins disciplines who were so eager to engage with one another and work across departments, diseases and boundaries. My immediate thought was: We need to make this an annual event.”

The theme for this year’s retreat was inspired by the hit musical Hamilton – the song “History Has Its Eyes on Us” and the lyrics, “The Room Where It All Happened.” As Cooper Greenberg and CIM Director David Hellmann noted in their invitation to the retreat, “With history’s eyes on us, let’s aim high and enjoy. Let’s be in ‘the room where it all happened!’”

And indeed, a lot did happen during the nearly daylong event, which started with an early breakfast and stretched into the afternoon. The retreat featured an opening perspective by Sarah Hemminger, founder and CEO of Baltimore’s Thread, Inc., which engages underperforming high school students by connecting each one with an extended “family” of committed volunteers – up to five volunteers per student – for nearly 10 years.

Launched in 2004, Thread is already changing the fabric of Baltimore, Hemminger noted: 87 percent of students who have been in Thread for five years have graduated from high school and 84 percent have been accepted to college. It’s worth noting that many of the 800-plus volunteers in Thread have Johns Hopkins connections – as students, faculty members and alumni.

Those at the retreat also heard from Mercedes Ferandes, a recent graduate of the MERIT Health Leadership Academy, which is focused on transforming underrepresented high school students in Baltimore into health care leaders. “She is only a sophomore in high school and already she has her sights set on becoming a doctor and treating HIV. She is the future,” says Cooper Greenberg.

Both presentations inspired thinking around one of the retreat’s central issues of focus: How can we better tackle health disparities within Baltimore City by embracing population health? “That’s a theme that really resonated with everyone there,” says Miller.

CIM has been a leader in partnering with community groups in Baltimore to improve health by addressing health disparities, notably by enthusiastically supporting Medicine for a Greater Good and Centro Sol. CIM’s aim now is to focus these programs and launch new ones to increase health outcomes and life expectancy for the disadvantaged who are living in the neighborhoods surrounding Johns Hopkins.

Along those lines, participants in two small groups focused on this issue. They discussed the fact that those born in poverty in Baltimore City live on average to age 61, while those with resources make it to age 82. What steps can be taken to improve the health odds of those living in poverty? While proposed solutions were wide-ranging, says Miller, most people agreed: “We need to think outside our historical model, where patients are sick and they come to us to be treated, and instead move toward preventing illness by focusing on the social determinants of health.”

Throughout the morning, retreat participants also discussed and brainstormed around two other vital issues:

• Precision medicine, and how it can be harnessed to improve patient outcomes by meeting a specific unmet medical need.
• How CIM can build on its leadership in recognizing, defining and rewarding “great doctors” at the senior level (through the Miller Coulson Academy for Clinical Excellence) by creating a pathway for clinical excellence for physicians during their first five years at Johns Hopkins. Among other questions discussed: “Could support for great clinicians be embedded in the development of service line models?” And, “What are we currently doing to identify individuals early on who will grow to become clinicians with distinction?”

As she sat in on small-group sessions and the full group wrap-up, Cooper Greenberg says that the spirit of synergy that filled the room was overwhelming. “It’s a really collaborative environment,” she says. “No one over speaks or steals the spotlight. People really listen to one another.”

Miller agrees and says she can’t wait to attend the retreat again next year. “It’s so energizing,” she says. “The CIM retreat creates a safe space to think outside the box – and to share thoughts that could be considered controversial or even crazy.

“If you’re going to have a big idea,” she says, “you need that kind of space.”

Don Willett November 11th, 2017

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