Dr. Priya Mammen is an emergency room physician at Thomas Jefferson University Hospital and a member of the Mayor’s Opioid Task Force. Dr. Mammen talked with PPR as part of our series on the Philadelphia Opioid Crisis. Interview has been edited for length and clarity.
Penn Political Review: Can you tell me a little about your background, how you got involved in this issue?
Dr. Mammen: In terms of the opioid epidemic, I think you would be hard pressed to find any emergency physician across the country who has not been a witness to the whole thing, depending how far into your career you are. I was educated and trained during the era where everybody was told it’s cruel and unusual punishment to not treat people’s pain. It was absolutely part of what we should be doing, in addition to addressing if someone has tachycardia, or fast heart rate, or a hard time breathing, or a fever; the same approach should be to how much pain they are in. ED’s (emergency departments) are a reflection of the community; we were the ones who started to raise the red flag 10-12 years ago, noticing how prevalent opioid prescribing was. Patients were coming to the ED wanting a refill of their medication, or having chronic pain issues, and then ramping up to being more aggressive or demanding of the emergency department. We were seeing it become more and more of a problem. As the epidemic progressed, it may have been most notable among prescription opiates, then it transitioned to increased deaths, increased use of heroin, all of the other negatives that follow. We’re the ones to see it first. As a group, emergency physicians have brought attention to this from the get-go. And now everybody else is seeing what we have been living for over a decade.
PPR: Right now, how do you interact most directly with people who have overdosed? How many people come into your emergency room, and what is your protocol when you get someone who has overdosed?
PR: We were seeing more straight overdose come in, and we had to completely resuscitate them. They would come in not breathing, may or may not have had a good heart rate. Before it was so common, we treated everybody the same. Part of that was to give Narcan and check for any reversible causes. Now they’re getting Narcan in the field from the EMS, the ambulance or the police, so when they come to us they’re already awake for the most part. They may not be completely awake if they have other drugs on board. Or they could be the other level, really, really, angry because one, they’re high, and two, they’re in active withdrawal from the Narcan. So we see the whole gamut.
PPR: How long does someone usually stay with you if they come in for overdose?
PR: A lot of people who are reversed want to leave immediately. If we are reversing them in the emergency room, if they haven’t been reversed in the field, we try to do it gently, making sure they’re breathing, and then giving them Narcan more slowly so they don’t go into immediate withdrawal and we can watch them longer. We try to watch them at least 90 minutes, because as the Narcan wears off, depending what is on board, they could go back under. Fentanyl requires higher doses of Narcan. So ideally you can watch them for that long. We also use that time to try to engage them in terms of their opioid use disorder, or any kind of treatment options they have done already or seek out. It doesn’t always happen.
PPR: Right. Do you also do the Warm Handoff program, if they’re interested in treatment?
PR: I’ve been working to streamline Warm Handoff for two years. It hasn’t been as successful in being able to get the program ramped up, but we’re starting the process. The key to the warm handoff is not just our side, but having people who will take them, and having them easily accessible and immediately available. We’re still working to have someone immediately available, or very quickly available, to talk to the patients directly. All over the city, emergency departments have tried to have Warm Handoff programs, but it’s a little slower to get going. But it’s a process for sure.
PPR: What percentage of people are open to treatment when they come in from an overdose?
PR: It’s a pretty small percentage, honestly. We try to have a discussion with everybody. A lot of people deny it’s a true, true problem, even though they’ve just been reversed from a near fatal overdose. Some people feel they can just stop on their own. As a rough estimate, 20-25 % will say in the moment, ‘Yes, I want something.’ The key point of Warm Handoff is that someone is going to engage the patient even after they leave, because in that space, they’re not really thinking right. They’ve had a pretty scary event. They may or may not be in some degree of withdrawal. We understand opiate addiction is a whole chemical process; their physiology has changed. They are responding to a lot of internal processes, stimulation and feedback that is not allowing them to think clearly. What we want is to be able to make that connection and then be able to re-engage that same patient in a couple days when they’re not in this same intense experience in the emergency room.
PPR: In terms of the numbers of people you see coming into your emergency room, is it getting better or worse right now? How is that trajectory looking?
PR: What’s getting better is that people are coming in reversed. Increased availability of Naloxone and Narcan in the community is huge. EMS has it; police in the highest risk areas of the city all carry it. And we’ve done a concerted effort to prescribe Narcan for people, to have it very easily available. There’s always room for improvement, but the increased use of Narcan outside of the hospital has made it so we’re not bringing people back to life in the emergency department. What happens with that…[a patient] is not breathing…somebody calls the ambulance, the ambulance arrives…they’re not breathing…no matter the fact that it was initially reversible, over time, if your brain and heart are not getting oxygen, you can’t really be resuscitated effectively. So the fact that they can be revived in the field and arrive with some degree of being awake, or at least not in a life-threatening situation immediately has helped a lot. In terms of sheer numbers…I can’t say in terms of specific numbers but it pretty much has been the same if not a tiny bit worse.
PPR: So if there’s someone who doesn’t have insurance, doesn’t have ID, do they have any decent options? What would you tell someone who’s saying they want treatment, but they don’t have those two things?
PR: The not having insurance is not necessarily the biggest barrier. In fact, some private insurances make it harder to get treatment because they have very specific options. Not having ID is even surmountable because there are social workers and organizations like corrections that, one of the things they do is help people get ID so they can have access. It’s just all of it together. For any individual it could be any five things, and for another individual it could be seven other things that could be a barrier. So we really engage our social workers and case managers to help us out. But here again is where the Warm Handoff process–someone, whether it’s a certified recovery specialist, or peer or even just a treatment program being very engaged right from the beginning can take a lot of those questions and uncertainties out of the picture.
PPR I want to touch on your role on the mayor’s task force. Could you tell me what that process was like?
PR: I was certainly very proud to be a part of it. It was a really powerful experience of people from all over the city from a very wide background, and different experiences and perspectives on the same issue, coming together and talking it through. My perspective as an emergency physician was very different from police perspective or fire perspective or someone who has lived the process. But all of those voices were important and equal to come together and try to come up with some focus areas where we thought we could make an impact without being too esoteric. I think the process of having so many different voices at the same table, and really bringing all those perspectives and experiences and realities to address something that is so multi-factorial is critical. If we approach it from just one perspective, it doesn’t take into account all the other things. There are people whose work is in housing, and food security…every little piece of it plays into the epidemic. It certainly plays into how accessible and how we make treatment options, and how we approach it in terms of stigma. From that vantage it was a very amazing experience.
Ultimately the report gives the full spectrum without being too onerous, which can easily happen. There are so many different things you have to address with any epidemic, and this one in particular. It’s not as easy as finding a vaccine and fixing it. It’s human behavior, it’s physiology, it’s our social determinants of health and all of the intricacies of the health system, and the penal system, and all of the rest came together.
PPR: Looking at all those recommendations, what do you think a student like me, or Penn as an institution, can do to play a role in solving this crisis?
PR: One of the bigger things is affecting stigma. I’m hoping that we’re coming into a new era, and I think just by definition of the way things have been addressing as a community, as a city, as a country the opioid epidemic is very different than how we have dealt with other drug epidemics in the past. I think there are some cynical perspectives on why that is, but definitely in the past we’ve had such things as crack epidemics, and they were not addressed in this kind of way. So the positive way of looking at it is that we just have a greater understanding of what addiction is and what chemical dependence is and it’s not just someone’s poor choices. There’s a point where things just take over, where physiology and chemistry take over. Reducing the stigma overall and increasing awareness overall are probably the most effective things to be able to have someone ask for help or be ready for help… trying to take away the shame of it and keep the concern, and making it easy for everyone to say ‘Yes, I can identify a problem, I acknowledge a problem, and here’s where it’s easy for me to get information or get services or get plugged into the system.’ There’s no question the stigma part of it adds to, from where I sit my biggest concern, is overdose deaths. I work in the life and death situations in the emergency department, and that’s most salient to me. The stigma leads into that.
Also, being aware of Narcan, having it available just because. Rachel Levine, the physician general of Pennsylvania, has said every pharmacy across the state should be able to dispense Narcan and you can walk in and get it, you don’t need a prescription. All of those things play into making sure that anybody who needs it has it, they don’t have to jump through hoops. But I would also say it doesn’t hurt for anybody who doesn’t have an opioid use disorder, doesn’t use or abuse prescription opioids or heroin or any of the rest of it, you can have Narcan with you, and administer it to someone. It doesn’t hurt someone, and it only works in the setting of an opium overdose or something like that. So that’s bringing it outside the medical realm, outside the treatment realm, outside of these not necessarily siloed areas but really making it accessible along all routes and accessible in the community and not thought of as just a horrible thing that reflects poorly on the person or family or community but just another thing we all have to be vigilant for, and really work to try to help people.
PPR: Thank you so much, Dr. Mammen.