How the Opioid Crisis Has Transformed Emergency Medicine at GBMC

One morning, in just a matter of hours, the Greater Baltimore Medical Center emergency room ran out of naloxone — the drug that treats opioid overdose. So many overdoses came in simultaneously that the ER’s entire 40 milligram supply vanished, explains Dr. Jeffrey Sternlicht, GBMC’s chair of emergency department services.

That’s just one way the opioid crisis has transformed emergency medicine. And Sternlicht isn’t alarmed just because he’s in the ER regularly. It goes much deeper than that.

“I really feel like I was gamed by the system,” he explains. “Big Pharma and everyone else who has made so much money [off opioids] did it off the backs of well-intended people.”

Sternlicht explains how physicians, nurses and even patients bought into the lie that opioids were not addictive — thanks, in no small part, to the Joint Commission’s 2001 pain standards, which stated as much. “We were taught to make pain a zero,” says Sternlicht — a lesson that led to prescription abuse, heroin addiction and the deadly overdoses that are the scourge of emergency rooms everywhere.

Sternlicht’s personal passion, now, is to try to reverse course.

Treating addiction in the ER

The ER is not a substance abuse treatment center, but it is on the frontlines of the opioid crisis. And new policies and procedures have transformed the services they provide.

At GBMC, says Sternlicht, most patients in the ER are now screened for substance abuse, part of the Maryland Screening, Brief Intervention, Referral to Treatment (SBIRT) program.

If someone screens positive, there are peer recovery coaches who do a brief intervention and, when appropriate, a warm handoff to an outside treatment center. Specifically for overdose patients, there’s a separate peer-based team that provides additional follow-up.

And for certain patients, explains Sternlicht, the ER at GBMC is one of a few places to administer buprenorphine — part of a medication-assisted treatment plan to help people wean off opioids.

Sternlicht was ambivalent at first, but the efficacy of buprenorphine was hard to ignore. “There are very few areas in medicine where I can decrease mortality by 60 percent,” he adds. “We’re doing that — and I’m proud of it. We’ve saved lives already.”

New ways to manage pain

Another way to reverse course is to reduce the amount of opioids in circulation. That starts with policies like not replacing lost or stolen medication, and prescribing the shortest course of opioids possible. Already, opioid prescriptions are down 15 percent in Maryland. Sternlicht estimates his own prescriptions are down by 60 percent.

That doesn’t mean patient pain has gone away. Instead, the medical community has become more creative when it comes to managing it.

Sternlicht and his colleagues are experimenting more with alternatives to opioids, called ALTOs, such as lidocaine patches, trigger point injections, ultrasound-guided nerve blocks, long-acting local anesthetics — even small doses of ketamine — as well as considering other alternative treatments like acupuncture.

“Our toolkit used to contain [over-the-counter pain relievers] and opioids,” says Sternlicht. “I look at it now as multimodal analgesia.”

Where we go from here

Despite all the policy and procedural changes, and growing public awareness, the opioid crisis is far from over. In fact, says Sternlicht, even in the best-case scenario, opioid overdose deaths will rise for several more years.

True change will require much more of the same — fewer opioid prescriptions and better treatment for addiction, as well as a new understanding of pain by patients and doctors alike. “We have pain for a reason,” says Sternlicht. “I hate to say it, but zero pain is not a reality.”

Sternlicht admits the work ahead is humbling. “I don't see this crisis ending in my career,” he says. “We have to try to act now.”