How opioid addiction is changing health care at the University of Kentucky
In 2009, the University of Kentucky’s Chandler Hospital and Good Samaritan Hospital treated about 1,500 people for problems stemming from opioid addiction, ranging from overdoses to blood infections to Hepatitis C. The cost of those treatments: $7.6 million.
By 2018, the number of patients treated for problems caused by opioid addiction had skyrocketed 481 percent to 8,782 and the cost had soared 733 percent to $63.3 million.
The total cost of treating opioid addiction at the two hospitals over the entire decade was $264 million, according to data compiled by UK at the request of the Herald-Leader. About 54 percent of those costs are paid by Medicaid; another 19 percent is paid by Medicare and the rest by private insurers or the patient.
The numbers, while jaw-dropping, are just one small but instructive sliver of the real cost this epidemic is demanding of state and federal coffers as it decimates Kentucky families and communities with one of the highest overdose death rates in the nation.
“This is just the tip of the iceberg,” said Sharon Walsh, executive director of the UK Center for Drug and Alcohol Research.
For example, figures from the Kentucky Cabinet for Health and Family Service show that 63,000 Kentucky Medicaid patients were diagnosed with opioid use disorder in 2018. The agency estimates the annual per capita cost to treat each of those patients tops $15,000. Using a conservative estimate, that’s almost $1 billion a year from federal and state coffers.
For UK, which serves as the regional hub for complex medical care for the eastern half of the state, the opioid crisis has affected nearly every facet of health care delivery, from rethinking pain control protocols to reworking how the emergency room operates. (Many doctors now recognize that the crisis was fueled by the over-prescription of pain pills that turned out to be far more addictive than they realized.)
None of these changes are cheap. For example, UK opened a special neonatal intensive care area for babies born addicted to opioids. They now stay longer in the hospital with their moms, which is a big expense. From 2009 to 2015, the annual costs for neonatal abstinence syndrome went from about $1.4 million to more than $6.1 million. In recent years, that number has dropped slightly.
“It’s a cost we’re putting in because we think it will help in providing better care to meet their needs,” said Phillip Chang, a UK surgeon and the Chief Medical Officer for UK HealthCare. “They’re staying in hospital longer, but by putting more resources on the front end, I’m hopeful the cost can come down.”
UK has big plans to figure out which strategies work best. On Thursday, it was awarded an $87 million grant that aims to lower opioid deaths in 16 Kentucky counties by 40 percent in three years. In 2017, 1,565 people in Kentucky died from drug overdoses.
Hard to quantify
Ethan Hawes, 26, is in recovery from opioid use disorder and recently finished his treatment at UK for Hepatitis C, which he estimates cost about $20,000.
Hepatitis C is one of the most widespread problems related to opioid use disorder. It’s a highly durable virus, spread through needles, that can cause liver disease and cancer. According to one study, an infected needle could sit at room temperature for six weeks and still be infectious. The virus is largely asymptomatic, so someone might not know anything is wrong until they start showing signs of liver disease later in life. It’s also curable, but the required drugs usually cost tens of thousands of dollars per person.
Since 2009, the number of UK patients diagnosed with opioid use and Hep C ballooned from 121 to 1,302. In 2018, the cost of treating Hep C in drug users at UK topped $10 million.
Hawes was able to get treatment for his opioid use disorder through the expansion of Medicaid under the Affordable Care Act. It also enabled him to get comprehensive treatment for opioid-related problems at UK, including his HIV infection.
He’s treated at the Bluegrass Clinic, one of four federally-funded Ryan White HIV/AIDS clinics in Kentucky. There he receives comprehensive care for HIV, which used to be a death sentence, but is now largely manageable through medication, and where he got the medication for his now cured Hep C. He also could have received medication assisted therapy for his opioid use disorder, although he has chosen abstinence with the help of peer support groups.
He thinks the comprehensive care he received at UK saved his life.
“Regardless of what our opinions are about drug users, harm reduction saves lives and money,” Hawes said. “There’s too many limitations based on stigma instead of science.
“The silver lining is that this death and loss and despair will be the thing that motivates us to make different decisions,” Hawes said.
UK researcher Jennifer Havens works on Hep C research in Eastern Kentucky, which has some of the highest rates in the country. She recently got a $15 million federal grant, with $50 million in drugs, to completely eradicate Hep C in Perry County through a combination of testing, counseling, needles exchanges, drug treatment and job and housing placements.
“There is really a high level of apathy about the infection, especially among our young drug users,” Havens said. “The course of the disease is so long, it’s hard for them to grasp the potential seriousness of the disease.”
Syringe exchanges can help stem the disease, and Kentucky has more than 30 exchanges in local communities, but elected officials continue to block them in many parts of the state.
“It just goes to show you how out of touch politicians are with the things that matter to everyday Kentuckians,” Hawes said.
UK’s emergency department has seen huge changes in the wake of the opioid crisis, said department chairman Roger Humphries.
First, there was an attitude shift. Doctors who were once suspicious about people coming to the emergency room to get a fix with pain pills have had to change their attitudes.
“Because this problem is so severe, we’ve realized over time that’s not the right approach,” Humphries said. “You have a disease, it needs to be recognized ... it’s been a paradigm shift because we tend to think of opioid use disorder as the patient’s fault ... we’re not going to make any progress if we continue with the old mindset.”
The emergency room now refers patients who come in after overdosing or with obvious problems to the UK Bridge Clinic at the Center for Drug and Alcohol Research, which can get them stabilized with medication assisted therapy, such as buprenorphine, and counseling and other resources. It’s often hard, though, to convince patients to accept a referral for treatment, especially those who have just been revived from an overdose with naloxone and put into deep withdrawal. They feel awful, and treatment may be the last thing on their minds.
“It’s not about getting high,” Humphries said. “It’s how do I get this awful flu-like feeling to stop?”
Emergency room doctors also can give patients buprenorphine, which can ease withdrawal symptoms and stabilize patients.
That’s a major mindset change, Humphries said. Many doctors have considered medication assisted therapy to be simply exchanging one drug for another. Buprenorphine can be diverted and abused on the street, and some question if long-term use is financially sustainable. But for Humphries, the matter is simple: “This will decrease the chance they will die of an overdose. They can re-enter society, take care of a family.”
Doctors have also realized the emergency room can be a front door to preventative health care needed in the opioid crisis. Dr. Daniel Moore got a grant to test UK emergency room patients for Hep C if their blood is already being drawn. Between July 2018 and today, 14,500 tests were done and about 10.8 percent of them were positive for having had the virus at some point. Roughly 52 percent of the positive tests had a current chronic infection and most of them are younger than 54.
“These patients don’t go to primary care, so they can tell us a lot about this public health issue,” Moore said. “It’s a massive public health problem that we’re identifying.”
Moore said most health care has been immediately focused on overdoses, but there are plenty of secondary and tertiary problems lurking in the future.
“This is much bigger of a problem than we have known,” he said. “Untreated HEP C will cost Kentucky billions of dollars if it goes unchecked.”
Medication Assisted Therapy
Medication assisted therapy is being used more often throughout the hospital, in part, thanks to the work of Laura Fanucchi, an infectious disease specialist who works in addiction medicine. But it’s still not considered part of standard care.
“For a long time, treatment of opioid use disorder was not really integrated well in general medical settings, hospitals or primary care,” she said. “As the opioid epidemic has worsened, we’ve started to provide evidence-based treatment for the disorder in the hospital. It’s a chronic medical illness so why would we not integrate it into primary care?”
Fanucchi has started an in-patient addiction consulting pilot program that tries to treat patients for their underlying opioid use disorder at the same time they’re being treated for what brought them to the hospital. She hopes to expand to the entire hospital throughout the year.
For example, endocarditis is a serious infection of the heart’s lining and valves. It is often caused by the dirty needles addicts use to inject various forms of opioids. At UK, 293 patients with opioid use disorder were treated for the malady in 2018 at a cost of $9.8 million. It requires weeks of intravenous antibiotics and can sometimes require surgery to replace heart valves.
Those patients, though, were often treated for endocarditis without being treated for the opioid use disorder that caused it, and patients who went into withdrawal might discharge themselves before antibiotic treatment was finished, risking recurrence.
Now, Fanucchi and her team will do a complete assessment of such patients and offer medication assisted therapy. They would also link that patient with UK’s First Bridge clinic, or if they live further away, connect them with residential treatment facilities. They also provide patients and their families with a naloxone overdose reversal kit.
“I think, overall, providing evidence-based treatment should decrease costs,” Fanucchi said. “People are not dying, not developing repeat infections, and entering treatment. When people are in treatment they are better able to meet their individual goals in life and ultimately work and participate in family life.”
Bethany Wilson would agree. Now three years in recovery, she spent almost three months in the hospital recovering from endocarditis that she contracted while using drugs. Despite almost dying on the operating table, she didn’t stop using completely until she was pregnant and entered the Pathways program at UK.
“I think MAT (medication assisted therapy) and counseling need to be more available outside of UK,” in rural areas where the crisis is even worse, Wilson said.
She now works with AVOL (AIDS Volunteers of Lexington), where she helps with testing and education for patients, many of whom have opioid use disorder.
“If you’re in a program with MAT, you’re not shooting up drugs,” Wilson said. “Then you’re not getting these other problems like endocarditis, Hep C or HIV, and you can work and take care of your kids.”
Medication assisted therapy will be a major push of the new federal grant that UK just received. Allen Brenzel, medical director for the Kentucky Department of Behavioral Health, said the state is trying to get more primary care doctors to prescribe drugs like buprenorphine, rather than waiting until they’ve gone to an emergency room with a life-threatening and highly expensive problem.
One potential complication, though, is that many people seeking treatment at UK have numerous drugs in their system, including the increasing presence of methamphetamines. There is no medical solution for meth addiction, which is why other resources, such as counseling and peer-supported abstinence programs, remain important parts of the puzzle that UK and others are trying to solve.
“I’m hopeful,” Brenzel said. “I think we’re turning the corner in keeping people alive.”
About the data
The numbers provided by UK only account for in-patient and out-patient treatment at UK Chandler Hospital and UK HealthCare Good Samaritan Hospital and includes only those patients whose billing codes included opioids. They don’t include UK physician visits or the numerous clinics and programs where doctors and counselors work with substance abuse disorder patients. So, for example, the numbers include mothers who have babies born with neonatal abstinence syndrome, but not participants in UK’s Pathways program, which helps expectant moms who have opioid use disorder with medication and therapy before birth so babies have fewer complications afterwards.
In addition, billing codes are an imperfect way to track opioid use disorder because many physicians might not include it as part of a diagnosis if a patient is seeing them for a seemingly unrelated disorder.