Managing the opioid epidemic with mobile integrated healthcare programs
A recent meeting between police and recovering addicts provided fascinating insight into the great extent of the opioid epidemic. Most of the dozen or so officers in the workgroup shared that the epidemic had an impact on their personal lives. One detective shared that her colleagues, burned out from too many overdose responses, had verbally attacked her son when he was arrested for heroin use and possession. They told him he was a “scumbag” and an embarrassment to his mother. According to the detective, her son was neither-he was simply an addict.
The recovering addicts in the meeting had all become advocates of recovery, dedicated to helping others through the process of getting and staying clean. In addition to their addiction, they shared another common trait: They had all been resuscitated with naloxone multiple times before they sought out the help they needed. Each participant described how they had been “narcanned” at least three and sometimes up to seven times.
All of them had also personally experienced the blunt end of police and EMS burnout: They were resuscitated, then insulted.
The magnitude of the opioid epidemic is unprecedented and growing. (See Figure 1) If EMS agencies are going to play a role in their communities’ response to the threat, we’ll need to change in order to meet the challenge. Fortunately, the evolution of mobile integrated healthcare and community paramedicine (MIH-CP) programs has put our systems in a better position to help. Here are some examples of and ideas about how your agency can do more than just administer naloxone to overdose patients.
Figure 1: Overdose deaths involving opioids, United States, 2000-2015
Resuscitation Isn’t the Goal
Cardiac arrest saves are celebrated as a pinnacle achievement in our careers. An important metric for our success in cardiac arrest management is the rate of return of spontaneous circulation (ROSC). But the ROSC rate or the reversal of respiratory arrest alone isn’t an adequate measure of success in opioid overdoses.
Although naloxone is an effective agent for reversing the physiological effects, it has no long-term impact on the patient’s desire to use opioids again. Too often we “save” patients, only to have them leave the scene against medical advice in a fit of anger, looking for ways to obtain their next hit.
Rather than focusing our efforts solely on the reversal of the opioid and cardiovascular or respiratory resuscitation, a more effective approach expands the focus of our intervention to include opportunities to help the patients into recovery.
In the world of rehabilitation, “ROSC” is an acronym for a recovery-oriented system of care. This type of response is a more promising system focus for EMS and public safety than our current response models. The real challenge is how we transition to that new model of care.
Offer a Safe Station
Addicts trying to quit drugs and escape environments where they’re likely to use again have few options when it comes to finding immediate rehabilitation support. While working in two separate counties in Western Pennsylvania, I saw patients faking suicide attempts to get entry into rehab programs. Despite the presence of intake centers and recovery specialists in these communities, addicts often fear legal entanglement and are embarrassed to been seen entering traditional recovery centers.
One low-cost intervention that communities can implement to transition to a more effective approach comes from a model program in Manchester, N.H. In Manchester, people who want to enter recovery have a different option. All fire stations in the city have been designated as safe stations for people who want to get into recovery.1
The process starts when someone walks into the station seeking help. If firefighters determine that the patient needs immediate medical care, they call for an ambulance. Otherwise, they call a local treatment center to transport the patient directly to their facility. After hours, a certified recovery specialist or a licensed drug and alcohol counselor will talk with the patient and arrange a safe place to spend the night until they can be admitted the next morning.
If the patient has illegal substances or firearms on them when they arrive, the police are called to dispose or take possession of the materials. If the patient has an outstanding warrant for violent or serious crimes, the individual is brought to the police department to resolve the warrant, but most criminal justice matters are put “on hold” until the patient finishes their treatment.
The initiative, which launched in 2016, has already helped approximately 1,100 individuals.2 Costs associated with the program are minimal, and come from equipping each station with a disposal bin for needles and other paraphernalia.
Resuscitate, Then Navigate
The primary response to a 9-1-1 call for an overdose will always include a resuscitative focus; however, once the patient is revived, most systems have little to offer in the way of providing follow-up support. One option for communities is to provide a warm handoff from the 9-1-1 response to the systems available to help with recovery.
Provide a visit by a community paramedic (CP) and/or a certified recovery specialist after the emergency medical phase of the call ends. Patients willing to accept help could be navigated to recovery services in the community. Those unwilling or unable to quit at that moment could be offered a variety of harm reduction alternatives that encourage safer use of their drugs.
This could include, for example, CPs directing patients to locations where they can obtain clean needles, or advising the patient, their friends and family members on techniques to minimize the likelihood of dying from an overdose (e.g., educate them on proper naloxone administration). Although more controversial, CPs could even teach the patient how to inject safely to minimize the longer-term risks of hepatitis and HIV infection.
Provide Detox Services
In many cases, the ED will still be the most appropriate venue for post-resuscitative care; however, once the medical crisis is resolved, ED staff are often left with few options for longer-term support-other than providing pamphlets when the patient is discharged. A third model for responding to the opioid crisis is to mirror the efforts of MIH-CP programs that navigate patients to the most appropriate venue for their care.
A program in Palm Beach, Fla., is offering a promising alternative that begins the detoxification and recovery services while the patient is in the hospital, and continues the services after the patient goes home.3 The detox process starts in the hospital with the administration of buprenorphine, which significantly increases the likelihood that a patient will successfully quit. The buprenorphine administration continues when the patient returns home, where the drug is administered daily for the following week by paramedics.
In addition to the medication, paramedics are accompanied by a peer recovery specialist who works on a longer-term plan for recovery with the patient through a network of inpatient, outpatient and community-based services. Palm Beach, which modeled their program after a similar service in New Haven, Conn., may provide a recovery-oriented system of care model for areas where traditional recovery services aren’t available immediately after an overdose.
The Vicious Cycle
As communities struggle with the opioid epidemic, a growing number of EMS agencies describe an increasing rate of provider burnout caused by treating overdose patients. If the EMS provider thinks treatment is futile, their usual compassion turns to agitation and annoyance. Many begin to believe that overdoses are a necessary risk, and a consequence of the patients’ bad choices. Their hope is that the threat of death will motivate the patient to quit their drug use.
However, more than one addict has described that the addiction to heroin quickly transitions from seeking the euphoria of the drug to using it simply to feel “normal.” As their tolerance increases, withdrawal symptoms begin sooner after their last use. The result is that patients become more dependent on the drug simply to function normally and avoid the symptoms of withdrawal.
Their dependence becomes a source of guilt and frustration as they begin to engage in riskier behaviors to sustain their addiction. To cope, they often turn to even more frequent drug use. When they finally overdose and are resuscitated by a burned-out paramedic or police officer who reminds them how worthless they are, the result is sometimes tragic. Rather than discourage future use, our burned-out colleagues’ reactions may inadvertently tap into the patient’s shame and need to use more.
Fortunately, the evolution of MIH-CP programs provide a way for our systems to break the cycle, and may provide a more effective approach to the epidemic.
1. Manchester, NH Fire Department’s Safe Stations Program. (April 5, 2017.) Addiction Policy Forum. Retrieved April 30, 2017, from www.addictionpolicy.org/single-post/safestations.
3. Capozzi J. (April 21, 2017.) Heroin epidemic: As deaths rise, program a ‘glimmer of hope’ for life. Palm Beach Post. Retrieved April 30, 2017, from www.mypalmbeachpost.com/news/heroin-epidemic-deaths-rise-program-glimmer-hope-for-life/c8ITU5Q2lJbVFfEjSZKwpK/.