Eight months ago, 35-year old Adam Smith (name changed to protect the patient’s identity) was living in his car in Houston, dealing with the fallout from opioid use disorder (i.e., addiction). Even after years of seeking help, he was struggling to pick up the pieces after spending time in jail, ruining relationships, being let go from jobs and losing homes. Adam is one of more than two million people dealing with opioid use disorder, a devastating brain disease with negative consequences to individuals, as well as their families and communities.
Adam was fortunate to have been connected to HEROES, a proactive treatment program, and has been sober ever since “¦ but not everyone is so lucky. Numbers from the Centers for Disease Control and Prevention show more than 130 people die every day from opioid overdose. Many of those fatalities start with a call to 9-1-1 for help following an overdose, making EMS a key player in the epidemic.
Challenges in Treatment
The challenge is that the current healthcare landscape has uneven accessibility; patients with overdoses have no arranged follow-up care, requiring individuals to seek treatment voluntarily on their own. The system of care is difficult to navigate, resources are limited, waitlists are long, and accessing care is almost impossible in some situations. A recent study shows that there are significant disparities in the availability of opioid treatment providers across the U.S.1
Despite this dark picture, there is good news. EMS, police, public health agencies, government entities, healthcare providers and other community partners are all looking for viable solutions to change and implement alternative care coordination strategies. The key is to get all these organizations working together across communities.
The HEROES Solution
The Houston Emergency Response Opioid Engagement System (HEROES) is one of the initiatives that’s taking on the challenge. HEROES aims to save lives, provide comprehensive treatment for opioid abusers, gain a more thorough understanding of the epidemic in Houston, and develop a coordinated system of care. The program was developed by The University of Texas Health Science Center at Houston (UTHealth), in partnership with multiple community organizations including the Houston Fire Department, Houston Police Department, Houston Recovery Center, and Memorial Hermann Hospital. The communitywide collaboration also includes public health, social services and substance treatment providers.
Last year alone there were just over 275 opioid-related deaths in Houston, and similar to many regions, mortality is increasing. In most cities, there are no coordinated programs actively reaching out to survivors to connect them to appropriate care. Figure 1 shows the program design.
Assertive Outreach
One innovation of the HEROES program is its use of the first responders, both to provide up-to-date surveillance data and to practice “assertive outreach” through community paramedicine to reach individuals who have overdosed or are high risk. Each week, information from EMS about individuals who have been revived with a naloxone intervention serve as data to drive outreach efforts. A quick response team, comprised of a paramedic paired with a peer recovery coach, knock on doors and walk through neighborhoods to locate and connect with these high-risk individuals, rather than waiting for them to present on their own to treatment.
This approach is based on cognitive theories of change suggesting there is a greater readiness for behavioral change during sentinel periods or life events. Motivational interviewing is used to establish rapport and to help individuals make a positive decision to start treatment and enter recovery.
Those afflicted with opioid use disorder who experience an overdose may be at higher levels of treatment readiness and commitment to change. Connecting with these individuals allows for conversations about risk, need, motivation and available treatment options.
There’s strong evidence that using a peer outreach model is an effective strategy. Peer recovery coaches can establish a rapport with prospective participants based on shared knowledge and understanding of a lifestyle of opioid use, engage in brief informational interventions and work with other familiar treatment and service providers in the target community.
The program in Houston is primarily funded by the Texas Targeted Opioid Response program, which is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA).
Medication-Assisted Recovery
Once the patient is engaged, treatment involves early induction, sometimes same-day induction, to medication-assisted treatment (MAT) with an opioid agonist medication (buprenorphine) that suppresses withdrawal and cravings and is less susceptible to overuse and addiction. This type of medication therapy is one of the most effective tools for opioid use disorders and has been shown to decrease the risk of overdose. There’s a growing consensus that providing rapid initiation of medication therapy to active users of opioids has a higher overall success rate than physically detoxing without assistance or going “cold turkey.”
Building on this knowledge, Yale University was the first to document in JAMA that getting an opioid-dependent patient started on medication-assisted treatment directly in the ED doubled the odds of a patient remaining successfully in outpatient addiction treatment and recovery for longer periods.2
HEROES was inspired by this model and expanded upon it. In addition to providing induction of buprenorphine in the ED, referrals are seen by an emergency physician who has undergone special training and is licensed or waivered, as termed by the Drug Enforcement Agency, to write a prescription for buprenorphine/naloxone medication. The initiation of medication therapy through a short-term prescription serves as a temporary bridge until the HEROES staff can assist in linking the individual to more permanent, outpatient treatment with community providers.
Comprehensive Treatment
As medication therapy helps the individual transition away from active opioid use, the patient is now able to focus on actively addressing the disease of addiction through the other aspects of the HEROES program, including peer recovery coaching, behavioral counseling, peer support groups and psychoeducational sessions. Figure 2 shows the intervention team’s components.
Enrolled individuals are provided ongoing certified peer recovery coaching, weekly individual professional behavioral counseling, and biweekly educational and support group sessions. Additionally, individuals are linked to ongoing outpatient medication therapy in the community and can be connected to other local resources if they are assessed as having other needs such as housing, legal or mental health.
HEROES staff members with knowledge about available resources and providers can assist the patient in navigating a fragmented system and eliminate some of the barriers encountered when seeking treatment. The objective is to attempt to connect some of the previously disjointed elements of care and offer holistic and inclusive treatment to enroll and engage opioid-dependent patients long-term.
Enrollment
Opioid-dependent individuals–including those who overdose, are in withdrawal or simply have a willingness to stop–are eligible to join the HEROES program. At inception, entry into the program would be offered when opioid-dependent individuals presented at the ED for an overdose or withdrawal symptoms. Additional referral and entry points, such as engagement through proactive outreach, have since been added.
Another route into HEROES arises from a grant-funded partnership with the local police department. This joint initiative helps opioid-dependent individuals that law enforcement has encountered to learn about the option to initiate same day treatment. Simultaneously, it allows an opportunity for officers to gather information about drug dealers to fight the opioid epidemic from both sides of the equation. Community providers, such as Outreach, Screening, Assessment, and Referral (OSAR) centers, are also able to refer individuals to the HEROES program. Additionally, people who have heard about the program from family, friends, the local news coverage, or from their own searching and research can enter the program via a self-referral process.
Measuring Success
The growth of the program during the last 12 months has been very rapid. Over 750 individuals have been contacted through outreach or participated in some form of services, while 225 have enrolled in the comprehensive treatment program.
Ultimately, the program’s success will be determined by measuring how long patients stay in recovery and how many lives are saved. Currently within the program, greater than 80% of patients have stayed sober and active in recovery for the first 30 days after enrollment, which is highly significant given the extremely high rates of relapse for this disease.
Real-time data and assertive outreach can guide patient identification and create opportunities to engage individuals earlier in the cycle. Being able to connect individuals with immediate access to treatment when they are motivated to change reduces the current gap between making a choice to enter treatment and being able to actually access treatment, thus reducing the amount of risk and decreasing negative outcomes associated with continued use of opioids.
Driven By Analytics
Comprehensive data on overdoses and deaths helps to drive outreach efforts. Geospatial modeling and real-time analytics provide insight into neighborhoods with high opioid use activity and present a roadmap for a concentration of resources. Figure 3 shows an example of a neighborhood cluster heat map for potential overdoses that helps guide efforts. Data for these analyses come from a variety of sources collected and analyzed by the team. Similar maps are used to examine mortality.
The hope is that future grants and funding will enable HEROES to expand the number of sites and partners that work together, develop an extensive telehealth recovery network and enhance social media peer-to-peer recovery tools. The multifaceted goal is to both save lives and to change the public health landscape of treating opioid use disorders.
Conclusion
HEROES prides itself on three things: 1) courage; 2) choice; 3) and collaboration. It takes courage to decide to make a change, and even more courage to both ask for and accept help. People are empowered to believe that the ability to make different, healthier choices is possible with the right treatment and support. The collaboration from numerous community partners and stakeholders to provide comprehensive medical and behavioral interventions creates the possibility of success and positive outcomes. It has been through these partnerships that the program has proven to be an effective way to continue saving lives that otherwise could have been lost to the depths of addiction.
References
1. Langabeer J, Gourishankar A, Chamber K, et al. Disparities between U.S. opioid overdose deaths and treatment capacity: A geospatial and descriptive analysis. J Addict Med. March 4, 2019. [Epub ahead of print.] doi: 10.1097/ADM.0000000000000523
2. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department—initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA. 2015;313(16):1636—1644. doi:10.1001/jama.2015.3474
