On the Front Lines of the Overdose Crisis

Melissa Killeen / The Fix
Thursday, May 19, 2016

Without a mechanism to connect the overdose patients to addiction services, Narcan creates a revolving door in emergency rooms.

Many people suffering from opioid dependence are repeatedly treated for overdose, only to return to previous patterns of use once the crisis has passed. Obviously, in many cases the next overdose is fatal. One issue is that emergency first responders and even medical professionals in emergency rooms lack the expertise needed to ensure that patients receive the kind of counseling on-site and in aftercare that can promote recovery. In keeping with the pervasive movement towards integrated care, hospitals are starting to embed recovery coaches in emergency rooms with the goals of striking while the iron is hot, in the hours following an overdose when patients may be more receptive to considering a change of lifestyle and entering ongoing treatment and recovery programs. Melissa Killeen reports on the front lines of the effort to reduce opioid overdose and death…Richard Juman, PsyD.

More than 1,000 Rhode Islanders have been brought back from the edge of death due to opioid overdose, thanks to first responders and emergency room workers, using the new lifesaving drug naloxone, or Narcan. When patients are overdosing on heroin or another opioid, first responders or emergency room nurses administer these new drugs, which will reverse an opioid overdose. The emergency department staff members use it so often it’s become a verb, as in: “We Narcaned him.” 

In 2015, a pilot program to train law enforcement officers to use Narcan prefilled syringes or nasal spray was started in the New Jersey counties of Monmouth and Ocean. It has been successful in reversing over 400 potentially fatal overdoses. Narcan kits are now available in police cars, ambulances, public transportation centers and even at your local CVS. But the growing number of overdoses has stretched the emergency department doctors and nurses to a breaking point. 

When "Narcaned" patients come to the ED, they can be angry and disorientated because when they wake up, their high is gone. Emergency rooms are handling a lot more opioid overdose patients. The number of overdoses coming to the ED has tripled in the past three years. Treating a patient recovering from an overdose can be frustrating. These patients are combative, upset, demeaning, often yelling or physically acting out. ED personnel, not trained in detox reactions, are perplexed. Also, they are being pulled away from the people who have more medically acute needs.

In a relatively short period of time, the use of Narcan is emerging as a very one-dimensional treatment. It is a lifesaver, but it doesn’t treat the problem that brings the patient into the emergency room. Kind of like using a defibrillator for a heart attack, it saves the life but it doesn’t treat heart disease. Using Narcan does not treat the disease of addiction. 

As a result, emergency room physicians, first responders and treatment experts across the country are saying the same thing, that without a mechanism to connect the overdose patients to addiction services, Narcan creates a revolving door in emergency rooms. Some addicts have returned from the edge of death four or five times, thanks to Narcan injections or nasal sprays. 

In Rhode Island, and in hospitals throughout New Hampshire, Massachusetts and New Jersey, ED doctors have called on a relatively new resource to help: the recovery coach. These coaches are not ED employees but are part of a new plan to assist ED personnel in dealing with the detoxing victims of an opioid overdose. These recovery coaches work with the detoxing patients, allowing the ED staff to continue with their tasks of treating others that come into an emergency room. These recovery coaches are peers, many of them are former addicts trained to work with an overdose patient as they come down from the opioid. These coaches are trained to move the patients into long-term treatment programs for their drug addiction.

One such program is LifelineED, at Cooper University Hospital in the heart of Camden, New Jersey, where roughly 70 overdose victims arrive at the ED every month. Camden County leads the state for the highest number of opioid-related deaths annually. “The goal of the LifelineED program is to get individuals who were Narcaned into detox and treatment,” says Sharon Chapman, program supervisor of the LifelineED program coordinated by the Center for Family Services in Voorhees, New Jersey. “Our Recovery Coaches and Patient Navigators work with each individual to help get them into a treatment facility. It’s important for these patients to know they’re not alone. We offer support to help the patients and their families as they go through the recovery journey.”

These recovery coaches offer peer to peer support. There’s nothing like being approached by another recovering drug addict who can help you in your time of need, someone who knows exactly what you’re going through at that moment of crisis. Often, the recovery coach draws on information and resources that the ED hospital staff does not have, such as a list of available beds in local detox facilities and outpatient treatment programs that accept Medicaid. ED staff acknowledge that it’s helpful to have recovery coaches who can spend time with a patient, who can begin moving them into treatment. These coaches know the recovery terrain better than the ED nurses and physicians. 

Of course, the patient decides whether they will take part in treatment, but willingness is often strongest when a patient realizes they have just been given a new lease on life. If they choose to go home, they take the recovery coach’s number with them. What makes these programs work so effectively is that when the patient leaves the ER, the program doesn’t leave the patient.

The recovery coach or a patient navigator from the LifelineED program will follow up with these individuals by phone in 24 hours. It is their goal to contact the patients every week by phone or with a home visit for the next eight weeks. The coaches or patient navigators (navigators are also trained recovery coaches) will repeatedly attempt contact with the patient until they are successful. Visits to the patient’s home are part of the LifelineED recovery coach’s commitment to the patient. Finding the time for a home visit is something that the ED staff could never do.

Overdose survivors are often willing to let recovery coaches into their homes to talk about the program immediately after returning home, because frequently the recovery coach is the only "sober" voice they will hear. Some patients need a few days of post-overdose revival to prepare for an extended stay in detox, or to balance the benefits of entering an inpatient rehab versus enrolling in an outpatient treatment program. They need to pack their bags, organize child care and call their employer to request time off. It is during the home visits with the recovery coach that the patients come to the realization that if they don’t accept the offer of treatment, there may not be another opportunity. 

In an ongoing effort to prevent opioid overdose and substance abuse in Rhode Island, the Providence Center’s AnchorED program provides recovery coaches for Narcaned patients at Kent Hospital in Warwick and the Memorial Hospital in Pawtucket. The AnchorED program is funded by the RI Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (DBHDDH) and has been in existence since the summer of 2014. In the first year of operation, the AnchorED program reported that 230 survivors had been seen by AnchorED recovery coaches, and 193 survivors, or 83%, had engaged with the recovery coaches and the available recovery supports after their discharge from the emergency department. Only 36 survivors declined recovery support services. Of the 230 survivors seen, only 12 (5%) have returned to the ED multiple times, a significant reduction in keeping with the goals of the program. 

There is one recovery coach ED program that deals with any substance-related medical condition that walks into the emergency room: the OIP-Overdose Intervention Program. OIP was launched in two southeastern Massachusetts hospitals, the South Shore Hospital in Weymouth and the Tobey Hospital in Wareham, in coordination with Gosnold Treatment Centers in Cape Cod. Ray Tamasi, President of Gosnold, explains that OIP is the outgrowth of a program in which Gosnold collaborated with 16 to 17 police departments in southeastern Massachusetts, that help individuals experiencing an opioid overdose. Any individual in an opioid overdose crisis can go to a police department and be aided by an officer—not arrested, but Narcaned—and brought to a hospital setting. After the medical release of the patient, there is a visit made with police officers and a Gosnold recovery coach at the home of the patient to discuss the next steps of possible treatment. These police department programs have realized a 70% conversion success rate in bringing non-fatal overdose patients into treatment.

So the natural progression of these programs was having recovery coaches embedded—not on call, but in the ED—during peak hours. The OIP program began at the end of March 2016 with a recovery specialist embedded in the emergency room, helping any patient that presented with an opiate overdose or any substance and alcohol-related medical condition. Tamasi states: “There are many more alcohol-related intakes in emergency rooms. However, these incidents do not make headlines because the alcoholics do not die in the ED, they sober up and walk out of the ED only to return again and again to the ED.” 

The number of individuals that opt for addiction treatment is around 70% for the OIP program in the first month since the inception of the program. Thirty-five people have been seen in the ED by OIP coaches and 28 have sought treatment. Tamasi notes that, “The key is an immediate connection and transfer to a treatment facility.” Gosnold Treatment Center is a local, not-for-profit organization with detox and treatment programs, however, they cannot handle all of the clients referred from the EDs, so they have reached out to six other treatment centers to accept the ED patients. There is no question of accepting the patients without insurance coverage or being denied treatment because the service is meant to be "blind to payer." Many of the patients move into treatment facilitates without any question as to who is paying for the treatment.

In the event that the individual says no to detox or treatment, the OIP recovery coach follows up after the ED visit, to "nudge" the patient into a treatment program that can suit the individual’s needs. The recovery coaches make three follow-up calls after the ED visit. The OIP coaches know how to engage with people in withdrawal, whereas most medical doctors or ED nurses are not knowledgeable and may be uncomfortable with having these types of conversations with the patients. 

More programs are starting all over the country. At the Mid-Michigan Medical Center in Gladwin, Michigan, a model program called Project Assert recently began. In Baltimore, Maryland, the Mercy Medical Center has collaborated with Behavioral Health System Baltimore (BHSB) in Maryland to implement a Screening, Brief Intervention, and Referral to Treatment (SBIRT) program. Both programs are meant to cut down on the number of return visits to the ED as well as link patients to appropriate treatment centers for coordination and continuation of care. 

Funding for these Emergency Department Recovery Coaching programs are popping up all over the United States, since President Obama and Michael Botticelli, the Director of National Drug Control Policy has requested over $1 billion to be placed into the 2017 budget to fight the growing opioid epidemic. This funding request surpasses the $400 million amount in the 2016 budget. State and federal government agencies are going all out to fund programs in hopes of addressing this harrowing epidemic, which has ravaged communities in all corners of the U.S.