PSC Backup - Item #4- Opioid Use Disorder Support Pgrm-EMS - Blake Hardy — original pdf

Backup

ATCEMS Community Health Paramedic OPIOID USE DISORDER SUPPORT AND BUPRENORPHINE BRIDGE PROGRAMS Addressing Opioid Use in Travis County The Opioid Use Disorder Support Program and its sub-program, the Buprenorphine Bridge Program were created by and are components of the Community Health Paramedic Team at ATCEMS Mission – to reduce morbidity and mortality associated with opioid use disorder and help bring support and recovery resources to people with opioid use disorder Acknowledgements • Opioid use and Opioid Use Disorder are significantly different from other drugs of abuse in how they start, and how opioid addiction works and it’s effects- it’s unique from other substances • Withdrawal from opioids, while not potentially lethal as with alcohol, is a wretched condition that few • Successful treatments for Opioid Use Disorder exist, but many patients are not aware or are poorly informed people can tolerate about the true facts Why Emergency Medical Services? 30% of Opioid users who die of an overdose, interact with EMS in the 12 months prior to their death • Of Opioid Users who die within a year of overdose, 20% die in the first month • Of those who die in the first month, 22.3% die within 48 hours Opiates kill more people nationwide than gun violence and car crashes1 • Annual mortality rate for untreated Opioid User is more than twice that of the frontline soldier in Vietnam Initiation of the Opioid Use Disorder (OUD) Support Program OUD program began in July of 2018 • State and Federal funding for supplies (Narcan) available • Growth in effective treatment options for Opioid Use Disorder (OUD) – Medication Assisted Treatment (MAT) • MAT is significantly more successful than older, more traditional forms of “rehab” • No evidence of significant fentanyl levels in Travis County at the time (2018) • Initially called Opioid Emergency Response Program – Renamed to Opioid Use Disorder (OUD) – Support Program as the scope of the program expanded Goals and Objectives Goal Community Health Paramedics establish contact with every person who experiences an opioid overdose in the ATCEMS response area within 24 hours of an overdose • Overdose follow-ups are assigned as “Opioid Alerts” to CHP medics 7 days/week Objectives • Provide education and opportunity to enter MAT (Medicine Assisted Treatment) • Provide Community Health Paramedic support services • Provide Opioid Overdose Rescue Kits • As the public safety medical provider, EMS is uniquely situated to identify and reach out to overdose patients • The Community Health Paramedic Team’s successes are rooted in meeting people where they are, in their situation, and providing holistic services tailored to their individual needs to solve the problem Opioid Overdose Rescue Kits Provided to anyone who feels they have a potential to be around a person who may overdose on an opioid Studies show that providing Narcan does not lead to an increase in abuse and can lead to an increase in enrollment in treatment2-4 Opioid Use Disorder Support Program Services Direct connection to MAT (Medical Assisted Treatment) programs • No referrals – all warm hand-offs with follow-up • MAT Programs include peer-recovery coaches, mental health support, medical providers Navigation to the best program for the individual • Programs vary significantly in how they are run, what funding they accept, and what, if any, out-of- pocket costs there will be • Some programs are much more progressive (and successful) than others • Many people try the first program they encounter and assume all programs are that way Assistance obtaining funding for those who have no income (primarily MAP) Routine CHP support services First 12 Months of the Program (2018-2019) In 2018, 911 encountered around 30 opioid overdoses per month. In 2022, the number of 911 encounters has risen to about 100 overdoses a month. Distributed an average of 30 rescue kits each month • Average of 4 known to be used each month prior to first responders arriving (Current total = 2361 overdoses, 1096 Kits distributed, and 347 known to have been used) Early Lessons Learned Origin of OUD (Opioid Use Disorder) for many people was a prescription, not recreational use • It can take only a few weeks of use in some people’s case to change a person’s brain chemistry to the point that the individual will go into withdrawal without opioids • When their doctor or dentist cut off their Rx, they are already addicted and turned to street substitutes Many people use opioids use “to get by” not “to get high” • Withdrawal is so miserable, people use opiates several times a day just to function and avoid withdrawal symptoms • Some people have to “use” before they can participate in getting help Opioid users are often hard to find – EMS may not have accurate home address • Often, individuals use within a mile of where they buy the drug, which is different from other substances of abuse and requires different strategies to locate them ATCEMS is more successful visiting people at their home the day after an overdose • Individuals are not often receptive in the ER or on scene of a 911 response Early Lessons Learned Follow-up visits also often result in connections to acquaintances who also have Opioid Use Disorder and want help Most people with Opioid Use Disorder do not overdose more than once in a 12-24 month period Intramuscular (IM) Narcan kits were problematic for patients • Most HARM-Reduction agencies had been distributing IM Narcan which we replaced with the intranasal version Fentanyl was not very prevalent in Travis County (yet) Identifying a Gap in Available Care Few patients receive anything more than comfort care in the ER or after discharge • ERs only treat opioid withdrawal symptoms superficially – Tylenol, fluids, Zofran for vomiting • As few as 16.6% of opioid overdose patients receive any treatment within 90 days of hospitalization for overdose5 Once a patient was ready to enter treatment, they had to wait as much as a week or more to start a MAT (Medication-Assisted Treatment) program • 7-14 more chances to overdose and potentially die CHP was seeing patients overdose, and in some cases die, while waiting for their intake at a MAT clinic Responding to 911 calls for people in opioid withdrawal because they wanted to stop using and CHP had nothing immediate to offer them The Buprenorphine Bridge Program (BBP) Buprenorphine (SuboxoneR) is an MAT medication, different than Methadone Unlike Methadone, Buprenorphine does not get the patient “high” – you can’t get high while taking it • Taking other opioids won’t result in any effects Cannot overdose on buprenorphine • If a person takes too much buprenorphine it will cause withdrawal = HARM Reduction Buprenorphine is inexpensive and easy to administer With Buprenorphine, we can eliminate withdrawal symptoms quickly and prevent the patient from overdosing until the patient enters Medicine Assisted Treatment (MAT) The Buprenorphine Bridge Program (BBP) The Buprenorphine Bridge Program is designed as a bridge – from the time someone is ready to get help, until they begin treatment in a Medication Assisted Treatment (MAT) program The goal of the BBP is treatment for 7 days or less (averaging 4 days right now*) 3 requirements for enrollment: 1) must remain active in enrolling in a MAT program 2) must meet with a CHP medic daily to receive a daily dose* 3) must initially be in withdrawal to start Buprenorphine treatment The Buprenorphine Bridge Program (BBP) BBP began at the end of November, 2020 Program only interrupted once in January 2021, after using what was anticipated to be a 6 month supply of buprenorphine in 6 weeks • Program grew rapidly due to word of mouth between users How effective is the Buprenorphine Bridge Program? 236 patients treated 1290 doses of buprenorphine administered = potentially 1290 overdoses prevented 92% success rate at BBP patients starting in MAT program 92% of those patients who start MAT are still active after the first, crucial 7 days Unexpected Results from the Buprenorphine Bridge Program MAT programs are reporting back that BBP patients are more successful in treatment • CHP has been coaching them for several days MAT programs in Travis County have reduced their delays to enroll new patients • MAT programs refer patients to CHP when there is a delay in intake 2 local Emergency Departments have developed buprenorphine programs to treat withdrawal patients and then refer the patients to CHP for MAT Community Care Clinics Street Med team that CHP partners with has begun providing MAT care to people experiencing homelessness • 44% of our BBP patients are experiencing homelessness And the success stories are amazing… References 1. Katz J. The first count of fentanyl deaths in 2016: Up 540% in three years. New York Times, Sept. 2, 2017, https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drugoverdose-deaths.html. 2. Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med, 2013; 158: 1–9. 3. Kim D, Irwin KS, Khoshnood K. Expanded access to naloxone: Options for critical response to the epidemic of opioid overdose mortality. Am J Public Health, 2009; 99(3): 402–7. 4. Maxwell S, Bigg D, Stanczykiewicz K, Carlberg-Racich S. Prescribing naloxone to actively injecting heroin users: A program to reduce heroin overdose deaths. J Addict Dis, 2006; 25(3): 89–96. 5. Kilaru AS, Xiong A, Lowenstein M, et al. Incidence of treatment for opioid use disorder following nonfatal overdose in commercially insured patients. JAMA Netw Open. 2020;3:e205852.