You’re dispatched to a residence for a possible overdose and immediately recognize the address—it’s your third time there this month. Upon arrival the patient is unresponsive, pale, and has pinpoint pupils and shallow respirations of six breaths a minute. An OPA is inserted and oxygen administered via BVM to assist respirations. You administer 2 mg of naloxone, and the patient revives and becomes alert. Despite encouragement to go to the hospital, they refuse transport. Frustrated, you and your partner leave, left wondering when, not if, you’ll return to this home.
If your agency is overtaxed trying to manage your community’s opioid problem, look to Palm Beach County Fire Rescue (PBCFR) of West Palm Beach, Fla. They’re on the tip of the spear of mitigating this national epidemic, utilizing mobile integrated healthcare (MIH) as the bridge between EMS and long-term treatment. Combined with telehealth, the MIH program connects patients who have a substance use disorder (SUD) with a clinic that provides medication-assisted treatment (MAT) for the disease.
All Hands On Deck
In Florida every region has a state-funded behavioral health initiative. Palm Beach County’s operates under the Southeast Florida Behavioral Health Network, a multidisciplinary program that staffs social workers and addiction nurses and physicians, offering group and family work as well as education on the neurobiology of addiction.
It serves as the county’s lead agency coordinating the opioid crisis response and works with entities like PBCFR and the C.L. Brumback Primary Care Clinics of the Health Care District of Palm Beach County (HCD), Recovery Research Network, their partner provider and triage center, as well as Rebel Recovery, an ethical peer support organization for people with SUD. Insured patients are fitted into the program, while uninsured patients receive free opioid treatment through the state grant.
PBCFR was recruited to participate in HCD’s outpatient medication-assisted treatment maintenance therapy pilot program from March through May of 2017. Its role was to treat patients who overdosed, transport them to JFK Medical Center, and deliver Suboxone to patients with SUD for eight days following discharge from the hospital.
Belma Andric, MD, MPH, chief medical officer, VP, and executive director of clinical services at HCD, recognized that patients in this program needed to pursue long-term care following the eight-day treatment to ensure a successful recovery. At this point PBCFR would hand off the patient to HCD, where they would receive long-term treatment plans from a psychiatrist that incorporated MAT and required individual and group psychotherapy. They also got social and financial services, primary care, and peer support through Rebel Recovery.
In the eight-day period, 27 of 30 patients were compliant with PBCFR’s MAT. In a 30-day period supplemented with care at HCD, 18 of 27 remained compliant with treatment, which declined slightly to 16 of 27 after 90 days. Following the end of the pilot, HCD has continued to treat hundreds of patients with SUD.
Planting the Seed Through Telehealth
Once the pilot program ended, PBCFR wanted to continue making a difference for this vulnerable population. With little funding available, Lauren Young, LCSW, the department’s in-house social worker, developed a low-cost, grassroots telehealth initiative. The model is simple: Make a phone call to a patient who has overdosed (this encompasses any type of substance, not just opioids) within 72 hours of the incident to ask how they’re doing and connect them with resources if they’re interested in receiving treatment. Currently the part-time MIH crews consist of two paramedics and a peer support member from Rebel Recovery, and they see about 600 patients annually.
“We approach them in a very open, nonjudgmental way starting where they are, not where we want them to be,” says Young, who oversees the program. Staff consists of people experienced in the field of addiction. “It’s my belief as a social worker that grassroots programs are often most effective with this population. There’s this stigma with substance use disorder—people really see it as a choice rather than as a chronic disease, so I see EMS as being a really fantastic starting point for building trust because they know we really care about them.”
Young says the majority of fire-rescue agencies’ calls are medical today because their fire-prevention efforts have been so successful in recent decades, and she believes EMS can reach that milestone if medical prevention services like MIH are run successfully. Patients are more trusting of these crews because they're not affiliated with law enforcement and they provide pertinent health education about chronic diseases—including SUD—patients may not have access to otherwise. Some patients are noncompliant or struggle with management of chronic diseases like diabetes or hypertension, and it’s no different with SUD, says Young.
“Some people will have challenges with self-management, but I don’t think that’s a failure. I think that’s an opportunity,” she says. One of the most critical components of the medical education is helping patients understand that they can comfortably manage their disease through MAT, which can be empowering to those who have dealt with stigma or criticism from people in their lives.
“They are not treated very well. They’re told, ‘You should be able to control this. Why are you doing this to your family? Why are you doing this to yourself?’ They don’t understand either. No one would choose this life,” Young says. “When we provide that medical education element about the neurobiology behind their use, it’s really eye-opening to them. They want to hear from us. They’re hungry for it.”
If they’re not ready to seek treatment, says Young, these conversations plant a seed. Maybe when they’re ready six months down the line, they’ll remember that phone call and reach out. Young sees it as a chance to build trust with the community early so they can leave the door open. “We’re in the business of saving lives, so if you save one life, then you’ve made a difference.”
According to Richard Ellis, division chief of medical services at PBCFR, who oversaw the operation when the MAT program started, there was a marked decrease in overdose calls. Within one year of implementing the program, PBCFR saw its monthly average of 200 opioid overdose calls decrease by half. In May 2017 when they began tracking the numbers, they ran 440 opioid-related calls. In July 2019 they ran 134. This decrease is also attributed to law enforcement and legislation cracking down on unethical (unlicensed or illegal) sober homes, but the numbers still speak volumes about the positive impact of MIH. Of course 134 is still a high number, and it remains a major issue all parties are committed to eliminating.
Pick the Low-Hanging Fruit
If your agency is thinking of starting an MIH program, Young says establishing partnerships with organizations that specialize in this arena is crucial—like ethical treatment providers and behavioral health collaboratives—because you need trained individuals who know how to work with people with substance use disorders.
This is where PBCFR recognized early on the unique skill set social workers bring to the table. They provide immense value to departments because they are trained in reaching out to other organizations in the community and building relationships with them, whereas EMS is accustomed to being the entity to which others reach out for assistance.
“Begin to forge those relationships, because the reality is that EMS can be a bridge, but we can’t be the end-all, be-all either,” says Young. “We have a unique opportunity to build on that trust because we’re the first line of access, but staying true to who we are in EMS and bridging them to resources in the community is critical.”
This is an affordable and convenient method for agencies that want to start an MIH program. The telehealth model only requires what every agency already has: medics and telephones. If you’re short on field medics, retirees or light-duty employees can help out. Launching task forces and brainstorming over several years is unnecessary.
“Things don’t need to be complicated,” says Young. “There are ways to help people now, low-hanging fruit, to get them into the hands of treatment providers in the community. They’re the experts at MAT. We’re the experts at prehospital care, so let’s bridge people over to them.”
On the Road to Recovery
The Health Care District of Palm Beach County provides primary care services in nine locations, including its addiction outpatient treatment program (AOTP). As a federally qualified health center, HCD’s mission is to provide care to underinsured and uninsured patients. Patients interested in participating in the AOTP must also have a primary care physician at the clinic to ensure they get well-rounded care—they’re expected to have weekly visits with a psychiatrist, an individual therapist, and group therapy while receiving MAT. HCD essentially acts as a one-stop shop.
“The idea is to stick with them for the long haul because this is a life-long illness that requires chronic management and isn't curable,” says Courtney Rowling, MD, a psychiatrist at HCD’s Lantana clinic. Patients with SUD “have to keep managing alongside a supportive clinical and social team. Substance use care is a team sport. We decided to work in a primary care setting so all members of the team are available to the patient.”
Depending on which substances a patient is using, they may be prescribed Suboxone, naltrexone, or Vivitrol to prevent overdose and relapse. If the patient is not appropriate for outpatient services, they are assessed and linked to an appropriate level of care. Regardless of the recommendation, the patient walks away with an evidence-based treatment plan that often involves referrals and appointments already made.
A patient using opioids typically receives Suboxone, an opiate that curbs drug cravings. Suboxone binds to the opiate receptors in the brain so strongly that if a person were to use another opiate, like heroin, it essentially bounces off those receptors and prevents an overdose from occurring. While it does produce a high, it’s much less intense than other opiates and hits a ceiling so the user cannot get higher by taking more. Over time Suboxone progressively helps quiet the cravings from withdrawal.
Addiction doesn’t start as a disease. It begins with a person at risk with a genetic predisposition, meeting access and likely socioeconomic or psychiatric risk factors. “That’s why prevention is important,” Rowling says. “Once this disease takes off, you can’t undo or cure it. You can only manage it.”
Two centers of the brain are involved with addiction: the nucleus accumbens, otherwise known as the pleasure center, and the reward center, the ventral tegmental area. When you experience pleasure, the pleasure center sends a signal to the reward center to reinforce the behavior associated with that feeling.
“When people who have a genetic tendency toward drug use take their first few highs, they are more pleasurable than any natural experience they’ve ever had in their life,” says Rowling—like good food, relationships, or getting your paycheck. “They feel normal, they feel less depressed. They’re genetically wired to actually feel and perform better.”
Meanwhile, the person lacks awareness as they’re giving up on other rewarding experiences in their life. Once at rock bottom in the hospital or prison, they make the connection between their substance use and circumstances and realize they need to get better.
“Telling people they need to change because they’re going to die doesn’t work. You have to find what motivates somebody to want to change their use,” Rowling says. “You disserve people when you say it’s not a disease, [because] what you’re saying is they’re making choices. Telling someone to stop using is like saying, ‘Just don’t be thirsty.’ It helps the person to know they’ll need support through this.”
Abstinence, 12-step programs, and rehab facilities have been the predominant methods of achieving sobriety. However, research shows these methods aren’t very effective by themselves, particularly for opiate use. A multidisciplinary approach to achieving and maintaining sobriety is necessary.
Rowling says EMS providers can relate the concept of MAT to bleeding control. “Number one: Stop the bleed. People need to stop dying. I think that’s the most amazing thing about Suboxone and Vivitrol. As imperfect as it can be at times, people are staying alive because you need to stay alive to do recovery. And they’re often very young people who are dying, so it has a big impact on society.”
Valerie Amato, NREMT, is assistant editor of EMS World. Reach Val at firstname.lastname@example.org.