MAT in the ED, Meth, and moreUpdate: the Clark County Comprehensive

Overdose Response Plan

Project Echo

Eric Yazel, MD FACEP

November 2019

Background

• Clark County, Indiana population 125,000• 376 square miles, yet 80% within ten miles of the Ohio River• Located between major urban area in Louisville, and Scott County• EMS coverage issues with greater than 15 min response times the norm in

numerous areas of the county

Numbers

• Baseline overdose death rate in Clark County was 25-30 until 2014• 2014 53• 2015 53• 2016 89

Numbers

• ED visits with ‘opiate’ in the diagnosis• 2014 49• 2015 51• 2016 182

Past Barriers

• Limited public understanding of substance use disorder• Stigma• Limited treatment options• Public Health issues (HIV, Hepatitis C, Infections) with little clinical

experience or support

• 100 million dollar impact on the economy in Clark County

So Where Do You Start?

• Clark County Cares- a grassroots organization composed of community members from all walks of life

• Support community activities related to recovery- treatment options, narcantraining, syringe service programs, residential recovery, job skills

• Must have community support!!!!!!

Who Is Represented

• Concerned Citizens• Law Enforcement• Judges• Recovery Organizations

• Healthcare • Elected Officials• Business Leaders• Media

Activities

• Core group meets every Monday morning• Goals, event planning, upcoming events, troubleshoot• Keeps momentum going• Monthly meetings- testamonials, updates on recovery options, etc. • Retreats, trips, etc

Questions to Consider

• How can we use technology to better serve our community?• How to we reach our overdose patients faster? Esp in outlying areas. • How do we develop surge capacity for overdose clusters?• How will we manage these patients when they present to the ED?• How do we combat the lack of inpatient beds in the area?

Response Phases

• Phase 1- Acute Use to Entry Into the Healthcare System• Phase 2- Entry Into the Healthcare System into Stable Recovery• Phase 3- Stable Recovery to Integration Back to ‘Everyday Life’

Systems of Care Approach

• Develop a ‘spokes of a wheel’ approach to the response plan• Continue to add new spokes and bolster old ones to adjust with the needs of

the community

• Understand that any break in the system can cause the system to fail as a whole

So What’s the Plan

• Pulse Point/Everbridge• MAT from the ED/Peer Recovery Coach• ED Follow-up Clinic• Syringe Service Program• Threat Matrix/Rapid Notification Protocol

Pulse Point

• County by County: Clark County went live in December 2018• Shows a running log of various incidents in the county- Medical Emergencies,

Motor Vehicle Accidents, Fires, etc.

• If you are within a certain radius of a patient that is unconscious, unresponsive, it will notify you with an alarm. It walks you directly to the patient

• Also has an AED map that walks you to the nearest AED for the patient• Free app, takes less than 30 seconds to sign up

Pulse Point

• You will not receive a notification if does not go out as unresponsive• Outside the radius, you will not receive a notification• Public places only• Totally anonymous- we get no info on who responded• Can still sign up to help even if not CPR trained• Covered by Good Samaritan Law

What else goes out as unconscious/unresponsive??

• We train for CPR and Narcan delivery at the same time• Only place in the country dispatching narcan trained providers directly to the

site of an overdose in real time

• Decreases lag time from respiratory arrest to delivery by several minutes, which can be life or death

Pulse Point

• Multiple unexpected benefits• Traffic, fires, etc• CPR and Narcan training in the county is up astronomically• People invested and involved in the community and in public health• Stigma reduction

Everbridge

• Previous notification system involved multiple steps and multiple agencies• One touch system that allows rapid notification• Can use ESSENCE alert to notify first responders, local ER, and behavioral

health entities of an overdose cluster and each can implement their response plan

• Also keep local providers updated on issues, trends, etc

MAT in the ED

• Rapid assessment for medical stability and appropriateness for program• COWS score• Induction, followed by observation period• Peer recovery coach contact• Discharge

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Flowsheet for measuring symptoms over a period of time during buprenorphine induction.

For each item, write in the number that best describes the patient’s signs or symptom. Rate on just the apparent relationship to opiate withdrawal.For example: If heart rate is increased because the patient was jogging just prior to assessment, the increased pulse rate would not add to the score.

Clinical Opiate Withdrawal Scale (COWS)

Patient Name:

Date:

Buprenorphine Induction:Enter scores at time zero, 30 minutes after first dose, 2 hours after first dose, etc.Times of Observation:Resting Pulse Rate: Record Beats per MinuteMeasured after patient is sitting or lying for one minute0 = pulse rate 80 or below • 2 = pulse rate101-1201 81-100= pulse rate • 4 = pulse rate greater than120Sweating: Over Past 1/2 Hour not Accounted for by Room Temperature or Patient Activity0 = no report of chills or flushing • = beads of sweat on brow or face31 = subjective report of chills or flushing • 4 = sweat streaming off face2 = flushed or observable moistness on faceRestlessness Observation During Assessment0 = able to sit still • 3 = frequent shifting or extraneousmovements of legs/arms1 = reports difficulty sitting still, but is able to do so• 5 a few seconds= Unable to sit still for more thanPupil Size0 = pupils pinned or normal size for room light • 2 = pupils moderately dilated

= pupils possibly larger than normal for room light1 • m of the iris is visible= pupils so dilated that only the ri5Bone or Joint Aches if Patient was Having Pain Previously,only the Additional Component Attributed to Opiate Withdrawal is Scored0 = not present • 2 = patient reports severe diffuse aching of joints/muscles1 = mild diffuse discomfort • 4 = patient is rubbing joints or muscles and is unable to sit still because of discomfortRunny Nose or Tearing Not Accounted for by Cold Symptoms or Allergies0 = not present • 2 = nose running or tearing1 = nasal stuffiness or unusually moist eyes • 4 = nose constantly running or tears streaming down cheeksGI Upset: Over Last 1/2 Hour0 = no GI symptoms • 3 = vomiting or diarrhea1 = stomach cramps • 5 = multiple episodes of diarrhea orvomiting

= nausea or loose stool2Tremor Observation of Outstretched Hands0 = no tremor • 2 = slight tremor observable1 = tremor can be felt, but not observed • 4 = gross tremor or muscle twitchingYawning Observation During Assessment

= no yawning0 • 2 = yawning three or more times during assessment1 = yawning once or twice during assessment • 4 = yawning several times/minuteAnxiety or Irritability0 = none • 2 = patient obviously irritable/anxious1 = patient reports increasing irritability or anxiousness• 4 = patient so irritable or anxious that participation

in the assessment is difficultGooseflesh Skin0 = skin is smooth • 5 = prominent piloerection

= piloerection of skin can be felt or hairs standing up on arms3

Total scoreScore: 5-12 =MildM d13 24

Diagnosis of Moderate to Severe Opioid Use DisorderAssess for opioid type and last use

Patients taking methadone may have withdrawal reactions to buprenorphine up to 72 hours after last use Consider consultation before starting buprenorphine in these patients

with specific time & date to opioid treatment providers/

COWSnone - mild (0-7)withdrawl

Dosing:None in ED

Waivered provider able to prescribe buprenorphine?

YES

Unobserved buprenorphine

induction and referral for ongoing treatment

NO

Referral for ongoing treatment

>8) mild - severe (withdrawl

Dosing: 4-8mg SL*

Observe for 45-60 minNo adverse reaction

If initial dose 4mg SL repeat 4mg SL for total 8mg

Observe **

Waivered provider able to prescribe buprenorphine?

YES

Prescription 16mg dosing for each day

until appointment for ongoing treatment

NO

Consider return to the ED for 2 days of 16mg dosing

(72-hour rule)Referral for ongoing treatment

All Patients Receive: -Brief Intervention-Overdose Education-Naloxone Distribution

*Clinical Opioid Withdrawal Scale (COWS) > 13 (Moderate-Severe) consider starting with 8 mg buprenorphine or buprenorphine/naloxone SL

** Patient remains in moderate withdrawal may consider adding additional 4mgand observation for 60 minutes

Warm hand-offs programs within 24-72 hours whenever possible

All patients should be educated regarding dangers of benzodiazepine and alcohol co-use

Ancillary medication treatments with buprenorphine induction are not needed

Dosing

• First few inductions are EXTREMELY important for buy-in from providers and staff

• Usually start with 8mg, unless other circumstances contributing• Observe for 2 hours, reassess• Vast majority will be moderately to greatly improved, ready for D/C• Keeps the throughput people happy

Other Protocol Points

• Don’t neglect the middle portion- discuss options, harm reduction, Narcan• We modify the follow-up – most we can place in MAT acutely, don’t have to return

to ED for dosing

• Don’t always send with 16mg, in fact I send more with 8. • Use of benzos does not rule you out, case by case• ‘Ancillary medication treatments are not necessary’ Disagree. Rarely is MAT dose

and patient symptoms a perfect match. Consider other meds as indicated

Logistics

• 1/3 of ED group are champions of the program, 1/3 are participating, 1/3 are not interested

• Due to double coverage and staggered shifts, have been able to accommodate most

• Peer recovery coaches can present in 10-15 minutes, follow-up next business day after hours

• Use ED follow-up clinic as bridge clinic to long term provider

Reality – Low Numbers

• Patient population seems to have changed over the last 2 years• Positive or negative?• Finally offering the gold standard• MAT options have exploded • Transition to meth has also exploded (at least co-abuse)

Challenges

• MAT availability in the community = less ED visits specifically for MAT• Varied quality of MAT programs, gravitation toward the ones with fewest

requirements

• Meth use and its impact on initiation and follow-up

MAT – Local Trends

• In anticipation of program, LifeSpring Health Services made data waiver training mandatory

• 2-3 other organizations have begun MAT operations locally, including local hospital• Several hundred MAT spots available, can often be induced in the office same day

or within a few days

• Program quality ranges widely, gravitate to least restrictive• Meth co-abuse and its effects on MAT programs

Return Visits

• Was a big concern pre-program• Have had zero returns in 14 days or less (for dosing specific visits)• Community MAT availability is a key in this• Must have solid logistics in place for transition

Outside the box

• Partnership with SSP, when a patient states they are ready to transition, peer recovery coach will come over, walk them to community partner or ED for induction

• Developing a partnership with jail, recovery coach will meet them on release and similarly present to community partner or ED

• The recovery coach program has access to ED schedule and when indicated will facilitate visit to a time when likely to have to most options

ER Follow-up Clinic

• Once weekly clinic where anyone who has been seen in the ER can follow-up on a walk-in basis, regardless of ability to pay

• Patient receives medical treatment, medication to assist withdrawal symptoms, scheduling for behavioral health appointment, basic need assessment- clothing, food, housing assistance, as well as Narcan training for patient and family

• Revisit the different community resources as available• Are welcome to return on an as needed basis until are stable inpatient or outpatient

management

ER Follow-up Clinic

• Also serves as the bridge clinic for the MAT in the ED program• Peer recovery coaches help navigate the patients here• Limits the length of Rx that an ED needs to write (major barrier)• Can do a warm handoff to long term MAT provider

Syringe Service Program

• Provides sterile equipment for those using drugs, as well as education regarding harm reduction

• Offers testing for HIV, Hepatitis, and other infectious disease testing• Daily/weekly interactions, builds trust and provides information regarding recovery

options

• Monday through Friday 9a-3p• Mobile unit ready• No direct tax money- grants and private donations

When to Notify Public

• Periodic spikes in overdose activity, especially as fentanyl becomes more ubiquitous

• Now have the ability to synthesize this data in real time, not retrospectively• But what do we do with it? How, What, When, etc• Politics and perceptions • Use Everbridge

Threat Matrix

• Anecdotal reports from users • Increase supply reports from law

enforcements

• Overdose fatality• Multiple fatality at same site

• Reports from local healthcare facilities of increased overdoses

• Reports from EMS of increased narcan use and overdose activity

• Reports from local recovery organizations of increased activity, overdoses etc

Threat Matrix

• Must tailor it to the resources and info available in your community• Monitor it at least weekly, preferably biweekly• Establish a baseline, then use upward deviations to guide your notifications

Public Notifications

• Social Media, Social Media, Social Media• Must develop a robust page with active followers and entertaining posts so

when you actually need to deliver information, they will pay attention

• When you do deliver important information, the news media and other sources will follow-up and help get your story out

• Keeps public motivated, trained, and engaged• Can’t overuse it, public will get notification fatigue

Data

• Overdose Death Total in Clark County • 2017- 59 • 2018 – 50• 44% decrease • Lowest death total since 2013• 2019 – anticipate 45-50

Data

• ED visits related to opiate use• 2017 – 171• 2018 – 103• 43% decline from peak• Likely that we were getting them to the ED, but didn’t offer much when they

got there!• 2019 – anticipate 100-110

Pulse Point - Successes

• 483 Private CPR incidents• 182 Public • Over 1300 citizens signed up• 5 successful resuscitations by Pulse Point responders, 5 Narcan deliveries• 88 AED’s registered• Huge increase in CPR training across the county• Narcan training numbers have tripled

MAT in the ED

• Limited data to date• First patient- Female in her 20’s. Pregnant. Presented to the ED on a

Thursday at midnight. Initiated on MAT from ED. Recovery coach met with her that next morning. ED follow-up clinic before lunch. Wrap around services and bridge prescription given. Long term provider for MAT and prenatal care appointment that Monday.

• In 2016? Patient leaves with a phone number for a facility with a 1-3 month wait

ED Follow-up Clinic Success

• Saw over 200 unique patients• Data quality limited but estimated decreased ED return rate by 30% and

prevented numerous hospital re-admits for our patient population

• Funneled numerous patients into primary care and intensive outpatient treatment programs

• Essentially served as the ‘medical home’ for patients that would otherwise not have a provider

Syringe Service Program Successes

• Over 70% return rate, even higher last several months• 30% reduction in IV drug related infections• Diagnoses 1 case of HIV and 16 cases of Hepatitis C• 220 visits where patients reported being active in recovery programs• Numerous patients in full recovery• Greater than 3 million dollars in positive impact to the local economy

Public Notification Successes

• Our first rapid response notification was in March of this year• Everbridge notified first responder, healthcare, recovery communities within

5 minutes of determination

• Social media push reached 50k people• Newspapers, TV stations picked up within 24 hours• Overdose activity normalized within 24 hours, surrounding areas continued

to see a spike

Rest of 2019-2020

• Pulse Point responder increase of 100 per year, classes at major employers and high school health classes

• Verified Responder program initiated• Public Narcan Hotspots (NaloxBox)• Standardized ‘detox protocol’ for comfort meds for those declining MAT – both in

ED, MD office, and local pharmacies• Public Health Educator position to serve as our county’s version of the “opiate

czar” – Education, coordination, Narcan training, assist peer recovery coaches in rapid response follow-up, etc.

AMP Team

• Amphetamine Medical and Psychosocial Team• Uses the community system of care model, apply what we learned in the

opiate epidemic

• Monitor other pilot programs, most recent data, publications, etc• Synthesize this into what fits best for the local resources

Overdose Fatality Review Team

• Team has been formed, developing our processes, data to review, logistics, etc.

• Will allow us to monitor emerging trends in overdose fatality• Multi-disciplinary, so can assess what ‘spokes in the wheel’ can be added or

altered in response to patterns and data

Flow Summary

• Pulse Point – keeps people alive• Everbridge – gets them to treatment more quickly and efficiently• MAT from ED/ED Follow-up Clinic- initiates and keeps them in treatment• Syringe Service Program- harm reduction for those who continue to use IV drugs• Threat matrix/Public notification system- closes the loop• AMP team and Overdose Fatality review – addresses and monitors new trends in

use and overdoses• Links must be constantly updated and tailored to the needs of the community

Goals

• Phase 1- Acute Use to Entry Into the Healthcare System• Phase 2- Entry Into the Healthcare System into Stable Recovery• Phase 3- Stable Recovery to Integration Back to ‘Everyday Life’

Questions????

MAT in the ED, Meth, and more�Update: the Clark County Comprehensive Overdose Response PlanSlide Number 2BackgroundNumbersNumbersPast BarriersSo Where Do You Start?Who Is RepresentedActivitiesQuestions to ConsiderResponse PhasesSystems of Care ApproachSo What’s the PlanPulse PointPulse PointWhat else goes out as unconscious/unresponsive??Pulse PointEverbridgeMAT in the EDSlide Number 20Slide Number 21DosingOther Protocol PointsLogisticsReality – Low NumbersChallengesMAT – Local TrendsReturn VisitsOutside the boxER Follow-up ClinicER Follow-up ClinicSyringe Service ProgramWhen to Notify PublicThreat MatrixThreat Matrix Public NotificationsDataData Pulse Point - SuccessesMAT in the EDED Follow-up Clinic SuccessSyringe Service Program SuccessesPublic Notification SuccessesRest of 2019-2020AMP TeamOverdose Fatality Review TeamFlow SummaryGoalsQuestions????