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What to Do After an Overdose Reversal: Engaging Patients in Addiction Treatment
Presenters:• Elizabeth Samuels, MD, MPH, Chief Resident, Emergency Medicine Residency Program,
Brown University
• R. Corey Waller, MD, MS, Medical Director, Center for Integrative Medicine, Spectrum Health Medical Group
• William J. Lynch, Jr., RPh, Clinical Staff Pharmacist, Kennedy Health System, and Member, Camden County Addiction Awareness Task Force
• Harry Earle, MA, Chief of Police, Gloucester Township (NJ) Police Department, and Member, Camden County Addiction Awareness Task Force
Clinical Track
Moderator: John J. Dreyzehner, MD, MPH, FACOEM, Commissioner, TN Dept.of Health, and Member, Rx and Heroin Summit National Advisory Board
Disclosures
• Harry Earle, MA; Elizabeth Samuels, MD, MPH; and R. Corey Waller, MD, MS, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.
• William J. Lynch, Jr., RPh wishes to disclose he is a consultant with Pernix Therapeutics and with Iroko Pharmaceuticals
• John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest: Starfish Health (spouse)
Disclosures
• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:
Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
Learning Objectives
1. Define the need to engage persons who experience an opioid overdose reversal in addiction treatment.
2. Identify best practices and strategies for first responders and emergency personnel to engage naloxone recipients in addiction treatment.
3. Describe one community’s program for engaging naloxone recipients in addiction treatment.
What to Do After an Overdose Reversal: Engaging Patients in Addiction Treatment
Elizabeth Samuels, MD, MPHLifespan Opioid Overdose Prevention Program
Brown University Department of Emergency Medicine
R. Corey Waller, MD, MSDirector for the Center for Integrative Medicine
Spectrum Health Medical Group
Disclosure
• Elizabeth A. Samuels, MD, MPH has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
• Corey Waller, MD, MS has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
1. Define the need to engage persons who experience an opioid overdose reversal in addiction treatment.
2. Identify best practices and strategies for first responders and emergency personnel to engage naloxone recipients in addiction treatment.
3. Describe one community’s program for engaging naloxone recipients in addiction treatment.
Outline• Emergency Department
overdose visits
• Lifespan Opioid Overdose Prevention Program
• Addiction treatment follow up
Increasing Drug-Related ED visits
Drug related ED visits, 2004-2011
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD.
RI Opioid Overdoses
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0
10
20
30
40
50
60
70
2014 Rhode Island Hospital Opioid Overdoses and Rhode Island Unintentional Opioid Overdose Deaths
RI Unintentional Opioid Overdose Deaths
RIH Opioid Overdoses
Month, 2014
Num
ber o
f Inc
iden
ts
Sources: RIH, RI DOH Medical Examiner
Lifespan Opioid Overdose Prevention Program Goals
Reduce deaths due to opioid overdose by:1. Increasing access to naloxone.2. Expanding ED overdose prevention
education and addiction counseling.3. Increasing ED referral to addiction
treatment.
LOOP Program Components
Take-home naloxone
Peer recovery coach consultation & referral to treatment
Overdose prevention and response education
ED Naloxone Distribution
Naloxone rescue kit assembled by pharmacy, stored in ED dispensary
Patient shown educational video
Retrieved by nurse and given to patient.
Patient Education
Program Utilization
Post-ED Follow Up
Transfer to detox or inpatient treatment from ED
Outpatient Treatment referrals
80% engage with recovery servicesInpatient & Outpatient
Outpatient follow up within 24-48h
Addiction 101
• Chronic neurobiological disorder• Need both medications and therapy
– Buprenorphine, Methadone, Naltrexone– CBT, MET, DBT, 12-Step
• Integrated care teams– Prescriber– Therapist– Case manager– Other (pharmacist, MA, CHW, etc.)
Questions?
What to Do After an Overdose Reversal: Engaging Patients in
Addiction TreatmentCamden County Addiction Awareness Task Force
Operation SAL: Save-A-Life
What to Do After an Overdose Reversal: Engaging Patients in Addiction Treatment
William J. Lynch, Jr. BS-Pharm, RPhClinical Staff Pharmacist-Kennedy University Hospital
Core Teaching Affiliate of Rowan School of Osteopathic MedicineRutgers University, Ernest Mario School of Pharmacy Preceptor
Camden County New Jersey Addiction Awareness Task Force Member-Education & Prevention Committee Co-Chair
State of New Jersey Police Training Commission InstructorCamden County College Police Academy Instructor
National Prescription Drug Abuse & Heroin SummitMarch 29, 20162:00 to 3:15 PM
What to Do After an Overdose Reversal: Engaging Patients in Addiction Treatment
Chief W. Harry Earle, MAChief of Police-Gloucester Township NJ Police Department
President, Camden County NJ Police Chiefs’ AssociationCamden County Addiction Awareness Task Force Member
-Availability Reduction Committee Co-ChairFBI National Academy #234
National Prescription Drug Abuse & Heroin SummitMarch 29, 20162:00 to 3:15 PM
Disclosure Statement
William J. Lynch, Jr. BS-Pharm, RPh wishes to disclose he is a consultant with Pernix Therapeutics and with Iroko Pharmaceuticals
He will present this content in a fair and balanced manner
Disclosure Statement
Learning Objectives
• Define the need to engage persons who experience an opioid overdose reversal in addiction treatment
• Identify best practices and strategies for first responders and emergency personnel to engage naloxone recipients in addiction treatment
• Describe one community’s program for engaging naloxone recipients in addiction treatment
5,217 Number of heroin-related deaths recorded
in New Jersey 2004-2014
http://www.nj.com/news/index.ssf/2015/12/herointown_nj_the_states_heroin_crisis_in_10_graph.html
New Jersey’s Heroin Epidemic: Deaths Doubled Since 2011
*Camden, Middlesex, Ocean and Monmouth had the highest number of overdose deaths in 2014
*Bergen, Camden, Cumberland, Gloucester, Middlesex, Monmouth and Warren had the percentage highest increases from 2013
http://patch.com/new-jersey/tomsriver/heroin-deaths-new-jersey-double-2011?utm_source=alert-breakingnews&utm_medium=email&utm_term=police%20%26%20fire&utm_campaign=alert
8.3Heroin Deaths in New Jersey per 100,000 >3
Times National Average
20.3 Heroin deaths in Camden County New Jersey per 100,000More than 7.8 times the national average, 2.45 times NJ averagehttp://www.nj.com/news/index.ssf/2015/12/herointown_nj_the_states_heroin_crisis_in_10_graph.html
Camden County Overdoses
ACCIDENTAL DEATHS RELATED TO ADVERSE EFFECTS OF DRUGS (CAMDEN COUNTY - 2010-2013)
RACE NUMBER PERCENTAGE AVG AGE 32.06 AVERAGE AGE 2010-2013 # of Deaths
Percentage
0-16 1 <1%White 382 74% 16-20 15 3%Black 81 16% ACCIDENT 496 21-30 115 22%
Hispanic 51 10% UNDETERMINED 4 31-40 138 27%
OTHER 2 <1% SUICIDE 16 41-50 150 29%TOTAL 516 100% 516 51-60 82 16%
61-70 14 3%FEMALE 134 26% 71-80 1 <1%MALE 382 74% 516 100%
516 100% YOUNGEST 18 OLDEST 69 # OF DEATHS 516 AVG AGE AT DEATH 40
AN EPIDEMIC
SAVE INITATIVES
INSPIRING CHANGE
THE POWER OF A PHONE CALL
WORKING TOGETHER TO SAVING LIVES
TOTAL UNITS:
1,230
WORKING TOGETHER TO SAVE LIVES
2014517
20155,092
2016158
NJ Statewide Naloxone Deployments, Regional Operations Intelligence Center, NJSP, Drug Monitoring Initiative Attorney General ‘s Heroin & Opiate Task Force. 1/26/16
NJ Statewide Naloxone Deployments, Regional Operations Intelligence Center, NJSP, Drug Monitoring Initiative Attorney General ‘s Heroin & Opiate Task Force. 1/26/16
• 517 deployments during 2014• 5,092 deployments during 2015• 158 deployments during 2016
SAVED BY NARCAN – NOW WHAT?
PREPARING FOR RE-ENTRY
Food Bank
Clothing Bank
SAVE Advocate
GTPD Family Resource Center
GT Library
Community Re-Entry Specialist
WE NEED TO PREVENT THE OVERDOSE!
SAVE ADVOCATE
47%
REMAINING 53%?
SOLICIT PARTNERS
Brought to you by the Camden County Board of Freeholders’ Addiction Awareness Task Force & Camden County Health Department
“We administered the naloxone … now what?”
Signing Out “AMA”• AMA: Against Medical Advice• Revived by Police/EMS in the field
– Do not want to go to the hospital– Sign out AMA
• Get to the hospital– Do not want to be there/stay– Sign out AMA
• For those who want treatment– Long wait time for inpatient treatment– Takes time to get Medication Assisted Treatment (MAT)– No place to go
• Recidivism rate is high
Where Do We Go From Here….
“
In Camden County New Jersey… • Camden County Addiction Awareness Task Force (CCAATF) has
implemented a successful nasal and injection naloxone program with 344 deployments by Law Enforcement & 1160 deployments by EMS personnel– Total: 1504 in 2015
• However, each save has brought with it the problems of where the patients go from here, especially when seeking treatment
• With increasing delays in treatment availability and patients signing out against medical advice from hospitals and first responders, the task force quickly realized our community was winning the battle but losing the war
• In response, the task force developed Operation SAL– Save a Life!
Heroin and Treatment in New Jersey
Camden County Future Admissions
From 2015-2018 Heroin and
Prescription Drugs are projected to account for 44.5% of Camden County’s
substance abuse admissions
NEARLY, 80% of these clients are from the suburbs
Treatment Availability• More than 1 in 2 adults (71,000) • More than 2 in 3 adolescents
(9,400) • Who wanted treatment for an
addiction to alcohol or drugs in New Jersey could not access it due to limited treatment capacity.*
• Average wait times for treatment
*National Council on Alcohol and Drug Dependence http://www.ncaddnj.org/page/access-to-treatment.aspx
We Have a Serious Problem • New Jersey has 21 counties• Camden County is:
– 8th most populated county (n=511,038 residents)– Has 4th highest number of substance abuse
treatment admissions• 6295 in 2012, 8.3% of total NJ Admissions of 75,837• 5830 in 2013, 8% of total NJ Admissions of 72,864• 5214 in 2014, 8.1% of total NJ Admissions of 64,766
– Was 1st, for greatest number of heroin deaths in the state for 2014 with 93 of 781 in NJ (11.9%)
2014 Substance Abuse Admissions by County of Residence in New Jersey
Rank County Total Admissions (N=64,766)
1 Ocean 65652 Monmouth 60493 Essex 56724 Camden 52145 Middlesex 43986 Atlantic 39217 Hudson 38538 Passaic 36409 Union 3096
10 Gloucester 288111 Bergen 270412 Burlington 268613 Morris 246614 Mercer 229315 Cape May 216216 Cumberland 192917 Somerset 174718 Sussex 117219 Warren 94620 Hunterdon 78321 Salem 589
Camden County Primary Drug Ranked Total Treatment Admissions, 2005-2012 (N=39,944)
Camden County Primary Drug Ranked Total Treatment Admissions, 2005-2012 (N=39,944)
Primary Drug at Admission
Number of Admissions Rank
Percentage of Camden County
Admissions
New JerseyAdmission Percentage
Heroin 12,982 1 32.5% 31.5%Alcohol 9,707 2 24.3% 34.8%
Marijuana 7,748 3 19.4% 15.0%Prescription 4,112 4 10.3% 8.4%
Cocaine/Crack
4,039 5 10.1% 8.8%
Other Illicit Drugs
1,356 6 3.4% 1.6%
Heroin and Prescription Drug Treatment Admissions from 2005-2012
Accounted for 42.8%
of Camden County’s
substance abuse admissions
Brought to you by the Camden County Board of Freeholders’ Addiction Awareness Task Force & Camden County Health Department
Projected/Actual Camden County Primary Drug Ranked Total Treatment Admissions, 2013
Projected/Actual Camden County Primary Drug Ranked Total Treatment Admissions, 2013
Primary Drug at Admission
2013 Projected
Number of Admissions
N=6717
2013 Actual
AdmissionsN=5830
Projected Percentage of
2013 Admissions
Actual Percentage
2013Admissions
Alcohol 2,020 1,278 30.1% 22.0%Heroin 1,587 2,096 23.6% 36.0%Prescription 1,421 569 21.2% 10.0%Marijuana 938 1,153 14.0% 20.0%Cocaine/ Crack 445 374 6.6% 6.0%
Other Illicit Drugs305
275 4.5% 5.0%
2013 Camden County Substance Abuse Admission Age at Discharge
Age at Discharge Percentage
<45 years 80%<35 years 62%<30 years 46%<25 years 27%<22 years 15%<18 years 4%
Treatment Rates by Patients New Jersey Hometown Address
http://www.nj.com/news/index.ssf/2015/12/herointown_nj_the_states_heroin_crisis_in_10_graph.html
http://www.nj.com/news/index.ssf/2015/12/herointown_nj_the_states_heroin_crisis_in_10_graph.html
•
5 Counties Where Heroin Death Rate Exceeds Number of Treatment Beds Available per
100,000 People
Mission:•To increase awareness among county residents of heroin and prescription drug abuse and the devastating effects on our community
Goals:•HELP to reduce the demand for and availability of heroin & prescription drugs•CREATE awareness programs to help educate residents about programs and resources available to prevent and treat addiction• SUPPORT the creation of additional resources to treat and prevent addiction to heroin & prescription drugs
Brought to you by Camden County Addiction Task Force & Camden County Health Department
OPERATION SAL (Save-A-Life)
Brought to you by the:Camden County Addiction Awareness Task Force &
Camden County Health Department
Operation SAL-Save A Life!• Naloxone successfully deployed by
County/Municipal police departments or EMT/Paramedics as a life saving measure
• Funded by Camden County Addiction Awareness Task Force (CCAATF)
• Response to increased number of overdoses & to provide care on an interim basis
• Program tailored for clients who seek inpatient substance abuse treatment admission
• For clients confronted by barriers & obstacles to receiving treatment
Operation SAL-Save A Life!• Offer up to 60 days* of either Suboxone® or
methadone maintenance while in Intensive Outpatient treatment at Delaware Valley Medical– *as funds are available
• DVM will keep client comfortable while waiting to be connected to another level of care
• Admissions occur 6 days a week 530am to 1100am• Healthcare institutions call for prior approval &
referral
Operation SAL-Save A Life!• To be considered clients must have:
– 1 Photo ID & another form of ID • May be hospital face sheet
– Naloxone administration by Municipal/County Police or EMT/Paramedic
– Discharge paperwork from hospital/medically cleared
– Prefer hospital transfers client directly from ER to DVM after they accept the client
– Validated legitimate benzodiazepine use permitted– Cannot be actively using illicit benzos
Client Engagement/Stability• Client Engagement begins from first contact at the
program
• Treatment appointment is coordinated with facility staff
• After admission, individualized goals will be identified and appropriate treatment referrals made
Delaware Valley Medical• Delaware Valley Medical provides comprehensive, high quality
addiction treatment services & is a community resource that prevents, reduces, & eliminates harm caused by substance abuse for the surrounding communities
• Admission for Operation SAL are Monday to Saturday – 5:30 AM to 12:00 PM– Same day screenings are available for immediate admission
• Applicants must be 18 years or older & be able to furnish two forms of identification (one of which is photo ID)
Delaware Valley Medical
Available services include:• Medically supervised withdrawal from opiates and
methadone• Methadone Maintenance/Suboxone® Therapy• Drug Counseling: Individual, group & family• Intensive Outpatient/Outpatient group therapy programs• Psychiatric services for qualifying clients• Referrals & linkages for additional services such as
vocational rehabilitation, pre-natal care• On site free rapid HIV testing
Four Major Hospital Systems Participating in Operation SAL
• Kennedy Health System– Cherry Hill NJ Division– Stratford NJ Division– Washington Township NJ Division (Gloucester County)
• Cooper Hospital, Camden NJ• Our Lady of Lourdes Hospital, Camden NJ• Virtual Health System
– Marlton NJ Division (Burlington County)– Mount Holly NJ Division (Burlington County)– Voorhees NJ Division
• Represents ALL hospital systems – in Camden County, NJ
Hospital’s Role• Ensure Social Workers and/or Nurse Navigators are aware
of the program– Medication Assisted Treatment & Intensive Outpatient
Program– Wrap-around linkage
• Provide referral & information to Delaware Valley Medical• Make smoothest & safest transition possible from ER to
Delaware Valley Medical– If feasible, direct admission
Operation SAL-Save A Life
• Camden County Department of Health & Human Services
Addiction Unit
(856) 374-6361
• Contact Community Helplines
(877) 266-8222
• Delaware Valley Medical
(856) 665-5100
Successful Case History• Difficult to implement• Every patient ready at a different time in their life• 23yoM with naloxone reversal three times• Given Operation SAL info each time by police officers & hospital
personnel• Info given to patient and family members• Police stop by to check up on how patient was doing • Third overdose nurse navigator gets patient into program• Picked up daily & taken to methadone maintenance tx• After 3 weeks admitted to inpatient treatment facility• Other funding available for this patient’ treatment• Driving patients into treatment• With & without insurance
Acknowledgements: Thank You!Rachel M. Lynch• Doctor of Pharmacy Candidate 2016• Rutgers University, Ernest Mario School of PharmacyBrian V. Blazovic• Doctor of Medicine Candidate 2018• Jefferson Medical College, Thomas Jefferson UniversityDavid Z. Yang• Pharmacy Intern-Doctor of Pharmacy Candidate 2016• Rutgers University, Ernest Mario School of PharmacyKurt D. Meakim, Pharm D• Pharmacy Intern-Rutgers University, Ernest Mario School of PharmacyEric W. Lynch• Doctor of Pharmacy Candidate 2020• Rutgers University, Ernest Mario School of PharmacyGregory E. Cabanas• Pharmacy Intern, Doctor of Pharmacy Candidate 2016• Rutgers University, Ernest Mario School of Pharmacy
We thank all of the members of our Camden County Addiction Awareness Task Force who engage in battling this epidemic in our community every day. Together we ARE making a positive difference!
What to Do After an Overdose Reversal: Engaging Patients in Addiction Treatment
Presenters:• Elizabeth Samuels, MD, MPH, Chief Resident, Emergency Medicine Residency Program,
Brown University
• R. Corey Waller, MD, MS, Medical Director, Center for Integrative Medicine, Spectrum Health Medical Group
• William J. Lynch, Jr., RPh, Clinical Staff Pharmacist, Kennedy Health System, and Member, Camden County Addiction Awareness Task Force
• Harry Earle, MA, Chief of Police, Gloucester Township (NJ) Police Department, and Member, Camden County Addiction Awareness Task Force
Clinical Track
Moderator: John J. Dreyzehner, MD, MPH, FACOEM, Commissioner, TN Dept.of Health, and Member, Rx and Heroin Summit National Advisory Board
