By Dorothy Brooks
While there is a big push to involve more EDs in initiating patients with opioid use disorders (OUD) on medication-assisted treatment (MAT), such a move still could leave gaps — namely, overdose patients who refuse transport to the ED once they are resuscitated at the scene. But what if pre-hospital providers were empowered to both initiate overdose patients onto MAT at the scene and also schedule follow-up appointments for ongoing treatment?
Investigators at Cooper University Health Care (CUHC) in Camden, NJ, instituted this model in August 2019. There are regulatory obstacles to surmount when implementing such a novel approach. The number of patients who accept MAT at the scene in Camden remains modest. Nonetheless, there is massive interest in such a low-barrier pathway to treatment. Early data on the protocol’s safety and impact are encouraging.
All emergency physicians (EPs) working at CUHC are X-waivered to provide buprenorphine to appropriate patients who present for care. The health system’s department of addiction medicine, which was created as the overdose crisis began to crescendo in the region in 2015, led the X waiver movement.
“Around that same period ... there was kind of an unofficial decriminalization of opioid use disorder and opiate possession in Camden where police weren’t really being dispatched to the [overdose] calls as often, and [the victims] weren’t being arrested,” explains Gerard Carroll, MD, FAAEM, EMT-P, an emergency medicine and EMS physician at CUHC.
The refusal rate jumped from about 3% to 36%, according to Carroll, meaning almost one in every three patients with OUD that EMS encountered in the field declined to go to the ED, thereby cutting off that pathway for patients to be initiated on MAT and referred to ongoing care. In addition, Carroll reports roughly 20% to 30% of patients with OUD who were transported to the ED were leaving before they were seen because of their frustration with the wait time in a busy, urban department.
In short, the overdose problem in Camden was feeling like a crisis. EMS workers who encountered these patients were feeling burned out and helpless to treat them. That is when the idea to empower paramedics to offer buprenorphine under the supervision of EPs came into focus.
“This medicine seems very safe; we have been using it extensively. Why can’t we use it in the field [and] bypass this piece?” Carroll recalls. “One of the byproducts of giving naloxone is that we induce opiate withdrawal, which, while not life-threatening in itself, is a huge motivator for our patients [to continue to use opioids]. They are terrified of going into withdrawal.”
Consequently, Carroll and colleagues developed a protocol under which paramedics could provide buprenorphine in the field. In late 2019, CUHC deployed the model as soon as the state provided a waiver to enable paramedics to administer the drug under the supervision of X-waivered EPs.
Running headlong into a pandemic, it has taken time to expand the approach and develop outcomes data to illustrate the protocol’s impact. Carroll and colleagues released a retrospective, matched cohort study of patients who experienced an overdose and either received EMS care from a buprenorphine-equipped ambulance or an ambulance that was not equipped with the drug during the study period (August 2019 to December 2020).
The study included 117 overdose patients who were seen by an ambulance equipped with buprenorphine, 43 of whom received the drug. There were 123 patients in the control arm who were seen by an ambulance without buprenorphine. Investigators found patients initiated on MAT in the field, along with scheduling a same-day or next-day appointment for ongoing care in the health system’s addiction clinic, recorded a sixfold higher odds rate of engaging in ongoing treatment for OUD within 30 days vs. other patients. The authors reported a 42% follow-up rate among patients receiving buprenorphine.1
“Getting these patients into long-term treatment is a huge win, especially given that this is a really difficult-to-reach and difficult-to-engage population,” Carroll observes, adding this is an at-risk population, considering a single overdose raises a person’s risk of mortality over the next year.
For patients receiving buprenorphine, there was a two-thirds reduction in naloxone-induced withdrawal symptoms, and there was no evidence of buprenorphine-precipitating withdrawal — a critical finding, according to Carroll. “The last thing we want to do is make anybody worse; we are here to help,” he says.
However, Carroll and colleagues were surprised to find there was no difference between the two groups regarding subsequent overdoses within the next seven days. It is a finding that requires additional research.
Before the CUHC protocol was implemented, there was some grant funding to support the training and education of both paramedics and EMTs about OUD and how to most effectively engage these patients. Paramedics received additional training, which included in-person observation at the addiction clinic. “We focused on [the paramedics] because they were the ones who were going to be administering the buprenorphine,” notes Rachel Haroz, MD, an EP and toxicology and addiction medicine specialist at CUHC. “We wanted to make sure they understood the disease [and] the consequences of [not undergoing] treatment.”
However, Haroz says one of the biggest changes she has observed from the protocol’s implementation has been among EMTs, even though they cannot access buprenorphine. Previously, EMTs did not really know what to say to patients with OUD — other than that they should stop using. Today, Haroz notes EMTs can offer options, and there is evidence suggesting these workers are engaging with OUD patients productively.
“Sometimes, an EMT will go to the ED and comment about how they talked with a specific patient, but the patient wasn’t ready [for treatment], and didn’t want to come in,” Haroz says. But then the EMT will reassure Haroz he will see the patient again. “Then, the EMT does see the patient again, and continues the conversation,” Haroz adds.
When patients are ready to engage in treatment, EMTs are well-positioned to provide guidance on how to start and where to go. Carroll leverages such engagement so OUD patients can be reached earlier and, potentially, continuously. However, this would require added waivers from the state. “My medics know where these patients live, we know where they stay, and we know where they get their drugs, so we are uniquely set up to reach them over time,” Carroll says. “This doesn’t have to be a one-time conversation at the point of overdose, even though that has been effective. We can start the conversation there, and then we can continue it.”
For example, Carroll proposes that with the right waivers and funding, EMS could provide something like an intensive outpatient treatment program. In this theoretical model, for the first few weeks, medics would observe patients while they are taking medication for OUD and stabilizing. “There are a number of ways I would like to innovate in this regard,” Carroll says.
Carroll reports that over the past three years, paramedics have initiated 174 patients on buprenorphine in the field, all of whom reported a reduction or elimination of their withdrawal symptoms. Further, there have been no cases in which treatment precipitated withdrawal, and there have been no adverse outcomes. “I don’t have randomized, controlled studies for this, but I am very confident in the safety of the intervention,” Carroll says.
The CUHC approach relies on a system and resources that are in place, making such a low-barrier solution potentially doable in many EMS systems. “It has turned out to be a very reasonably priced program to run, [and] we believe there is no good reason not to scale it across the U.S.,” Carroll says.
Haroz believes the approach has worked well in Camden because EMS carries considerable recognition in the community.
“The ambulances are not subtle vehicles. They are big, they are loud, and they are present,” she says. “Patients will flag them down because they recognize them, and [ambulances] are seen as helpers.” Also, given community members know ambulances carry Suboxone, they will contact EMS for help when there is a person in need of rescue.
Haroz agrees with Carroll that there are opportunities to leverage this new EMS capability upstream. “If we create a system where [people] know this is a potential pathway [to treatment for OUD], it is just one more way to ask for help before there is an overdose,” she says.
Haroz acknowledges putting the resources in place to respond to the opioid crisis has been critical to the CUHC protocol’s success. For example, she recalls how in the early days of the pandemic, many other MAT providers in the region were closing their doors. “Telemedicine was not really a big thing back then. These offices were not set up to do telemedicine, and many of them were terrified of having patients spreading COVID,” Haroz explains, noting this left many patients who were engaged in MAT with no way of obtaining their medicine.
CUHC was in a position to quickly respond to this need. “We created a complete walk-in clinic,” Haroz reports. “Interestingly, at CUHC, addiction [care] was the only area that experienced a significant growth in volume during the pandemic because we just opened our doors and said everybody can come.”
In turn, this walk-in clinic has proved invaluable to the CUHC OUD treatment protocol. “We didn’t know we could absorb everybody, but then when we went to this absolutely open-access model, and we realized we could,” Haroz explains. “It is easier for the medics because they don’t have to really think about where to send the patients. They all go to the walk-in clinic [for follow-up]. It has made the program all a little bit more cohesive and longitudinal.”
Since the protocol was instituted, CUHC has heard from dozens of other health system leaders in both the United States and Canada who are interested in developing something similar in their regions. Further, according to Carroll and Haroz, other states have taken steps, or are in the process of taking steps, to enable paramedics to administer buprenorphine.
Beyond the needed regulatory changes, Carroll’s advice to health systems or communities interested in this approach is to take stock of available OUD treatment resources. “We are really blessed with a really progressive addiction service that was willing to open its doors and make that follow-up easy, but everyone has something,” Carroll says. “I have been trying to dispel this idea that you need a big EMS service with a lot of money and a lot of resources.”
For example, Carroll notes the Camden program had just $250,000 in grant funding to implement the program, and that was in 2018. The price of the medicine, which is given sublingually, is just $6 per strip, so it costs less $20 on the scene to administer, he adds.
While more funding could boost the program’s training efforts, Carroll says the CUHC EMS program has integrated OUD education into its regular training process without additional resources. He believes other EMS systems would be able implement the approach. “This is not that difficult in the medical space,” he says. “I think the engagement is something that you can work on over time as you are doing it.”
Haroz agrees establishing relationships with treatment providers who can handle follow-up is critical to making this approach work. “There is nothing worse than not knowing where to send the patient,” Haroz says. “Make sure you have very close collaborations with people who know what they are doing on the addiction side [who] can mentor the [EMS] team.”
Haroz observes she and colleagues are fortunate all the relevant pieces that make the protocol effective are interconnected in one system. “Having a receptive ED that will understand when you have a patient that has already received buprenorphine, is aware of what is happening, and is able to be a partner is very helpful,” she says.
REFERENCE
1. Carroll G, Solomon K, Heil J, et al. Impact of administering buprenorphine to overdose survivors using emergency medical services. Ann Emerg Med 2022; Sep 30: S0196-0644(22)00506-6. doi: 10.1016/j.annemergmed.2022.07.006. [Online ahead of print].
What if pre-hospital providers were empowered to both initiate overdose patients onto medication-assisted treatment in the field and also schedule follow-up appointments for ongoing care?
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