Paramedics can help fight the opioid epidemic

In between calls to Emergency Medical Services (EMS) in Camden, NJ, Cooper University Health Care EMS staff looks from the ambulance at a group of heroin-using people under a bridge with fresh eyes. Frustration was replaced by hope and a version of excitement. What once felt like a drain on their resources to fight a worsening and seemingly desperate crisis is now an opportunity for change.

The key: an innovative initiative to train and arm paramedics with buprenorphine, a drug that treats withdrawal and starts addiction treatment immediately, interrupting the ongoing cycle of repeat overdoses.

Opioid use disorder (MOUD) has been shown to Reduce the death rate And the cost reduction of health care, but there are many barriers to delivery. In particular, the combination of disease-inherent behaviors and abuse outcomes in the health care system leaves many patients with opioid use disorder (OUD) unwilling to engage, even in the event of a life-threatening overdose. In Cooper University healthcare, our EMS responded to 5-15 overdose per day in 2019. Nationwide, according to the Centers for Disease Control and Prevention, overdose mortality has increased about 30% 2019 to 2020 amid the pandemic. This is our crisis.

Towards a new intervention model

Cooper’s Department of Addiction Medicine began in 2015 with one full-time, fellowship-trained physician and two part-time toxicologists. We are now the Cooper Recovery Center, an integrated center for pain, behavioral health, and substance use disorder that provides both hospital and outpatient care. We have developed educational programs at the undergraduate, graduate and attendance levels, and rapidly deployed the skills needed for clinicians to treat OUD across our system. We have led the front line, our emergency department, as all of our buprenorphine X providers have been waived since 2017. We have seen a shift in philosophy among our healthcare providers by integrating addiction services across service lines. Unfortunately, despite reaching this tipping point, overdose mortality rates have remained stable in our county. We soon discover that nearly 40% of overdoses in Camden refuse hospital transport, never interacting with the system we set up for them.

In response to the escalating crisis, we examined our current health care system and, as with the emergency department, realized that US health care already had a 24/7 community medicine infrastructure: EMS. Available in both rural and urban environments, these well-trained providers are trusted members of the community.

Similar to emergency department caregivers that we have already trained, the task of traditional EMS is emergency care, not patient participation or daily monitored treatment. However, paramedics are trained in the challenging interactions they encounter in the field, and they are mobile, carrying life-saving medicines and equipment. We hypothesized that addiction training could add patient engagement and MOUD delivery to EMS. We believe these tools expand the profession and increase the importance of EMS to the healthcare system.

In the fall of 2019, we launched the first buprenorphine field initiative for paramedics at the point of overdose. The program uses all EMS resources to continually engage Aoude patients, provide resources and open community dialogue. Paramedics carry buprenorphine and are supported by X-exempt EMS doctors either at the scene or by phone. To date, we have field-initiated 174 patients on buprenorphine. 100% reported a reduction or removal of withdrawal symptoms and 35% reached their first follow-up appointment. We had no precipitous withdrawals, nor negative outcomes. Peer-reviewed data on the intervention are in the final stages of publication.

In our model, paramedics actively engage patients after reversal with naloxone, begin the first dose of 16-24 mg sublingual buprenorphine at the scene and arrange an appointment at the clinic the next day. The system is dynamic and able to provide engagement, OUD care, and link to care 24/7. Like the emergency department, EMS acts as another gateway for us MOUD CARE SYSTEM. Unlike other low-barrier solutions, it uses existing resources and is scalable for most EMS systems. It is designed to withstand the ebb and flow of grant cycles because EMS is a necessary service.

Other solutions with low barriers have been proposed: mobile units, MAT integration into harm reduction centers, and mobile clinics. While these initiatives can be crucial, they still require patients to seek care, which is often prevented by their disease. Our model allows life-saving medicines to be deployed to patients wherever they are, using the infrastructure that is reliably available across the country.

However, an EMS program for oud cannot exist in a vacuum. Key components and partnerships that have made our program successful include: a flexible and innovative addiction medicine department with easy access to EMS patients, a fully waived X emergency department, organizational partners in case EMS progresses, EMS medical guidance with addiction training, and EMS prepared operations personnel To defend and implement the program. Most importantly, there is a need for ongoing engagement and training of the EMS service providing addiction care.

The impact of the program on medic burnout has been a silver lining. In the past, our EMS professionals, like other healthcare providers, often expressed frustration with patients who overdose. The perceived cycle of relapse, recurrence of overdose, and eventual death is disheartening for acute care professionals who rarely notice patients longitudinal improvement with medication and therapy. Even when buprenorphine was initially not effective, our paramedics reported feeling connected and excited to continue their new interactions. “I’m no longer frustrated because I know we’re trying to do something,” said one of the paramedics. There is pride in reaching what was previously inaccessible and stemming the tide of this devastating disease.

Sharpen and expand the model

Although we were successful in initiating the first dose of buprenorphine at the point of overdose, our fully implemented model would add additional roles, beyond strict emergency response. In the future: EMS providers will search for this population before they experience a serious event, provide daily monitored treatment, community resources, and connect patients to the health care system. Paramedics are already done It has been used successfully To treat chronic illnesses such as heart failure at home, reduce hospital use, and increase patient independence. We created a path to save more lives, and by chance, we saw other unexpected positive effects.

Famous Fred Rogers called for We have to look at emergency responders as helpers: “Always look for helpers… If you look for helpers, you know there is hope.” Communities struggling with opioid use are asking for help, and EMS can fulfill that role.

On their next call, instead of just resuscitation with naloxone, Cooper University paramedics can now seize the opportunity to connect with the patient, start buprenorphine, and care for them during the process of getting their first appointment at the clinic. Paramedics know that their patients may fail to follow up, that they may have to resuscitate them, but this is their community and they will be here 24/7 with the right tools when their patients are ready. With this model, in any community, an EMS can initiate an important new pathway to recovery.

Gerard Carroll, MD, He is an emergency physician and EMS physician at Cooper University Healthcare, and associate professor in the Cooper Division of Emergency Medicine. Rachel Harrose, MD, He specializes in emergency medicine, toxicology, and addiction medicine in healthcare at Cooper University, and is an associate professor in the Cooper Division of Emergency Medicine. Caitlan Baston, MD, MSc, He is a specialist in family medicine and addiction medicine in healthcare at Cooper University and an assistant professor in the Cooper Division of Medicine.

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