lakecountyopioidinitiative

Everett, WA needle cleanup behind a Home Depot.

From the Boston Globe, October 30, 2017—One in 10 Massachusetts residents who were revived from an overdose by a fast-acting antidote went on to die within a year, according to research providing stark evidence that merely reversing overdoses will not end the opioid crisis. The study, presented Monday at a medical conference, tracked what happened to thousands of people who received the overdose rescue drug naloxone, commonly known by the brand name Narcan.

Nearly all were successfully revived, but a high percentage later died, most likely because their underlying substance-use disorder went untreated, said Dr. Scott G. Weiner, the study’s lead author and an emergency medicine physician at Brigham and Women’s Hospital. “Naloxone is just a Band-Aid,” Weiner said. “It’s not the cure.” In Massachusetts, state and local health officials have worked to make naloxone widely available, training thousands of laypeople in its use and getting the drug into the hands of first responders around the state.

But Weiner, who directs the Brigham Comprehensive Opioid Response and Education Program, said his research shows that “it’s not going to work if we just give naloxone. We need to get them to the next step.” Hospitals should provide medications to treat addictions and immediate links to ongoing care in the community, but few do, he said.

Dr. Kevin P. Hill, director of the Division of Addiction Psychiatry at Beth Israel Deaconess Medical Center, who was not involved with the study, called the findings important but not surprising. “I might see 10 of these people a day. The fact that one of them isn’t going to be here a year from now says the situation is dire,” Hill said. “What this study shows is that the window of opportunity may only be open for a short period of time. Once somebody has had an overdose, the clock is ticking.”

Weiner presented a summary of his study, which has not been published in a medical journal, at the annual conference of the American College of Emergency Physicians in Washington, D.C. To conduct the study, Weiner and colleagues delved into a trove of data collected by the Massachusetts Department of Health, which enabled them to connect ambulance, hospital, and death records. They examined what became of 12,192 people who were administered naloxone by emergency medical services in the state between July 1, 2013, and Dec. 31, 2015.

Naloxone initially saved most lives; only 6.5 percent died the day they received the medication. But among those who survived the first day, 9.9 percent died within a year. Their median age was 54. Among those who died, nearly 40 percent did so outside of the hospital and more than half passed away in the first month.

The researchers had no information on people who were saved with naloxone by a friend or relative or who declined transport to the hospital after treatment by ambulance crews, and thus may have underestimated the death rate, Weiner said.

‘Once somebody has had an overdose, the clock is ticking.’ Said Dr. Kevin Hill, of Beth Israel Deaconess Medical Center “This study highlights the grim reality that individuals who survive a non-fatal overdose have a shockingly high mortality rate at one year,” Dr. Sarah Wakeman, medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital, wrote in an e-mail.

Wakeman, who was not involved with the study, said that other data from the state show that people who started taking the addiction treatments methadone or buprenorphine after surviving an overdose were half as likely to die as those who did not receive the medications. But only 5 percent of overdose survivors receive those medications, which quiet the cravings for opioids and can pave the way to long-term recovery. “The most tragic aspect to me is the fact that we have this life-saving treatment and yet for logistical and ideological reasons it is not widely available to our most vulnerable community members,” Wakeman wrote. “There is no reason we should have delays in starting life-saving medication.”

At Mass. General, Wakeman said, people who come to the emergency department after an overdose are walked over to the hospital’s Bridge Clinic, where they receive a prescription for buprenorphine, commonly known by the trade name Suboxone. Both the Brigham and Beth Israel are working to make buprenorphine readily available to emergency room patients but face challenges in educating emergency room clinicians and making connections to treatment programs in the community.

“It’s not an easy thing to do,” Weiner said. “People are coming in at all hours. To have these services available right then and there is very important.” A sweeping state law passed last year to address the opioid crisis included a provision requiring hospitals to assess patients who come to the emergency room after an overdose and help connect them to a program. But a Globe survey of hospitals in July found that most patients declined even to be assessed.

Weiner said the law has been ineffective because hospitals rely on social workers instead of recovery coaches, who have firsthand experience with addiction and stay with patients through the often hours-long process of finding a treatment spot. Some patients are merely handed a list of numbers to call.

“That’s not doing anybody a service,” Weiner said. “This is a brain disease. Some people aren’t organized to do this. . . . You need to meet people where they are.”

At the annual conference of the American College of Emergency Physicians, Brigham researchers also presented a separate naloxone-related study. Dr. Scott A. Goldberg, an emergency medicine physician at the Brigham, and colleagues found that untrained bystanders are willing and able to administer naloxone to strangers. In a daylong experiment in Cambridge’s Central Square, researchers asked passersby to participate in a mock overdose rescue on a mannequin. Of the 50 who completed the experiment, only one failed to properly administer the drug by squirting it in the mannequin’s nostril. That person held the device upside down.

“We were really surprised that almost all were able to do this,” Goldberg said. “These are preliminary results,” he added. “By the same token the results were really strong and very encouraging.” After additional study, Goldberg hopes that lock boxes containing naloxone will be routinely placed in public places where overdoses frequently occur.

The opioid epidemic has been fueled by soaring numbers of prescriptions written for pain medication. And often, those prescriptions are written by dentists.

“We’re in the pain business,” says Paul Moore, a dentist and pharmacologist at University of Pittsburgh School of Dental Medicine. “People come to see us when they’re in pain. Or after we’ve treated them, they leave in pain.”

Indeed, 12 percent of prescriptions for immediate-release opioids are written by dentists. In 2012, dentists ranked fourth among medical specialties for their opioid prescribing rates, according to data from QuintilesIMS. It has made dentists targets for people “doctor shopping” in order to get opioids.

How Dentists Compare With Other Specialties In Prescribing Opioids

“I have dentures,” said Shawn Bishop, who is recovering from an opioid addiction at Hope House, a treatment center in Boston. “I had went to get some legitimate work done. And I got some Percocet. I realized that by going to another dentist, I could get some more Percocets.”

Bishop, now 59, recounts the times he teamed up with others to play dentists for their opioid pills.

“He would look at our teeth or Mark’s teeth in particular,” Bishop said. “He would look at his teeth and say, ‘Yeah, we need to take this one, this one, and this one.’ And Mark will always say, ‘Well, I can’t do it today. Can we make an appointment for next week?’ And then the doctor will say, ‘Yeah, I need to write a prescription of Percocets.’ He kept bad teeth and toothaches just so he can do that, you know?”

For Bishop and his friends, the enterprise of getting opioid pain pills from dentists grew so routine that, he says, he became a professional at it.

“It was almost like they knew their part to play and we knew ours,” he said. “It was like actors in a little sketch there.”

Massachusetts has taken the lead in trying to reduce opioid prescription abuse. Last year, Gov. Charlie Baker’s office passed a law to prevent drug misuse. Dental schools in the state are also required to teach a set of core competencies that their students are required to meet before graduating. Students will have to demonstrate that they know how to consider nonopioid treatment options.

“At least at the medical school, the dental school, nursing school and pharmacy school level, you don’t graduate from those places without having studied this stuff and understanding both the positives and the negatives associated with using it,” Baker says. “In addition to that, making sure as a condition of relicensure, you’re getting everyone who is writing prescriptions as part of that process.”

Now, after decades of criticizing health care providers for undertreating pain and not prescribing enough pain medication, the pendulum is swinging back. Some dentists are getting back up to speed about alternatives to opioids.

“For most dental pains, the nonsteroidal anti-inflammatory drugs (NSAIDS) —that’s Advil, Aleve, Naproxen — those agents are every bit as effective as one Vicodin or one Percocet,” Moore says. “That’s been shown over and over and over again.”

Third-year students at the Harvard School of Dental Medicine learn how to trim crowns and prep a tooth for a crown. They’re also learning to deal with the aftereffects, studying alternatives to opioids for pain relief.

This next generation of dentists is not only learning about how to prescribe opioids appropriately, but also about how to think about pain differently. At the Harvard School of Dental Medicine, students are learning how to approach pain a world away from opioids.

“You can approach it from opioid therapy, you can approach it from different neuropathy drugs, you can approach from stretching exercises to meditation,” says Kellie Moore, a fourth-year dental student at Harvard. “And just kind of like, exhausting all the options.”

Leaning on different methods of pain treatment can yield mixed success, she says: what works with one patient might not work for another.

Dental students are also rethinking what the goal of treating pain is. “On a scale of 0 to 10, with 10 being the worst, if we can get you to a 4 or 5, could you live with that and still function daily?” says Sam Lee, a fourth-year dental student. “If the answer is yes, then I think it’s important to the patient understand that that’s what we’re going to try to maintain as the new normal for them.”

Mannequin patients are stationed at the Harvard School of Dental Medicine’s Preclinical Lab, ready to have their teeth restored with crowns by a class of third-year dental students.

David Keith, an oral surgeon at Massachusetts General Hospital, agrees. “I think it does us a disservice, making us and the patients assume that they should have a total smiley face and a zero level of pain,” he said. “That’s not the real world. So we take a tooth out. We do a dental implant. You’re going to be sore for a few days, but that doesn’t mean you can’t go to work.”

The changing definition of pain is part of a larger change in the profession of dentistry. And Jeff Shaefer, an orofacial pain specialist who teaches at the Harvard School of Dental Medicine, says the role of the dentist is changing as a direct result of the opioid crisis.

“Dentistry is part of the problem and I think that hurts — that we’ve been overprescribing medication,” he says. “Having a standard regimen to give every patient is not appropriate.”

Nationally, the profession of dentistry is starting to change as well. This summer, the Commission on Dental Accreditation, which sets accreditation standards for all dental schools, ordered all graduates to be competent in accessing for substance use disorder.

But currently practicing dentists may not be so eager for a change to their profession. Keith, who regularly gives lectures to dentists in the state, has heard their complaints.

“There is a reluctance to add that, as there is reluctance to check blood pressure or check a list of medication their patients are on because it adds time to the day,” he said.

http://www.npr.org/sections/health-shots/2017/09/08/549218604/dental-schools-add-an-urgent-lesson-think-twice-about-prescribing-opioids

Notes for the table

• “Non-physician prescribers” include nurse practitioners and physician assistants.
• “General practice” includes specialists in osteopathic medicine, general practice and preventive medicine.
• “Surgery” includes specialists in general, orthopedic, plastic, cardiothoracic, vascular, colorectal, spinal and neurologic.
• “All others” includes specialists in cardiology, critical care, dermatology, endocrinology, gastroenterology, geriatrics, hematology, infectious disease, neurology, obstetrics and gynecology, oncology, otolaryngology, palliative care, pathology, pediatrics, podiatry, psychiatry, pulmonology, radiology, rheumatology, urology and veterinary.

Challenge

Eric’s suburban Chicago police department started to see a spike in heroin and prescription drug use. What officers reported, however, was that they were returning to some homes as many as three times to reverse overdoses. They wanted to figure out how to provide help on the front end, before the overdose.

Solution

Eric reached out to seven other police chiefs in the county to come up with a strategy to divert drug users from the criminal justice system to health treatment. That concept became The Way Out program through which drug users can walk into a police station and ask for help without fear of being handcuffed.

The police departments partner with the county health department to screen drug users through a 24-hour crisis line to get them to appropriate care (i.e. inpatient, outpatient, or hospital). The Way Out Program launched June 1, 2016, and now averages 12 cases per month.

Eric also became part of the Lake County Opioid Initiative, a collective of roughly 70 groups that come together monthly to discuss strategies. He became co-leader of the first responders group and the department launched a Naloxone program in which all law enforcement responders were trained to administer the drug that reverses an overdose. Over three years, the program has reversed 170 overdoses.

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The Lake County Opioid Initiative (LCOI) today reported an expansion of its groundbreaking law enforcement pre-arrest diversion program, A Way Out. Four new agencies have been added as entrance sites including Deerfield Police Department, Fox Lake Police Department, Zion Police Department, and the Lake County Sheriff’s Office. A Way Out co-coordinator and Mundelein Director of Public Safety, Eric Guenther said, “A Way Out has far exceeded anyone’s expectations. This is a direct result of diligent teamwork, but most importantly because the individuals utilizing this program have placed their faith and trust in us.”

By taking advantage of A Way Out, participants and their loved ones are given the opportunity to access support and treatment to end the destructive cycle that addiction has caused in their lives. Participants are given the chance to avoid the biological, psychological and environmental harms, and are set on a direct course to recovery through services provided by Gateway Foundation, Nicasa Behavioral Health Services, the Lake County Health Department’s Substance Abuse Program and other providers across northern Illinois and the state. The only requirement of participants is self-motivation. Karen Wolownik Albert, Gateway Foundation, Executive Director-Lake County Treatment Services said, “For persons struggling with a Substance Use Disorder, the decision to seek help can be scary. Navigating the challenges of finding an available treatment resources can be daunting, and many people may give up. A Way Out guides and supports persons through the process of accessing treatment and taking those first steps toward recovery. We are so fortunate in Lake County to have a multidisciplinary network of individuals and organizations working collaboratively to end overdose and provide assistance to persons struggling with Substance Use Disorders.”

Since the launch of A Way Out in June 2016, 170 people were connected to treatment and recovery programs. A Way Out graduate, Danya Vasquez said, “It is impossible to measure the value of the lives that this program has saved and the lives that it continues to save. Allowing people like me the opportunity to receive treatment without fear of incarceration is beneficial to everyone. A Way Out literally saved my life.”

A Way Out is available 24 hours a day at participating police agencies across Lake County and ensures no criminal charges will be sought for those that may be in possession of narcotics or paraphernalia, as long as assistance is sought out by the prospective program participant. Individuals struggling with addiction to any substance or who are from outside of Lake County are eligible. Participants can locate a participating police agency, walk through the main entrance, and inform the staff that they are looking for A Way Out. After regular business hours (including weekends), participants can utilize the call box near the front door which will connect him/her to a dispatch operator who will them through the next steps.

The process for accessing care through the Lake County Sheriff’s Office is broader to accommodate for all unincorporated areas of the County as well as contract communities, and communities without a full-time law enforcement agency. During regular working hours, which are Monday through Friday from 8:00 AM – 5:00 PM, participants may come to one of three Sheriff’s Office locations including:

• 25 S. Martin Luther King Jr. Ave., Waukegan
• 1301 N. Milwaukee Ave., Libertyville – Call (847) 549-5200 to inform of intent to participate
• 703 U.S. Rt. 12, Fox Lake – Call (847) 549-5200 to inform of intent to participate

The Sheriff’s staff will contact a deputy to work with the participant. If a participant reaches out for assistance and has no transportation, the Lake County Sheriff’s Office will dispatch a deputy to pick up the participant. After regular business hours, participants may call (847) 549-5200 and request A Way Out. A deputy will be dispatched to the participant’s location if no transportation is available.

Sheriff Mark Curran stated, “Unfortunately, most of us know of a family devastated by addiction. In most cases, family members endure suffering along with their addicted loved ones. As leaders in public safety, we continuously seek solutions that keep families intact and ensure jails house criminals, not people suffering from substance use disorders. We cannot cure addiction through arrests and incarceration, but, we can be a supportive link to services for those who are ready for help. A Way Out is a way into sobriety and self-sufficiency, one person at a time and one day at a time.”

Information and instructions can be found at AWayOutLC.org or via the Lake County Helps app which is available for Android and IOS devices.

About Lake County Opioid Initiative:

The Lake County Opioid Initiative’s mission is to develop, implement, evaluate and sustain a multi-strategy county-wide effort to prevent opioid abuse, addiction, overdose, and death. LCOI was founded by Michael G. Nerheim, Lake County State’s Attorney, Chelsea Laliberte, Executive Director of Live4Lali, Bruce Johnson, CEO of Nicasa Behavioral Health Services, and George Filenko, Chief of the Round Lake Park Police Department.

Recognized by the White House Office of National Drug Control Policy (ONDCP) and National Association of Counties (NACo), LCOI has achieved national acclaim as a collaborative, cutting edge, countywide task force developed to overturn the devastating effects caused by the opioid epidemic. Since its inception in 2013, LCOI retains a membership of more than 300 people across 80+ agencies, and has developed groundbreaking programs, of which two focus on public safety as critical change agents in the fight against addiction and overdose. Anyone can become a member of LCOI. Meetings are held the third Thursday of every month. For more information, please visit: http://www.opioidinitiative.org or http://www.awayoutlc.org

The Lake County Help mobile app was developed by LEAD and is intended for residents of Lake County, IL and surrounding communities. Included in this app is access to a 24/7 anonymous text crisis line (Text-A-Tip), access to the law enforcement assisted diversion drug treatment program (A Way Out), signs and symptoms of an overdose, and information about Naloxone (Narcan) and the Illinois Good Samaritan law.  Click here to download the app via iTunes.