EXECUTIVE SUMMARY

The CDC has unveiled alarming data showing that ED visits for opioid overdoses increased by 30% between July 2016 and September 2017. While it is clear that more action must be taken to address the problem, some pioneering states already have taken steps to respond to the opioid epidemic in a coordinated way. For example, in Rhode Island, hospitals and EDs are working with state health authorities and law enforcement to address the epidemic of opioid overdoses in the region. The approach involves standardizing the care provided to patients who present with opioid use disorders, quickly reporting on cases of suspected opioid overdoses in the ED, and coordinating a system of surveillance and response.

  • Rhode Island is in the process of certifying all the hospitals in the state that offer standardized care for patients who have presented with opioid overdoses or opioid misuse disorders. The state has established three tiers of care that hospitals can achieve.
  • The state also requires hospitals and EDs to report cases of suspected opioid overdoses to the Rhode Island Department of Health within 48 hours.
  • A multidisciplinary team reviews the data on a weekly basis so that affected regions of the state can be alerted to increases in overdose activity.
  • The data collection requirements have proved challenging to hospitals, although the state is working to streamline the reporting process. Also, the use of on-site champions has helped the state implement the levels of care approach.

Startling new ED-based data unveiled by the CDC clearly show much more must be done to stem a rising tide of opioid overdoses in the United States. Specifically, the CDC reports that the number of patients with opioid overdoses treated in the ED increased by 30% between July 2016 and September 2017. These increases were seen in all regions of the country, although particularly hard hit were Midwestern states, which reported a 70% increase.

In a media briefing about the new statistics, Anne Schuchat, MD, the acting director for the CDC and acting administrator for the Agency for Toxic Substances and Disease Registry, noted that opioid overdoses are increasing in most states for both men and women, and in most age groups. “We’re currently seeing the highest drug overdose death rates ever recorded in the United States, driven by prescription opioids and by illicit opioids such as heroin and illicitly manufactured fentanyl,” she explained. “In 2016, there were more than 63,000 drug overdose deaths and more than 42,000 of those deaths involved an opioid. This means that, on average, 115 Americans died each day from an opioid overdose involving prescription or illicit opioids in 2016.”

The data stem from a CDC Vital Signs report, drawing from EDs in 52 jurisdictions in 45 states. Out of 91 million ED visits, Schuchat noted there were 142,557 suspected overdoses involving opioids. “The largest increases were in Wisconsin, at 109%, which means the rate more than doubled there,” she said. “A similar rise of 105% was seen for Delaware.”

Three states (Massachusetts, New Hampshire, and Rhode Island) showed modest decreases in ED visits for opioid overdoses, although the decreases were not statistically significant. However, such visits declined by 15% in Kentucky, a change that is not yet well understood by investigators.

The biggest increases were seen in large metropolitan areas with populations of more than 1 million residents. Schuchat noted that in these areas, overdose-related ED visits increased steadily in each successive quarter for a total increase of 54%. She also stressed that for every fatal overdose, there were many more non-fatal cases, representing a big opportunity for emergency providers to intervene.

“Research shows that people who have had at least one overdose are more likely to have another,” Schuchat said. “If the person is seen in the ED, we are presented with an opportunity to take steps toward preventing a repeat overdose, ideally linking the individual to care and potentially preventing an overdose death, and ideally alerting community partners to opportunities to improve prevention in the surrounding areas.” (See also in this issue: The surgeon general urges clinicians to take a role in ending addiction stigma.)

Take Steps to Standardize Care

In fact, in some pioneering states, emergency providers have moved forcefully to work with public health authorities, law enforcement, and community partners to address the high number of opioid overdoses, and connect patients who have overdosed with effective treatment. For example, in a CDC Vital Signs Town Hall held on March 13, presenters from Rhode Island discussed their initiative to combat one of the highest opioid overdose rates in the country. The effort began with a strategic plan aimed at reducing the prescription of opioids while expanding access to naloxone, medication-assisted treatment (MAT), and resources to support recovery for individuals with opioid use disorders.

“Recognizing the unique and vital role of hospitals and EDs, in 2017 the Rhode Island Department of Public Health and the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals released levels of care for Rhode Island hospitals for treating overdoses and opioid use disorders,” explained Elizabeth Samuels, MD, MPH, an emergency medicine physician and the levels-of-care implementation lead for the Rhode Island Department of Health. “The levels of care outlined three different tiers of service for hospitals and EDs to provide care for patients with opioid use disorder, and after having had an opioid overdose.”

Hospitals categorized or certified at the tier 3 level, the most basic level of care, must ensure they are adhering to a discharge planning law mandated throughout the state that requires hospitals or EDs to contact a patient’s emergency contact and primary care provider (PCP). Level 3 also requires:

  • standardized substance use disorder screening for all patients;
  • education on safe opioid storage and disposal for all patients who are prescribed opioids;
  • the dispensing of naloxone to all patients found to be at risk according to a clear protocol;
  • the offer of peer recovery support services;
  • active referral to appropriate community providers;
  • compliance with 48-hour reporting of overdoses to the Rhode Island Department of Health;
  • laboratory drug screening, including screening for fentanyl, for patients who overdose.

Level 2 facilities must meet all the criteria of level 3 hospitals, and they also must provide comprehensive standardized substance use assessment. Further, they need to maintain capacity for the evaluation and treatment of opioid use disorder with the support of addiction specialty services.

Level 1 facilities must meet the criteria for level 3 and level 2 facilities and also maintain the ability to initiate, stabilize, or re-stabilize patients on MAT. Further, these facilities need to evaluate and manage MAT, and ensure the transition of patients to community providers to facilitate recovery.

Samuels has led the effort to implement the levels of care in the state’s 12 licensed hospitals, and this effort is ongoing.

“As of today, nine hospitals are now certified. Seven hospitals have achieved level 1 certification and two have achieved level 3,” she said. “There are three remaining hospitals to certify. Two level 3 hospitals are currently under review and one is in process.”

Collect and Report Data

A key component of the state’s surveillance and response system to the opioid overdose epidemic is the requirement for hospitals to report overdoses to public health authorities within 48 hours. This step was initiated by the Rhode Island Department of Health Emergency Regulation, and then passed by state legislators in 2014.

Samuels noted that the reporting is facilitated with the use of an online tool that has been revised continuously to improve data quality, accuracy, and usability for surveillance. The data are made available, along with other resources, on a public dashboard, www.PreventOverdoseRI.org, which is maintained by the Brown University School of Public Health in Providence, RI.

“On this dashboard, you can do aggregate reports from 48-hour reporting, including monthly changes in ED utilization for overdoses, reported naloxone distribution, and the provision of on-site counseling at the time of the ED visit,” Samuels shared. While the reporting is vital to the state’s efforts to carry out surveillance and response activities, Samuels acknowledged that the task has proved challenging to hospitals, especially smaller facilities with fewer resources. “It requires the manual extraction of data and the manual filling out of the [reporting] form, which is not specifically onerous in itself, but does take staff time to complete,” she said. “We have been trying to minimize and streamline this process by narrowing down the data we need for response to the epidemic, and we are exploring some other ways to streamline the data transmission process.”

Nonetheless, the data give the state current information on overdose activity that authorities can then act on, explained Meghan McCormick, MPH, the lead epidemiologist for the state’s drug overdose prevention program. “Our surveillance response intervention [SRI] team is a collaboration between staff at the Rhode Island Department of Public Health, the Department of Behavioral Health Care, Disabilities, and Hospitals, and the Rhode Island Fusion Center, [a multidisciplinary resource that works with state and local agencies as well as the Department of Homeland Security to assess threats, facilitate effective decision-making, and empower effective emergency response],” she said. “We meet every Tuesday to review the past week’s overdose data. Recommendations based on emerging trends are made and stakeholders are alerted to any increased overdose activity.”

Monitor, Respond to Data

During the SRI meetings, participants review data from multiple sources, including toxicology reports, law enforcement alerts, and EMS data. However, McCormick stressed that most of the panel’s response is based on the 48-hour reporting system, requiring hospitals to report any suspected opioid overdose within two days.

The system provides a treasure trove of information that has not been available before, McCormick observed. “Prior to the development of this reporting system, most of our information about people who overdosed was based on fatal overdoses, but a very small percent of overdoses resulted in fatalities,” she said. “This system allows us to learn more about non-fatal overdoses and possibly prevent a subsequent overdose death.”

One of the lessons the SRI team learned from regularly monitoring the data from the 48-hour reporting system is that even though Rhode Island is a very small state, different areas of the state experience increased overdose activity at different times, McCormick noted. “As a result of these regional differences, we divided the state into 11 regions based on a year and a half of 48-hour reporting data,” she said. “Thresholds for normal overdose activity were set based on two standard deviations away from the weekly average for that region. If a region goes over that threshold, we send out a public health advisory to stakeholders and community partners to alert them of increased overdose activity in their area.”

The SRI team is focused on leveraging the data further to respond more forcefully to overdoses in the community. “In December [2017], we brought in stakeholders [from] every city and town in the state, and helped them to think about the development of an emergency response plan specific to the overdose epidemic,” McCormick shared. “We have received letters of intent from 31 municipalities planning to complete the emergency response plan. We have continued with technical assistance calls with these municipalities and are expecting completed emergency response plans in May.”

The idea is to improve the response by municipalities when they receive a public health advisory regarding overdoses as well as longer-term planning to prevent overdoses in the future, McCormick explained.

Address Barriers

Perhaps not surprisingly, there have been a few roadblocks on the path toward implementing the levels of care at all the hospitals in the state. For example, Samuels noted that stakeholder engagement in the process probably was hampered initially by the fact that the levels of care policy was not written by the hospital or ED clinicians charged with implementing the required tasks. Ultimately, though, Samuels said the hospitals demonstrated dedication to integrating the policy requirements into their workflows and improving the standard of care they were providing to overdose patients.

“Given the high prevalence of deaths [from opioid overdoses], it is very common [for] people to have their own personal lives touched by the loss of a loved one or to know someone who has unfortunately lost a loved one,” Samuels observed. “People were truly motivated to do something different to be able to provide innovative, comprehensive care to patients with opioid use disorder.”

One continuing challenge has been the rising cost of naloxone. Some hospitals have been able to make a dent in these costs by purchasing the drug in bulk or by obtaining grants. “Hospitals that have been unable to provide naloxone physically at the time of an ED visit at a minimum will provide patients with a prescription,” Samuels said.

There also have been scheduling challenges, especially for EDs that are initiating MAT. The clinics that offer MAT typically operate on bankers’ hours while the ED treats patients on a 24/7 basis, with most overdose patients presenting in the evening hours, Samuels explained. “What has been successful in hospitals when they have implemented ED-initiated buprenorphine is the development of clear protocols with the development of clear routes of acquiring an appointment or drop-in hours the next day with partnering MAT providers,” she noted. “This is to ensure that patients do have follow-up after the ED visit.”

By far the biggest barrier to the policy’s implementation has been stigma, and this has been evident among hospital staff as well as some patients when it comes to MAT, Samuels advised. Staff training on the disease of addiction as well as evidence-based treatments has helped address the problem.

Leverage Champions

On the plus side, the presence of local champions has made a big difference in helping to implement the policy and alleviate challenges, Samuels stressed. “The champion has been a different person at each site. The champions have been ED directors, ED clinicians, social workers, nursing leadership, pharmacists, and hospital administrators,” she said. “Community hospitals in particular have done a great job of leveraging their departments of social work and pharmacy, really [fulfilling] their full scope of practice and taking leadership on policy implementation.”

Another key to the policy’s success has been partnering, both externally between the state agencies, hospitals, and community-based organizations, and internally between the different departments in each hospital, including pharmacy, social work, psychiatry, and the ED. “Without these partnerships, the implementation would have failed,” Samuels emphasized.

The next steps for the program involve improving the timeliness and efficiency of the surveillance data to help in the public health effort to address the opioid overdose epidemic. Samuels also has three hospitals left to complete certification in the levels of care process, but she noted that this task should be completed soon. Ultimately, the goal is to evaluate both the services that are offered to patients with opioid use disorder and those patients treated for an opioid overdose. Further, developers aim to assess the program’s overall impact on mortality, recurrent overdoses, incarceration, and whether appropriate patients have initiated MAT.

SOURCES

  • Meghan McCormick, MPH, Lead Epidemiologist, Drug Overdose Prevention Program, Rhode Island Department of Health, Providence, RI. Email: meghan.mccormick@health.ri.gov.
  • Elizabeth Samuels, MD, MPH, Levels of Care Implementation Lead, Rhode Island Department of Health, Providence, RI. Email: liz.samuels@health.ri.gov.