EXECUTIVE SUMMARY

Cooper University Health Care in Camden, NJ, is rolling out a new approach that will enable paramedics to administer buprenorphine to overdose (OD) patients in the field. The paramedics will be operating under the guidance of emergency physicians who have been X-waivered to prescribe the drug. The idea is to reduce the barriers that prevent many patients from entering into treatment for their substance use disorders.

  • The program was developed in response to EMS providers contending they are providing nothing more than a Band-Aid when they administer naloxone to OD patients on the scene, thereby saving the patients’ lives (but often plunging those patients into severe withdrawal).
  • Patients often refuse transport to the ED, instead opting to quickly find another source of opioids to relieve their withdrawal symptoms.
  • Considering buprenorphine can relieve withdrawal symptoms, developers hope that more OD patients will be receptive to entering into long-term treatment for their addictions.
  • To move forward with the approach, New Jersey’s health commissioner issued an executive order giving paramedics the ability to administer buprenorphine under the supervision of an X-waivered physician.

While many EDs are struggling with the idea of enabling emergency providers to administer buprenorphine to patients who present with symptoms of opioid withdrawal, Cooper University Health Care in Camden, NJ, is out front on this issue. Not only have all emergency physicians (EPs) in the health system been trained and X-waivered to prescribe buprenorphine to appropriate patients, EPs, addiction medicine specialists, and Camden EMS are developing a protocol that allows paramedics to administer buprenorphine in the field.

Many patients who overdose (OD) refuse transport to the ED after they have received OD-reversal drugs, which often plunge these patients into immediate, severe withdrawal. As a result, OD patients miss out on effective linkages to treatment, choosing instead to find a new source of opioids to ease their symptoms. The protocol in development is designed to end this cycle, thereby capturing more patients into treatment.

The ED will play a big role in the approach. Paramedics will be able to administer buprenorphine under the supervision of an EP. Many patients who receive buprenorphine in the field will be transported to the ED, where they will be linked into effective treatment. The idea relies on treatment resources and approaches that already are well-developed in this community. The proposal has captured the interest of other communities and healthcare providers, too.

Listen to EMS

Gerard Carroll, MD, FAAEM, a paramedic, EP, and medical director for EMS at Cooper University Health Care, notes that the idea for this new approach stems directly from concerns expressed by EMS personnel. “The highest call type in Camden is ‘unconscious and OD,’ whereas in the past it had been chest pain or respiratory distress,” he explains.

Frustrated with the status quo, EMS providers approached leadership, complaining that the way they were responding to calls was a Band-Aid, Carroll relates. “[They said] we are waking people up with Narcan [naloxone] until the next OD until finally they are dead. How do we combat this?”

The plea prompted a discussion among leaders from EMS, emergency medicine, and addiction medicine specialists about what more could be done to address the opioid OD problem. At this point, there already were Suboxone (buprenorphine and naloxone) and methadone treatment programs in place, and a bridge clinic had been established through the ED.

“The idea behind the bridge clinic was that we could begin patients on medication-assisted therapy in the ED and then bridge them into the clinic so we would hit that opportunity,” Carroll notes.

However, it was clear that the healthcare system was missing a chunk of the population that was in need of treatment. “EMS was interacting with these people on the frontlines. Many of them were not ever coming to the hospital. Even if they were, they often couldn’t get through the volume of the ED [before leaving]. We thought how could we interact with them there [in the field],” Carroll says.

To approach these patients in a different way, paramedics first began to share information and research about opioid use when they interacted with patients with opioid use disorders in the field. “We see a lot of these patients recurrently,” Carroll shares.

Further, with the knowledge that buprenorphine was provided to these same types of patients in the ED and in the addiction clinic, EMS leaders then considered whether they also could use the drug in the field. Considering this is something that has not been done before, it would require state-level regulatory approval to clear the way. But that was not the only roadblock. Not all paramedics were on board with the idea.

Begin With Education

When EMS staff were first approached about the concept six months ago, feelings were mixed, observes Rick Rohrbach, BSN, RN, CFRN, CCRN-K, MICP, EMS director for air and ground services at Cooper University Health Care. “We had some folks that have been out there a long time. They had dealt with this for years, and they were a bit resistant,” he explains.

To overcome this resistance, the first step toward implementation of the new plan involved educating EMS staff. “They spent time in our addiction clinic and they spent time with our physicians. We really made them see what this disease [of addiction] is really all about,” Rohrbach says. “Just like with diabetics and just like with cardiac patients, we do have a role in treatment and prevention that is more than just a 911 call.”

Gradually, more EMS personnel have become supporters (if not fans) of the new approach. “That education and the feeling that they are actually part of something that is new to EMS ... have energized a lot of them,” Rohrbach reports. “They are very much engaged now. We are still getting requests from frontline staff members who want to spend time in the [addiction] clinic. They want to see how that works, and how we communicate [with patients].”

Participating staff’s active engagement is critical; yet, others interested in this approach should understand that it can be a heavy lift. For instance, even Carroll acknowledges that he was initially resistant to empowering paramedics to administer buprenorphine in the field.

“What got through to me, and what is getting through to the majority of my colleagues, is that the mortality of this disease is so much higher than so many of the things that we think are our bread and butter,” he says. “When you explain that to our paramedics, when they see the graphs, and when they realize that having a heart attack is almost less dangerous than this, that is when we really get that buy-in from them.”

Put Pieces in Place

Another game changer is the fact that effective treatment for opioid addiction is available, explains Rachel Haroz, MD, an EP and an assistant professor of emergency medicine and medical toxicology at Cooper Medical School of Rowan University. Haroz also helps run the health system’s addiction clinic.

“I did residency and fellowship training almost 20 years ago. Back then, buprenorphine hadn’t even been approved yet,” she says. “With the exception of methadone, which everyone was probably unjustly very leery of [back then], we had nothing that we could do for [patients with opioid withdrawal] in the ED. Other than sending them to rehab and detox, which we now know is not good evidence-based treatment for these patients, there was nothing we could do.”

However, with the approval of buprenorphine, there is a treatment that works, and it is not ethical to withhold this treatment, Haroz stresses. “We know it works, and we know it decreases mortality by two-thirds, which in the world of medicine is huge,” she says.

Nonetheless, reaching the point where it makes sense to put buprenorphine in the hands of paramedics to administer in the field has taken some time. For instance, Haroz notes there first needed to be an addiction clinic or “landing pad” where these patients could receive longer-term treatment. Also, many more physicians in Camden needed to undergo the X waiver training required by the Drug Enforcement Administration (DEA) to prescribe Suboxone. (Learn more about waiver training at: http://bit.ly/2MsbHPU.)

“In 2015, we had a waitlist of 600 patients [to receive Suboxone], and that was simply not feasible. We had to open our own landing pad; hence, we launched our outreach clinic, which now functions five days a week, and we have five physicians staffing that,” Haroz explains. Also, beginning in fall 2016, the health system started providing resident EPs with the training required to prescribe Suboxone. The next spring, attending EPs received this training.

“We actually used the X waiver course as a way to change hearts and minds,” Haroz notes. “What is great about emergency physicians is that they do like evidence-based medicine and data, and the treatment for [opioid addiction] is evidence-based. There are even ED-specific data that we were able to show them.”

Another critical key to the success of the approach was that the healthcare system’s administrative and clinical leadership strongly supported the effort. “Our own department chair simply mandated that all of the emergency medicine physicians become X-waivered,” Haroz notes. “Once emergency physicians started to use buprenorphine, they realized it is a fantastic tool in their toolbox, and that they could actually help their patients,” Haroz says. “The more they did it, the more they wanted to do it.” The strong integration between ED and EMS providers has been instrumental in the push to further expand the use of buprenorphine to paramedics in the field, Carroll notes.

“Day in and day out, our paramedics use our ED for their patients and for medical command,” he says. “For every ALS [advanced life support] call, they talk to one of our emergency medicine physicians to go over the case and the treatment options. They are already very used to working in tandem in that very classic model with the paramedic [operating as] a physician extender.”

Paramedics always want to bring OD patients to the ED. However, even in cases in which patients refuse transfer to the ED, a decision on whether to administer buprenorphine will be made in concert with an X-waivered physician in the ED, Carroll explains.

“We are very sure that this medication is safe and we know it reduces mortality. How well it can work in this venue is a part of this program that we are going to find out,” he says. “We are going to train the paramedics, and they will have the full support of a board-certified emergency physician ... every step of the way. We are going to bring that expertise out of the hospital to the patients where they need it and when they are in the most trouble.”

Carroll makes the case that administering buprenorphine in the field will enhance the opportunity to engage patients in treatment. “When someone is given [naloxone] and resuscitated, it precipitates varying degrees of withdrawal, some of which can be very severe,” he says.

Generally, the more severe the symptoms of withdrawal are, the less willing patients are to engage with providers, Carroll notes. “By the time they get to the hospital, some of these patients are so fed up and dope sick that they just walk out because they would rather just go find some more [opioids] because they are miserable,” he says.

“We just saved their life, but this is a side effect of the [naloxone]. Our hope is that by getting them right away with this treatment [the buprenorphine], we can alleviate those symptoms, and we can lower that barrier to entering care.”

The patient interaction with EMS will not necessarily be a one-time event under the new program, according to the protocol that is in development. “Once patients [agree to] enter into treatment, our mobile integrated health program through our EMS service is willing to go out daily to bring the patients [buprenorphine] while we bridge them to the clinic so they can get into long-term therapy,” Carroll explains. “We will be bringing this treatment to the patients to give them that time to re-enter their lives and to function [without] relapsing.”

Consequently, patients will not just receive a dose of buprenorphine with the hope that they will make it to the addiction clinic in a week. “We are going to engage with them daily in some form as best we can to make sure we support them through this highest-risk period before they get to the clinic,” Carroll says. “We are going to do everything we can to keep patients from just going back to their addiction cycle in that really critical period of three to six days before they get [into longer-term care].”

Precisely how patient interactions will proceed following an initial paramedic encounter likely will vary under the new program, Haroz shares. “In a city like Camden, an unusually large number of patients don’t want to go to the ED at all after they have received [naloxone]. Many of them refuse transfer,” she says. “Part of our mission is to engage that population that won’t even come to the ED, whatever we can do to keep them safe and try to engage them in treatment.”

The paramedic-focused effort is rolling out in stages. To this point, the education piece has been the primary focus. “I think it is important that we have laid the foundation for this over the past six months through education and talking to our folks about how to engage these patients because that is half the battle,” Rohrbach shares.

In June 2019, New Jersey Health Commissioner Shereef Elnahal, MD, issued an executive order enabling paramedics in the state to administer buprenorphine under the supervision of an X-waivered physician, although only the state’s 21 mobile ICUs are authorized to carry the drug. Nonetheless, the move has given program developers in Camden the green light to move forward with protocol development. (Editor’s Note: Elnahal left his post as state health commissioner in July 2019 to become president and CEO of University Hospital in Newark, NJ.)

“We have already been using our X-waivered EMS physicians to respond to calls to start this program in the field in a limited way,” Carroll observes. “Our plan is that we will actually have a physician on scene for a lot of these calls initially. This will provide apprenticeship training [to the paramedics] above and beyond just reading a book or taking a test. That is our safety valve to make sure this is rolled out correctly.”

Such an approach will allow for any tweaking of the protocol that may need to take place as developers observe what happens when paramedics respond to calls involving patients who have overdosed. “We are trying to figure out the best way to treat these patients and save their lives,” Carroll says.

Haroz stresses that none of this would be possible without close collaboration among emergency medicine, addiction medicine, EMS, and community partners. “We are hoping to be able to bridge these patients not just to [our own addiction clinic], but also to some of our community partners,” she says. “Some of these patients are going to be homeless and have other needs. Some will be best serviced by our local FQHC [Federally Qualified Health Center], which does a phenomenal job treating these patients with Suboxone as well.”

With all these pre-existing partnerships, Camden, NJ, is perhaps uniquely prepared to roll out this approach, but other communities are taking an interest in the model, too. “I have had four or five EMS directors from around the country contact me and ask for our protocol,” Carroll shares.

There may be other communities in New Jersey that eventually adopt the model, too, although Carroll is unsure at this point which communities have developed the appropriate partnerships and put the infrastructure in place to go down this road. “I am hoping that we have a model that [others] can learn from and adapt to their needs,” he says.