Project POINT
Meeting post-overdose patients where they are
THE DEPARTMENT OF EMERGENCY MEDICINE
Drs. Dan O’Donnell and Krista Brucker
Indiana University School of Medicine
Department of Emergency Medicine
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Objectives
1. Not your typical narcan talk
2. Discuss the current opioid epidemic
3. Describe the public safety response to this epidemic
4. What is going on from the hospital end
5. Future possibilities
INDIANA UNIVERSITY SCHOOL OF MEDICINE
D
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C a u se s o f d e a th in th e U nite d S ta te s 2 0 15
N u m b er o f d e ath s
INDIANA UNIVERSITY SCHOOL OF MEDICINE
INDIANA UNIVERSITY SCHOOL OF MEDICINE
2 0 1 1
2 0
1 2
2 0 1
3
2 0
1 4
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0 1 5
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IE M S n a lo x o n a d m in is tra tio n s b y y e a r
Y ear
N u m b er o f n alo xo ne
a d m in istra tion s
S ingle
a d m inistra tio n
R epeat
a d m in istra tio n s
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Repeat Customers
Approximately 20% of our patients are re-receiving naloxone
Anywhere from 2-12 times
– Almost ½ within 1 year
• Some as early as 1 day
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Fatalities
In a sample of IEMS Naloxone administrations over a 5 year period
– 9.4% have died
• 3.3% from a drug related issue
Having multiple incidents requiring EMS naloxone increases hazard of
death by 65%
– Hazard of death from drug related causes by 200%
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Why Is This Happening?
ENOUGH WITH THE GLOOM
AND DOOM
IU Department of Emergency Medicine
Public Response
• Increased access to Naloxone
– Police
– Fire
– First Responders
• Layperson Naloxone
IU Department of Emergency Medicine
Police Naloxone
• Often first on scene
– Almost 90% had seen an overdose
• Officers can be easily trained to recognize overdose and safely give
naloxone
– Majority felt comfortable delivering
– There to keep scene safe
• IMPD has been delivering since 2014
IU Department of Emergency Medicine
• Reviewed all police naloxone administrations
(N=126)
• Officers appropriately recognized opiate overdose
• Majority of officer delivered naloxone did well
• Overall positive medical response
– Regained consciousness
– Only 1 became combative
IU Department of Emergency Medicine
Police Naloxone
• Can be safely done
• Effective
• Indiana Law allows for this (SB 227)
What About Lay Person Naloxone?
IU Department of Emergency Medicine
Does It Work?
• Massachusetts experience
– 20% of rescue attempts were by family members
• People want to be trained
– Most literature confirms this
• Some communities seeing a “trend” towards decrease in opiate
overdose deaths
• More research has to be done to look at effectiveness
INDIANA UNIVERSITY SCHOOL OF MEDICINE
So, now
what
happens?
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Post-discharge services provided within 30 days following an opioid-
related hospitalization among the privately insured: 2010-14
INDIANA UNIVERSITY SCHOOL OF MEDICINE
INDIANA UNIVERSITY SCHOOL OF MEDICINE
INDIANA UNIVERSITY SCHOOL OF MEDICINE
INDIANA UNIVERSITY SCHOOL OF MEDICINE
What if we
treated an
overdose
like a heart
attack?
INDIANA UNIVERSITY SCHOOL OF MEDICINE
OD or
Referral
ED Evaluation
Stabilization
Long-term
substance
(mis)use/MH
care
Rapid ED
follow-up
ED Brief
Intervention
and linkage to
care
IU Department of Emergency Medicine
POINT Goals
- Learn more about our opiate overdose patients
- Increase access to Naloxone among high risk patients
- Provide a brief intervention/harm reduction information
- Link people to treatment/services
- Investigate barriers to accessing treatment
- Collect data
- Use data to improve services in the ED and linkage to care
INDIANA UNIVERSITY SCHOOL OF MEDICINE
INDIANA UNIVERSITY SCHOOL OF MEDICINE
IU Department of Emergency Medicine
• Randomized ED patients to either:
– Buprenorphine Rx
– Referral only
– ED engagement and referral to treatment
• 30 day follow up
– Significant increase in treatment-rates in suboxone
group
– 78% vs. 35% vs. 46%
INDIANA UNIVERSITY SCHOOL OF MEDICINE
POINT
Total 82
Sex
Male 63.4%
Female 36.6%
Median Age 33
Median Age of 1st Drug Use 13.4
Source: Project Point Data Set
POINT Demographics
Feb-Dec 2016
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Total Percentage
Total Interviews 82
Reported hx mental illness 31 37.8%
Previous Visits at Midtown 45 54.9%
Source: Project Point Data Set
Mental Health History
POINT Feb-Dec 2016
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Total Percentage
Total Interviews 82
Naloxone
Knowledge 53 64.6%
Has access 3 3.7%
Source: Project Point Data Set
POINT Observational data
Feb-Dec 2016
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Total Percentage
Sharing Needles 43 52.4%
Known Hepatitis Positive 26 31.7%
% of +hep C sharing needles 21 80.8%
POINT Observational data
Feb-Dec 2016
Source: Project Point Data Set
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Total Percentage
Interested ED intervention
Treatment referral 73 89.0%
HIV testing 57 69.5%
Hepatitis C testing* 23 41.1%
*56 without known hep C
Source: Project Point Data Set
POINT Observational data
Feb-Dec 2016
Lesions from POINT’s 1
st
year
IU Department of Emergency Medicine
The role of chronic pain and adulteration
• “I got Norco when I was 12 for a knee injury”
• “I’ve worked construction my whole life. Now, I need it just to go to
work”
• “I bought a Xanax bar to help me relax and sleep before a test.”
• “I was bored, so I tried it. I thought it was an Oxy.”
INDIANA UNIVERSITY SCHOOL OF MEDICINE
“Heroin is the only way to make my
mind stop racing.”
“I am on a whole bunch of meds,
but they just don’t work.”
Total Percentage
Total Interviews 82
Hx mental illness 31 37.8%
Depression 17 20.7%
Bipolar 10 12.2%
Anxiety 8 9.8%
PTSD 8 9.8%
Schizophrenia 2 2.4%
Previous Visits at Midtown 45 54.9%
Table 3: Reported Mental Health History
Feb-Dec 2016
Source: Project Point Data Set
The role of psychiatric disease
INDIANA UNIVERSITY SCHOOL OF MEDICINE
“I was in foster care and it was the
only way to make it through.”
“It’s the only way I can forget, just for
a little bit, what happened.”
“My mom gave me my first hit when I
was eight.”
0
1
2
3
4
5
6
7
0 1 2 3 4 5 6 7 8 9 10
Number of patients
ACE Score
ACE Scores
The role of childhood trauma
INDIANA UNIVERSITY SCHOOL OF MEDICINE
The role of healthcare system dysfunction
0
5
10
15
20
25
30
35
40
45
50
55
60
Percentage of Patients
Prescriptions Before the Overdose
INDIANA UNIVERSITY SCHOOL OF MEDICINE
The role of healthcare system dysfunction
0
5
10
15
20
25
30
35
40
45
50
55
60
65
Percentage of Patients
Prescriptions After the Overdose
INDIANA UNIVERSITY SCHOOL OF MEDICINE
0
5
10
15
20
25
Outpatient
non-MAT
Buprenorphine Methadone Naltrexone Inpatient (all
Bup)
Other (no Bup)
Percentage of Patients
Initial Follow Up
INDIANA UNIVERSITY SCHOOL OF MEDICINE
0
10
20
30
40
50
60
Engaged in 3+
visits
Active at 3
months
Active at 6
months
Active on
Methadone
Active on Bup Active on
Naltrexone
Percentage of Patients
Six month follow up
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Project challenges
• Limited Treatment Resources
• POINT team availability
• Follow-up on often transient and/or skeptical patients
• Lack of community-based needle exchange/Naloxone distribution
• Limited down-stream resources
– Detox, MAT availability
– Legal, DCS advocates
• Limited funding for monitoring and evaluation
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Next Steps
Grant Funding from Richard M. Fairbanks Foundation allowing us to:
– Expand POINT outreach/brief intervention
– Provide take home Naloxone kits
– Offer rapid Hepatitis C testing
– Incorporate Peer Support (Recovery Coaches)
– Integrate and support existing outreach efforts
– Incorporate our work flows into existing EMR
– Implement a robust monitoring and evaluation protocol
– Utilize expertise at a local treatment center
INDIANA UNIVERSITY SCHOOL OF MEDICINE
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Thank you
POINT team
Dr. Dan O’Donnell, Jennifer Hoffman, AJ Warren, Twila Fuqua, Jennifer Dutton
Melissa Reyes, Gloria Haynes
Early Supporters
Andy Chambers, MD, Dan Rusyniak, MD, Dennis Watson, Ph.D.
Eskenazi Health
Midtown Mental Health Addictions Team
Fairbanks School of Public Health
IU School of Medicine, Department of Emergency Medicine
Richard M. Fairbanks Foundation
