What to Do After an Overdose Reversal: Engaging Patients in Addiction Treatment

1. What to Do After an Overdose Reversal:
Engaging Patients in Addiction Treatment
Presenters:
• Elizabeth Samuels, MD, MPH, Chief Resident, Emergency Medicine Residency Program,
Brown University
• R. Corey Waller, MD, MS, Medical Director, Center for Integrative Medicine, Spectrum
Health Medical Group
• William J. Lynch, Jr., RPh, Clinical Staff Pharmacist, Kennedy Health System, and Member,
Camden County Addiction Awareness Task Force
• Harry Earle, MA, Chief of Police, Gloucester Township (NJ) Police Department, and
Member, Camden County Addiction Awareness Task Force
Clinical Track
Moderator: John J. Dreyzehner, MD, MPH, FACOEM, Commissioner, TN Dept.
of Health, and Member, Rx and Heroin Summit National Advisory Board

2. Disclosures
• Harry Earle, MA; Elizabeth Samuels, MD, MPH; and R.
Corey Waller, MD, MS, have disclosed no relevant,
real, or apparent personal or professional financial
relationships with proprietary entities that produce
healthcare goods and services.
• William J. Lynch, Jr., RPh wishes to disclose he is a
consultant with Pernix Therapeutics and with Iroko
Pharmaceuticals
• John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Define the need to engage persons who
experience an opioid overdose reversal in
addiction treatment.
2. Identify best practices and strategies for first
responders and emergency personnel to engage
naloxone recipients in addiction treatment.
3. Describe one community’s program for engaging
naloxone recipients in addiction treatment.

5. What to Do After an Overdose
Reversal: Engaging Patients in
Addiction Treatment
Elizabeth Samuels, MD, MPH
Lifespan Opioid Overdose Prevention Program
Brown University Department of Emergency Medicine
R. Corey Waller, MD, MS
Director for the Center for Integrative Medicine
Spectrum Health Medical Group

6. Disclosure
• Elizabeth A. Samuels, MD, MPH has disclosed no
relevant, real or apparent personal or
professional financial relationships with
proprietary entities that produce health care
goods and services.
• Corey Waller, MD, MS has disclosed no relevant,
real or apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services.

7. 1. Define the need to engage persons who
experience an opioid overdose reversal in
addiction treatment.
2. Identify best practices and strategies for first
responders and emergency personnel to engage
naloxone recipients in addiction treatment.
3. Describe one community’s program for engaging
naloxone recipients in addiction treatment.

8. Outline
• Emergency Department
overdose visits
• Lifespan Opioid Overdose
Prevention Program
• Addiction treatment
follow up

10. Increasing Drug-Related ED visits
Drug related ED visits, 2004-2011
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2011
Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD.

11. RI Opioid Overdoses

12. 0
10
20
30
40
50
60
70
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
NumberofIncidents
Month, 2014
2014 Rhode Island Hospital Opioid Overdoses and Rhode
Island Unintentional Opioid Overdose Deaths
RI Unintentional
Opioid
Overdose
Deaths
RIH Opioid
Overdoses
Sources: RIH, RI DOH Medical Examiner

14. Lifespan Opioid Overdose
Prevention Program Goals
Reduce deaths due to opioid overdose by:
1. Increasing access to naloxone.
2. Expanding ED overdose prevention
education and addiction counseling.
3. Increasing ED referral to addiction
treatment.

15. LOOP Program Components
Take-home naloxone
Peer recovery coach consultation
& referral to treatment
Overdose prevention and
response education

16. ED Naloxone Distribution
Naloxone rescue kit
assembled by pharmacy,
stored in ED dispensary
Patient shown educational
video
Retrieved by nurse and given
to patient.

17. Patient Education

18. Program Utilization

19. Post-ED Follow Up
Transfer to detox or inpatient treatment from ED
Outpatient Treatment referrals
80% engage with recovery services
Inpatient & Outpatient
Outpatient follow up within 24-48h

20. Addiction 101
• Chronic neurobiological disorder
• Need both medications and therapy
– Buprenorphine, Methadone, Naltrexone
– CBT, MET, DBT, 12-Step
• Integrated care teams
– Prescriber
– Therapist
– Case manager
– Other (pharmacist, MA, CHW, etc.)

22. Questions?

23. What to Do After an Overdose
Reversal: Engaging Patients in
Addiction Treatment
Camden County Addiction Awareness Task Force
Operation SAL: Save-A-Life

24. What to Do After an Overdose Reversal:
Engaging Patients in Addiction Treatment
William J. Lynch, Jr. BS-Pharm, RPh
Clinical Staff Pharmacist-Kennedy University Hospital
Core Teaching Affiliate of Rowan School of Osteopathic Medicine
Rutgers University, Ernest Mario School of Pharmacy Preceptor
Camden County New Jersey Addiction Awareness Task Force Member-
Education & Prevention Committee Co-Chair
State of New Jersey Police Training Commission Instructor
Camden County College Police Academy Instructor
National Prescription Drug Abuse & Heroin Summit
March 29, 2016
2:00 to 3:15 PM

25. What to Do After an Overdose Reversal:
Engaging Patients in Addiction Treatment
Chief W. Harry Earle, MA
Chief of Police-Gloucester Township NJ Police Department
President, Camden County NJ Police Chiefs’ Association
Camden County Addiction Awareness Task Force Member
-Availability Reduction Committee Co-Chair
FBI National Academy #234
National Prescription Drug Abuse & Heroin Summit
March 29, 2016
2:00 to 3:15 PM

26. Disclosure Statement
William J. Lynch, Jr. BS-Pharm, RPh wishes to disclose
he is a consultant with Pernix Therapeutics and with
Iroko Pharmaceuticals
He will present this content in a fair and balanced
manner

27. Disclosure Statement

28. Learning Objectives
• Define the need to engage persons who experience
an opioid overdose reversal in addiction treatment
• Identify best practices and strategies for first
responders and emergency personnel to engage
naloxone recipients in addiction treatment
• Describe one community’s program for engaging
naloxone recipients in addiction treatment

29. 5,217
Number of heroin-related deaths recorded
in New Jersey 2004-2014
http://www.nj.com/news/index.ssf/2015/12/herointown_nj_the_states_heroin_crisis_in_10_graph.html

30. New Jersey’s Heroin Epidemic: Deaths Doubled Since 2011
*Camden, Middlesex, Ocean and Monmouth had the highest number of overdose deaths in 2014
*Bergen, Camden, Cumberland, Gloucester, Middlesex, Monmouth and Warren had the
percentage highest increases from 2013
http://patch.com/new-jersey/tomsriver/heroin-deaths-new-jersey-double-2011?utm_source=alert-
breakingnews&utm_medium=email&utm_term=police%20%26%20fire&utm_campaign=alert

31. 8.3
Heroin Deaths in New Jersey per 100,000
>3 Times National Average
20.3 Heroin deaths in Camden County New Jersey per 100,000
More than 7.8 times the national average, 2.45 times NJ average
http://www.nj.com/news/index.ssf/2015/12/herointown_nj_the_states_heroin_crisis_in_10_graph.html

32. Camden County Overdoses
ACCIDENTAL DEATHS RELATED TO ADVERSE EFFECTS OF DRUGS (CAMDEN COUNTY - 2010-2013)
RACE NUMBER PERCENTAGE AVG AGE 32.06 AVERAGE AGE 2010-2013
# of Deaths
Percentage
0-16 1 <1%
White 382 74% 16-20 15 3%
Black 81 16% ACCIDENT 496 21-30 115 22%
Hispanic 51 10% UNDETERMINED 4 31-40 138 27%
OTHER 2 <1% SUICIDE 16 41-50 150 29%
TOTAL 516 100% 516 51-60 82 16%
61-70 14 3%
FEMALE 134 26% 71-80 1 <1%
MALE 382 74% 516 100%
516 100%
YOUNGEST 18
OLDEST 69
# OF DEATHS 516 AVG AGE AT DEATH 40

33. AN EPIDEMIC

34. SAVE INITATIVES

35. INSPIRING CHANGE

36. THE POWER OF A PHONE CALL

37. WORKING TOGETHER TO SAVING LIVES

38. WORKING TOGETHER TO SAVE LIVES
2014
517
2015
5,092
2016
158
NJ Statewide Naloxone Deployments, Regional Operations Intelligence Center,
NJSP, Drug Monitoring Initiative Attorney General ‘s Heroin & Opiate Task Force. 1/26/16

39. NJ Statewide Naloxone Deployments, Regional Operations Intelligence Center,
NJSP, Drug Monitoring Initiative Attorney General ‘s Heroin & Opiate Task Force. 1/26/16
• 517 deployments during 2014
• 5,092 deployments during 2015
• 158 deployments during 2016

40. SAVED BY NARCAN – NOW WHAT?

41. PREPARING FOR RE-ENTRY
Food Bank
Clothing Bank
SAVE Advocate
GTPD Family
Resource Center
GT Library
Community Re-
Entry Specialist

42. WE NEED TO PREVENT THE OVERDOSE!

43. SAVE ADVOCATE
47%
REMAINING 53%?

44. SOLICIT PARTNERS

45. Brought to you by the Camden County Board of Freeholders’ Addiction Awareness
Task Force & Camden County Health Department

46. “We administered the
naloxone … now what?”

47. Signing Out “AMA”
• AMA: Against Medical Advice
• Revived by Police/EMS in the field
– Do not want to go to the hospital
– Sign out AMA
• Get to the hospital
– Do not want to be there/stay
– Sign out AMA
• For those who want treatment
– Long wait time for inpatient treatment
– Takes time to get Medication Assisted Treatment (MAT)
– No place to go
• Recidivism rate is high

48. Where Do We Go From Here….
“

49. In Camden County New Jersey…
• Camden County Addiction Awareness Task Force (CCAATF) has
implemented a successful nasal and injection naloxone
program with 344 deployments by Law Enforcement & 1160
deployments by EMS personnel
– Total: 1504 in 2015
• However, each save has brought with it the problems of where
the patients go from here, especially when seeking treatment
• With increasing delays in treatment availability and patients
signing out against medical advice from hospitals and first
responders, the task force quickly realized our community was
winning the battle but losing the war
• In response, the task force developed Operation SAL
– Save a Life!

50. Heroin and Treatment in New Jersey

51. Camden County Future Admissions
From 2015-2018 Heroin and
Prescription Drugs
are projected to account for
44.5% of Camden County’s
substance abuse admissions
NEARLY, 80% of these clients
are from the suburbs

52. Treatment Availability
• More than 1 in 2 adults (71,000)
• More than 2 in 3 adolescents
(9,400)
• Who wanted treatment for an
addiction to alcohol or drugs in
New Jersey could not access it
due to limited treatment
capacity.*
• Average wait times for treatment
*National Council on Alcohol and Drug Dependence
http://www.ncaddnj.org/page/access-to-treatment.aspx

53. We Have a Serious Problem
• New Jersey has 21 counties
• Camden County is:
– 8th most populated county (n=511,038 residents)
– Has 4th highest number of substance abuse
treatment admissions
• 6295 in 2012, 8.3% of total NJ Admissions of 75,837
• 5830 in 2013, 8% of total NJ Admissions of 72,864
• 5214 in 2014, 8.1% of total NJ Admissions of 64,766
– Was 1st, for greatest number of heroin deaths in
the state for 2014 with 93 of 781 in NJ (11.9%)

54. 2014 Substance Abuse Admissions by County of
Residence in New Jersey
Rank County Total Admissions (N=64,766)
1 Ocean 6565
2 Monmouth 6049
3 Essex 5672
4 Camden 5214
5 Middlesex 4398
6 Atlantic 3921
7 Hudson 3853
8 Passaic 3640
9 Union 3096
10 Gloucester 2881
11 Bergen 2704
12 Burlington 2686
13 Morris 2466

55. Camden County Primary Drug Ranked Total
Treatment Admissions, 2005-2012 (N=39,944)
Camden County Primary Drug Ranked Total Treatment
Admissions, 2005-2012 (N=39,944)
Primary Drug
at Admission
Number of
Admissions Rank
Percentage of
Camden
County
Admissions
New Jersey
Admission
Percentage
Heroin 12,982 1 32.5% 31.5%
Alcohol 9,707 2 24.3% 34.8%
Marijuana 7,748 3 19.4% 15.0%
Prescription 4,112 4 10.3% 8.4%
Cocaine/
Crack
4,039 5 10.1% 8.8%
Other Illicit
Drugs
1,356 6 3.4% 1.6%

56. Heroin and Prescription Drug Treatment
Admissions from 2005-2012
Accounted for
42.8%
of Camden
County’s
substance abuse
admissions
Brought to you by the Camden County Board of Freeholders’ Addiction Awareness
Task Force & Camden County Health Department

57. Projected/Actual Camden County Primary Drug
Ranked Total Treatment Admissions, 2013
Projected/Actual Camden County Primary Drug Ranked Total
Treatment Admissions, 2013
Primary Drug at
Admission
2013
Projected
Number of
Admissions
N=6717
2013
Actual
Admissions
N=5830
Projected
Percentage of
2013
Admissions
Actual
Percentage
2013
Admissions
Alcohol 2,020 1,278 30.1% 22.0%
Heroin 1,587 2,096 23.6% 36.0%
Prescription 1,421 569 21.2% 10.0%
Marijuana 938 1,153 14.0% 20.0%
Cocaine/ Crack 445 374 6.6% 6.0%
Other Illicit Drugs
305
275 4.5% 5.0%

58. 2013 Camden County Substance Abuse
Admission Age at Discharge
Age at Discharge Percentage
<45 years 80%
<35 years 62%
<30 years 46%
<25 years 27%
<22 years 15%
<18 years 4%

59. Treatment Rates by Patients New Jersey Hometown Address
http://www.nj.com/news/index.ssf/2015/12/herointown_nj_the_states_heroin_crisis_in_10_graph.html

60. http://www.nj.com/news/index.ssf/2015/12/herointown_nj_the_states_heroin_crisis_in_10_graph.html
•
5 Counties Where Heroin Death Rate Exceeds
Number of Treatment Beds Available per
100,000 People

61. Mission:
•To increase awareness among county residents of heroin and
prescription drug abuse and the devastating effects on our
community
Goals:
•HELP to reduce the demand for and availability of heroin &
prescription drugs
•CREATE awareness programs to help educate residents about
programs and resources available to prevent and treat addiction
• SUPPORT the creation of additional resources to treat and prevent
addiction to heroin & prescription drugs
Brought to you by Camden County Addiction Task Force & Camden County Health Department

62. OPERATION SAL
(Save-A-Life)
Brought to you by the:
Camden County Addiction Awareness Task Force &
Camden County Health Department

64. Operation SAL-Save A Life!
• Naloxone successfully deployed by County/Municipal
police departments or EMT/Paramedics as a life
saving measure
• Funded by Camden County Addiction Awareness Task
Force (CCAATF)
• Response to increased number of overdoses & to
provide care on an interim basis
• Program tailored for clients who seek inpatient
substance abuse treatment admission
• For clients confronted by barriers & obstacles to
receiving treatment

65. Operation SAL-Save A Life!
• Offer up to 60 days* of either Suboxone® or
methadone maintenance while in Intensive
Outpatient treatment at Delaware Valley Medical
– *as funds are available
• DVM will keep client comfortable while waiting to
be connected to another level of care
• Admissions occur 6 days a week 530am to 1100am
• Healthcare institutions call for prior approval &
referral

66. Operation SAL-Save A Life!
• To be considered clients must have:
– 1 Photo ID & another form of ID
• May be hospital face sheet
– Naloxone administration by Municipal/County
Police or EMT/Paramedic
– Discharge paperwork from hospital/medically
cleared
– Prefer hospital transfers client directly from ER to
DVM after they accept the client
– Validated legitimate benzodiazepine use permitted
– Cannot be actively using illicit benzos

67. Client Engagement/Stability
• Client Engagement begins from first contact at the
program
• Treatment appointment is coordinated with facility
staff
• After admission, individualized goals will be identified
and appropriate treatment referrals made

68. Delaware Valley Medical
• Delaware Valley Medical provides comprehensive, high quality
addiction treatment services & is a community resource that
prevents, reduces, & eliminates harm caused by substance
abuse for the surrounding communities
• Admission for Operation SAL are Monday to Saturday
– 5:30 AM to 12:00 PM
– Same day screenings are available for immediate admission
• Applicants must be 18 years or older & be able to furnish two
forms of identification (one of which is photo ID)

69. Delaware Valley Medical
Available services include:
• Medically supervised withdrawal from opiates and
methadone
• Methadone Maintenance/Suboxone® Therapy
• Drug Counseling: Individual, group & family
• Intensive Outpatient/Outpatient group therapy programs
• Psychiatric services for qualifying clients
• Referrals & linkages for additional services such as
vocational rehabilitation, pre-natal care
• On site free rapid HIV testing

70. Four Major Hospital Systems
Participating in Operation SAL
• Kennedy Health System
– Cherry Hill NJ Division
– Stratford NJ Division
– Washington Township NJ Division (Gloucester County)
• Cooper Hospital, Camden NJ
• Our Lady of Lourdes Hospital, Camden NJ
• Virtual Health System
– Marlton NJ Division (Burlington County)
– Mount Holly NJ Division (Burlington County)
– Voorhees NJ Division
• Represents ALL hospital systems
– in Camden County, NJ

71. Hospital’s Role
• Ensure Social Workers and/or Nurse Navigators are aware
of the program
– Medication Assisted Treatment & Intensive Outpatient
Program
– Wrap-around linkage
• Provide referral & information to Delaware Valley Medical
• Make smoothest & safest transition possible from ER to
Delaware Valley Medical
– If feasible, direct admission

72. Operation SAL-Save A Life
• Camden County Department of Health & Human
Services Addiction Unit
(856) 374-6361
• Contact Community Helplines
(877) 266-8222
• Delaware Valley Medical
(856) 665-5100

74. Successful Case History
• Difficult to implement
• Every patient ready at a different time in their life
• 23yoM with naloxone reversal three times
• Given Operation SAL info each time by police officers &
hospital personnel
• Info given to patient and family members
• Police stop by to check up on how patient was doing
• Third overdose nurse navigator gets patient into program
• Picked up daily & taken to methadone maintenance tx
• After 3 weeks admitted to inpatient treatment facility
• Other funding available for this patient’ treatment
• Driving patients into treatment
• With & without insurance

77. Acknowledgements: Thank You!
Rachel M. Lynch
• Doctor of Pharmacy Candidate 2016
• Rutgers University, Ernest Mario School of Pharmacy
Brian V. Blazovic
• Doctor of Medicine Candidate 2018
• Jefferson Medical College, Thomas Jefferson University
David Z. Yang
• Pharmacy Intern-Doctor of Pharmacy Candidate 2016
• Rutgers University, Ernest Mario School of Pharmacy
Kurt D. Meakim, Pharm D
• Pharmacy Intern-Rutgers University, Ernest Mario School of Pharmacy
Eric W. Lynch
• Doctor of Pharmacy Candidate 2020
• Rutgers University, Ernest Mario School of Pharmacy
Gregory E. Cabanas
• Pharmacy Intern, Doctor of Pharmacy Candidate 2016
• Rutgers University, Ernest Mario School of Pharmacy

78. We thank all of the members of
our Camden County Addiction
Awareness Task Force who
engage in battling this epidemic
in our community every day.
Together we ARE making a
positive difference!

79. What to Do After an Overdose Reversal:
Engaging Patients in Addiction Treatment
Presenters:
• Elizabeth Samuels, MD, MPH, Chief Resident, Emergency Medicine Residency Program,
Brown University
• R. Corey Waller, MD, MS, Medical Director, Center for Integrative Medicine, Spectrum
Health Medical Group
• William J. Lynch, Jr., RPh, Clinical Staff Pharmacist, Kennedy Health System, and Member,
Camden County Addiction Awareness Task Force
• Harry Earle, MA, Chief of Police, Gloucester Township (NJ) Police Department, and
Member, Camden County Addiction Awareness Task Force
Clinical Track
Moderator: John J. Dreyzehner, MD, MPH, FACOEM, Commissioner, TN Dept.
of Health, and Member, Rx and Heroin Summit National Advisory Board