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Outreach to people who survive opioid overdose: Linkage and retention in treatment

Open AccessPublished:December 21, 2019DOI:https://doi.org/10.1016/j.jsat.2019.12.008

      Highlights

      • Many individuals with prior opioid overdose do not voluntarily engage in treatment.
      • Mobile peer and paramedic outreach teams were used to engage people who survived a recent overdose into treatment.
      • 33% of people contacted chose to engage in treatment and 88% of these remained in treatment for the first 30 days.
      • Outreach could be a promising strategy to motivate and retain people who have survived an overdose in treatment.

      Abstract

      Cognitive motivation theories contend that individuals have greater readiness for behavioral change during critical periods or life events, and a non-fatal overdose could represent such an event. The objective of this study was to examine if the use of a specialized mobile response team (assertive outreach) could help identify, engage, and retain people who have survived an overdose into a comprehensive treatment program. We developed an intervention, consisting of mobile outreach followed by medication and behavioral treatment, in Houston Texas between April and December 2018. Our primary outcome variables were the level of willingness to engage in treatment, and percent who retained in treatment after 30 and 90 day endpoints. We screened 103 individuals for eligibility, and 34 (33%) elected to engage in the treatment program, while two-thirds chose not to engage in treatment, primarily due to low readiness levels. The average age was 38.2 ± 12 years, 56% were male, 79% had no health insurance, and the majority (77%) reported being homeless or in temporary housing. There were 30 (88%) participants still active in the treatment program after 30 days, and 19 (56%) after 90 days. Given the high rates of relapse using conventional models, which wait for patients to present to treatment, our preliminary results suggest that assertive outreach could be a promising strategy to motivate people to enter and remain in long-term treatment.

      Keywords

      1. Introduction

      Opioid use for nontherapeutic purposes has been an increasing issue in the United States over the past 15 years, prompting the Centers for Disease Control and Prevention (CDC) to declare accidental overdose deaths from opioid use disorder (OUD) a national public health epidemic and state of emergency (
      • Centers for Disease Control and Prevention (CDC)
      Understanding the epidemic.
      ;
      • Cicero T.J.
      • Surratt H.L.
      • Kurtz S.
      • Ellis M.S.
      • Inciardi J.A.
      Patterns of prescription opioid abuse and comorbidity in an aging treatment population.
      ). The risk of overdose deaths is rising particularly due to the increased availability of fentanyl and synthetic opioids (
      • Centers for Disease Control and Prevention (CDC)
      Opioid basics: Fentanyl.
      ).
      High-risk persons with OUD and especially those who have prior overdoses, could benefit from medication-based treatment (
      • Kampman K.
      • Jarvis M.
      American Society of Addiction Medicine (ASAM) National Practice Guideline for the use of medications in the treatment of addiction involving opioid use.
      ;
      • Miller J.M.
      • Griffin III, O.H.
      • Gardner C.M.
      Opiate treatment in the criminal justice system: A review of crimesolutions.gov evidence rated programs.
      ;
      • Saloner B.
      • Barry C.L.
      Ending the opioid epidemic requires a historic investment in medication-assisted treatment.
      ;
      • Volkow N.D.
      • Jones E.B.
      • Einstein E.B.
      • Wargo E.M.
      Prevention and treatment of opioid misuse and addiction: A review.
      ;
      • World Health Organization (WHO)
      Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence.
      ). Medications for opioid use disorder (MOUD) are now recommended for treatment of opioid use disorder (
      • National Academies of Sciences, Engineering, and Medicine
      Medications for opioid use disorder save lives.
      ). Yet many with this use disorder do not voluntarily seek treatment, even after an overdose (
      • Koyawala N.
      • Landis R.
      • Barry C.L.
      • Stein B.
      • Saloner B.
      Changes in outpatient services and medication use following a non-fatal opioid overdose in the West Virginia Medicaid program.
      ). Cognitive motivation theories suggest that individuals have increased readiness for change at certain points (
      • DiClemente C.
      Addiction and change: How addictions develop and addicted people recover.
      ;
      • Herman D.B.
      • Mandiberg J.M.
      Critical time intervention: Model description and implications for the significance of timing in social work interventions.
      ), and patients who have survived a recent life-threatening overdose might be more willing to engage in treatment and recovery if they were approached and presented with specific options for linking into treatment.
      Outreach is a model that involves deploying a specialized mobile response team to the home of high-risk populations to potentially motivate them to engage in treatment (
      • Fisk D.
      • Rakfeldt J.
      • McCormack E.
      Assertive outreach: An effective strategy for engaging homeless persons with substance use disorders into treatment.
      ;
      • Formica S.W.
      • Apsler R.
      • Wilkins L.
      • Ruiz S.
      • Reilly B.
      • Walley A.Y.
      Post opioid overdose outreach by public health and public safety agencies: Exploration of emerging programs in Massachusetts.
      ;
      • Ozechowski T.J.
      • Waldron H.B.
      Assertive outreach strategies for narrowing the adolescent substance abuse treatment gap: Implications for research, practice, and policy.
      ). Recent pilot evidence demonstrated that a peer recovery outreach network could improve linkage of individuals into outpatient-based MOUD (
      • Scott C.K.
      • Grella C.E.
      • Nicholson L.
      • Dennis M.
      Opioid recovery initiation: Pilot test of a peer outreach and modified recovery management checkup intervention for out-of-treatment opioid users.
      ) treatment. Building data surveillance systems in communities between hospitals and first responder agencies could provide useful data to guide outreach efforts (
      • Ising A.
      • Proescholdbell S.
      • Harmon K.J.
      • Sachdeva N.
      • Marshall S.W.
      • Waller A.E.
      Use of syndromic surveillance data to monitor poisonings and drug overdoses in state and local public health agencies.
      ). A surveillance system comprised of data flows from multiple sources, including hospital emergency departments, first responder overdose incidents, and even medical examiner death data, could be useful to provide more precise outreach services to high-risk neighborhoods and individuals.
      Innovative mechanisms to motivate persons with OUD into treatment are necessary to improve access and engagement in treatment services. The objective of this study is to report preliminary findings from a pilot study of an intervention in a major metropolitan city that integrates outreach guided by hospital emergency department and first responder surveillance data to engage and retain patients in a treatment program.

      2. Material and methods

      We designed an intervention involving outreach to engage people who have recently experienced an opioid overdose into treatment. Participants were recruited between April and December 2018. The program is based at The University of Texas Health Science Center at Houston and is called the Houston Emergency Response Opioid Engagement System (HEROES; registered as a national clinical trial 03396276). The University of Texas Health Science Center at Houston institutional review board (IRB) approved the study. Data were exchanged between participating organizations using legal contracts and business associates agreement that ensures patient privacy and confidentiality. All data were maintained and secured on password-protected, encrypted drives and networks that are in compliance with University IRB standards and the Health Insurance Portability and Accountability Act.
      Study inclusion criteria were non-medical opioid use (including heroin) in the past 30 days with a recent overdose and lack of current enrollment in opioid use disorder treatment. All participants were adults (>18 years old), non-incarcerated, able to speak/write English and motivated to begin treatment.

      2.1 Study population: identification and motivation screening

      Identification of eligible persons came from two sources: (1) the emergency department (ED) of Memorial Hermann Hospital (MHH) in the Texas Medical Center, which is an academic tertiary care hospital; and 2) the Houston Fire Department (HFD) emergency medical services (EMS) agency, which is the largest EMS agency in the region. Houston is the fourth largest city in the United States with a population of approximately 2.3 million people. According to data from the CDC, there were 275 reported opioid-related deaths in 2017 in Houston (
      • Centers for Disease Control and Prevention (CDC)
      Understanding the epidemic.
      ). This represents only a portion of the people in the community with OUD who experience an overdose.
      In the ED, patients who have overdosed were approached by their treating physicians and/or by on-duty research associates. A visual analog scale (VAS) or readiness ruler assessed the patient's readiness for change based on the question “On a scale of 0 to 10, how ready are you today to start a treatment and recovery program for your opioid addiction?” We anticipated that those individuals with higher readiness would have higher commitment to follow-through on treatment services. We established a minimum level of 3 which has been used by others as a cutoff for lack of readiness for change (
      • Hesse M.
      The Readiness Ruler as a measure of readiness to change poly-drug use in drug abusers.
      ). After patients were discharged and consented by the ED, they were entered into the surveillance system for next-day home outreach.
      In addition, all patients who overdosed and were successfully treated by EMS with naloxone (Narcan) were electronically shared in the surveillance system, regardless of which hospital they were taken to for treatment. Research coordinators and the PI accessed the database multiple times per week. An outreach team, comprised of a peer recovery coach and a licensed paramedic, were dispatched to the locations of individuals in the surveillance system. Peer coaches provided non-clinical recovery support to serve as a positive role model and to help guide participants through the initial stages of recovery. Peer recovery specialists were nationally certified by the National Association of Alcoholism and Drug Abuse Counselors (NAADAC) and were licensed by the state of Texas for their peer services. Paramedics did not receive special training, but were in the agency's community paramedicine team which focuses on public health interventions.
      All outreach was performed directly to the home of the individual. During outreach, motivational interviewing techniques were used to screen, inform, and motivate participants to elect treatment. Informed consent was received at the place of residence, and all other study registration paperwork was completed at the research office prior to the baseline medical exam. A script was developed for the outreach team that involved establishing rapport with the individual, discussing past drug use and the most recent overdose, and offering assistance for treatment and recovery. If the patient chose to engage, they were required to present to the primary research office site for all enrollment paperwork, which included a written informed consent for participation and initial collection of data on patient demographics, contact information, and the patient's prior history of OUD treatment, family, and mental health history.
      All patients during the enrollment process were provided with no-charge medication examination by either a physician or an advanced nurse practitioner. This screening and medical examination was utilized to confirm diagnosis of an OUD, and obtain other baseline clinical information such as vital signs and drug use history.

      2.2 Intervention

      The outreach team followed up on all individuals at regular intervals to track progress and outcomes. All patients, including those that chose to enroll and those that did not enroll, received information resources about local treatment programs, information about opioid use disorder, education on Naloxone reversal medication, and contact information to reach out by phone or email. Written informed consent was provided by all individuals in the study when they chose to enroll in the program.
      Enrolled participants underwent rapid induction using buprenorphine by Drug Addiction Treatment Act of 2000 (DATA 2000) waivered emergency medicine physicians. While we chose buprenorphine to initiate treatment, ongoing treatment in the intervention was not limited and could be any of the three approved medications. The EM physicians were part of the HEROES research team and, in most cases, provided prescriptions for same-day induction within 24 h of enrollment, thereby preventing a multi-day physical withdrawal period that would increase the likelihood of relapse.
      All services were provided free of charge to participants. There were three weekly counseling sessions within the HEROES offices that participants were encouraged to utilize for support. These included: one-on-one meetings with a professional addiction counselor; group counseling led by a peer recovery coach; and educational groups discussing the science of addiction and strategies for successful long-term recovery.
      Immediately after enrollment, research coordinators facilitated placement of participants into an ongoing, outpatient-based MOUD treatment clinic for disease management. Patients and their outpatient provider made the decision on whether to utilize methadone, buprenorphine, or naltrexone for ongoing medications. Linkage to care was performed by our study's social worker. If placement into a community clinic was delayed, physicians would provide an additional bridge prescription to prevent withdrawal. The model for utilizing EM physicians to initiate MOUD was developed at Yale School of Medicine. (
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • Chawarski M.C.
      • Busch S.H.
      • Owens P.H.
      • Fiellin D.A.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: A randomized controlled trial.
      ).
      In addition, the peer recovery specialist and a social worker assisted with finding homeless participants stable, free housing. For those without employment, the team would work to find jobs for participants. And for those without medical insurance, an expedited process was used to get individuals enrolled in the county health care system.

      2.3 Outcome measures

      The primary outcomes were willingness to engage in a medication and behavioral treatment program, and the retention in treatment at both 30- and 90-day endpoints. Engagement was defined as the patient's willingness to participate and attend a treatment program. We measured this as the percentage of eligible individuals who elected to participate in an outpatient-based medical and behavioral treatment program divided by the total number of people approached. Treatment retention was defined as ongoing confirmed participation in a medication-based and behavioral treatment program through the 30- and 90-day endpoints. Participation was documented by counselors, social worker, peer coaches, and physicians. Secondary outcomes were the numbers of subsequent relapses and overdoses in the enrolled sample. Data on engagement and retention were collected based on attendance records and responses to follow-up evaluations, and were conducted by the research staff who were in daily contact with all participants. Data on relapse incidents were collected via patients' reports during interviews and phone surveys.

      2.4 Analyses

      Demographic and baseline characteristics were examined for this sample, as well as prior history of using opioids and prior treatment. Patient status was measured as retention in treatment on the 30th day and 90th day post-enrollment in the program. It was recorded as either active (still engaged in treatment) or inactive/lost to follow-up. We calculated descriptive statistics, including means and medians, for all patient characteristics for those individuals that enrolled into the study, as well as frequency analysis. Chi-square analysis was used to examine frequency differences between genders, and P values <.05 were considered statistically significant. Follow-up telephone calls were made at least weekly to collect patient status, and any missing data from initial enrollment. SPSS was used to perform all analyses (SPSS, version 25, IBM: Armonk, NY).

      3. Results

      The demographic and baseline characteristics of enrolled patients are presented in Table 1. Although we did not collect identifying information from those that chose not to enroll, we found no significant differences between the groups on the basis of gender (enrolled = 56% male, not enrolled = 58% male, p = .409). Due to the limited data sharing, we did not have complete information on those that did not enroll to assess for other differences in age, risk, or other factors. There were 103 individuals contacted and screened for eligibility, and 34 chose to enter the program, representing a 33% engagement rate. Most of the participants were male (55.9%), and the average age was 38.2 ± 12 years. Most individuals reported a high level of readiness (9.58 ± 1.22). A majority reported being homeless or in temporary housing, unemployed, and without health insurance.
      Table 1Demographic and baseline characteristics for enrolled participants.
      CharacteristicsEnrolled subjects n = 34

      n(%)
      Male (%)19 (55.9)
      Race/ethnicity
       White, non-Hispanic21 (61.8)
       Black, non-Hispanic8 (23.5)
       Hispanic, any race3 (8.8)
       Other2 (5.9)
      Primary type of opioid drug usage
       Heroin/illicit opioid20 (58.8)
       Prescription opioids5 (14.7)
       Poly-substance9 (26.5)
      Veteran1 (2.9)
      Smoking status
       Non-smoker5 (14.7)
       Smoker29 (85.3)
      Housing situation
       Own or rent home8 (23.5)
       Homeless/temporary housing26 (76.5)
       Any health insurance7 (20.6)
      The initial surveillance data provided a list of 251 individuals with suspected overdoses. There were 148 (59%) that the outreach team were not able to locate, due to lack of accurate physical addresses for all individuals. The primary reasons for this are two-fold: 1) many of the individuals who overdosed are homeless or living in temporary housing and therefore do not have stable home locations; and 2) while the first responder data captures location of the overdose, this address might be different than the permanent home address for that individual. Hotels and apartment buildings with no room numbers, and parking lots, and other addresses were frequently listed. In many cases, these address issues could not be resolved which resulted in multiple potential individuals being excluded from outreach.
      Fig. 1 presents the summary of the enrollment and follow-up patient flow.
      Fig. 1
      Fig. 1Study enrollment and follow-up diagram.
      Of the 103 individuals identified, 69 elected not to participate during the interview process. The primary reasons given were low willingness for change which we recorded as less than a 3 on a scale of 1 to 10 (n = 15), they denied having substance problems involving opioids (n = 50), or they were deceased at the time of the visit from an overdose (n = 4). In these cases, the team expressed sorrow for the dead family or household members. Due to the pilot nature of the study and limited resources, the study protocol did include more extensive grief intervention for family members. Therefore, we were successfully able to engage 34 patients (33%) in the intervention. All patients received information resources about local treatment programs, information about opioid use disorder, education on Naloxone reversal medication, and contact information to reach out by phone or email.
      Participants were engaged during the outreach and provided informed consent, but then were formally enrolled with all other registration paperwork at the primary research office where they received medical evaluation. All (100%) of these individuals were seen by an emergency physician affiliated with the study who wrote a prescription on the same day as they were enrolled. Patients were provided a manufacturer coupon for discounted pricing, and prescriptions were filled at community retail pharmacies across the city. Patients were then provided access to behavioral counseling and peer recovery interventions, which were provided both individually and as groups. They were linked to ongoing outpatient MOUD treatment to a network of community treatment providers in the region. The study had one patient lost to follow-up at the end of 30 days, and 6 at the end of 90 days.
      The primary outcome, retention in treatment, was 88% (30 of 34 patients still active in treatment) after 30 days. One was lost to follow-up and three discontinued the intervention. Retention in treatment for 90 days decreased to 56% (19 of 34), with 6 lost to follow-up and 9 discontinuing the intervention. Using weekly follow-up from peer recovery coaches for all active patients, we identified 3 patients with subsequent relapses. Relapse was operationalized here as re-use of an opioid for non-medical purposes after a period of remission or abstaining (
      • ASAM
      American society for addiction medicine.
      . All three patients who relapsed however continued in the treatment program. There were no subsequent overdoses or deaths in this sample over the 90-day period.

      4. Discussion

      The rise of opioid-related mortality following overdoses is causing regions and states to examine structural mechanisms to identify individuals with OUD and navigate them into treatment and recovery programs. Cognitive theories of motivation suggest that many people with addiction will not actively seek treatment until they are ready and motivated for change. Outreach techniques could be useful to provide an opportunity to inform and link people to treatment at critical moments, when they might be more willing to accept assistance. In this study, we found that approximately one-third of individuals we were able to locate, and had confirmed opioid overdoses, were ready and willing to engage in treatment. The majority (88%) of those remained active in the medical and behavioral treatment program at 30 days. This number decreased to 56% at 90 days. While many people we approached did not elect to engage in treatment, it is possible that the harm reduction and educational information left behind could plant seeds for behavioral change that when they have higher readiness, could be acted upon. Multiple attempts to engage those with substance use is commonly necessary given the nature of this chronic disease. In addition, it is likely that many of these patients would not have received any treatment based on their lack of awareness of options if they had not received outreach.
      The sample in this study was vulnerable financially. Nearly 80% reported no health insurance and 75% had no employment. There is a lack of options for securing treatment for individuals, especially in the city of Houston which has one of the highest reported uninsured rates and limited access to substance use disorder treatments. Community-based outreach strategies represent a potentially promising strategy to engage and retain participants in treatment, especially in these vulnerable populations that might otherwise not seek care. Those that did engage had very high levels of readiness, which helped motivate individuals to change and could partially explain our initial outcomes. However equally as important, nearly two-thirds of the population did not respond to outreach efforts. The use of other techniques to engage those patients, such as the use of digital technology to provide education for patients on risks and effects of substance use, should be further explored.
      There are barriers to achieving this in communities on a larger scale. First, partnerships are necessary between first responder organizations to share data seamlessly for purposes of assisting those with OUD. In this study we relied on legal documentation and secure data sharing agreements between agencies, which take time and require strong willingness to collaborate across communities. Collaborative programs tend to require complex processes and these need to be established for each region. There are also numerous barriers to linking patients to ongoing outpatient-based medication-based treatment. While this intervention was provided for no cost to participants, ongoing medical treatment is difficult to obtain in most areas. The use of peer support services to address the social determinants such as housing and transportation is especially necessary for this population. Other studies have found that peer support intervention models have been associated with improvement in a variety of outcome measures (
      • Bassuk E.L.
      • Hanson J.
      • Greene R.N.
      • Richard M.
      • Laudet A.
      Peer-delivered recovery support Services for Addictions in the United States: A systematic review.
      ). There are significant gaps in access and availability to treatment programs (
      • Langabeer J.R.
      • GOurishankar A.
      • Chambers K.A.
      • Giri S.
      • Madu R.
      • Champagne-Langabeer T.
      Disparities between US opioid overdose deaths and treatment capacity: A geospatial and descriptive analysis.
      ;
      • Rosenblatt R.A.
      • Andrilla C.H.
      • Catlin M.
      • Larson E.H.
      Geographic and specialty distribution of US physicians trained to treat opioid use disorder.
      ). Lack of insurance and employment among individuals in our study further complicated access to ongoing care, since most treatment providers do not take Medicaid and state-funded programs often have excessively long wait lists, and the expansion of the state's Medicaid program for substance use disorders would be extremely beneficial for improving access to care for this population. Given the time-sensitive nature of this program, responding to incidents involving overdoses, it is important to address these structural and policy barriers.
      This study was originally conceived as a developmental project to assess prevalence of opioid overdoses across the city and to examine feasibility for a coordinated comprehensive treatment program. We found that there are multiple opportunities to improve on this pilot study. First, we were not able to locate many of the individuals who met our inclusion criteria of a recent overdose and it's possible there were differences in the groups between those we did locate and those which we did not locate. This study was not controlled or randomized, and therefore cannot attribute causality. Also, we report only preliminary findings from this study which has a small sample size and only included English speakers in a city with a large Spanish-speaking population. In future studies, building larger-scale surveillance systems and larger outreach teams, encompassing multiple agencies and hospitals would help ensure that more people get the opportunity to be linked to treatment. Future studies could also examine results in rural areas or over a longer period of time. It is important to note that we also have obtained additional funding to continue to expand on this initiative which is still currently ongoing.

      5. Conclusion

      Results from our preliminary study of first responder surveillance data utilization to initiate outreach suggest that a strategic intervention can successfully motivate at-risk individuals into treatment. This is encouraging as this high-risk patient population might otherwise not receive care. By providing comprehensive medical, behavioral and recovery services, the program enrolled nearly one-third of the persons contacted, and a majority of these remained in active treatment for 30 and 90 days. Given the high rates of relapse using conventional models which wait for patients to present to treatment, our preliminary results suggest that outreach could be a promising strategy for engaging and retaining people in treatment.

      CRediT authorship contribution statement

      James Langabeer:Conceptualization, Methodology, Writing - original draft, Writing - review & editing, Funding acquisition, Project administration.Tiffany Champagne-Langabeer:Writing - original draft, Writing - review & editing, Project administration.Samuel D. Luber:Investigation, Methodology.Samuel J. Prater:Investigation.Angela Stotts:Writing - original draft, Writing - review & editing.Katherine Kirages:Data curation, Investigation.Andrea Yatsco:Methodology, Writing - original draft, Writing - review & editing, Project administration.Kimberly A. Chambers:Writing - original draft, Writing - review & editing, Validation, Methodology.

      Acknowledgments

      We wish to acknowledge all of the medical, behavioral, and peer recovery providers who provided treatment and consultation to patients in this study. In addition, we acknowledge our network of partner agencies who provided data and collaborated for this study. We also appreciate the support of our program sponsor at the Texas Targeted Opioid Response.

      Funding source

      This study was funded through a grant from the Health and Human Services Commission of Texas, through the State Opioid Response program from the Substance Abuse and Mental Health Services Administration.

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