The United States' drug overdose epidemic is a widespread public health crisis that continues to evolve and escalate year after year. According to the Centers for Disease Control and Prevention (CDC), in 2021 alone, drug overdose deaths claimed the lives of over 107,000 individuals in the country. At the state level, between 2019 and 2020, a 37% increase in age-adjusted drug overdose fatalities per 100,000 individuals was observed in Florida. An increase was also witnessed at the local level, with Broward County, the second-most populous county in the state of Florida, seeing an increase of 49% in age-adjusted drug overdose deaths per 100,000 individuals between 2019 and 2020 (Florida Health Charts). In the second quarter of 2022, white males between the ages of 25 and 64 experienced the most accidental deaths due to overdoses with the cities of Fort Lauderdale, Pompano Beach, Hollywood, and Deerfield Beach having the greatest number of deaths (Broward County OMETS, 2022). The increase in drug overdose rates and deaths has devastated communities and burdened public health organizations in every state, leading to a rise in emergency medical service (EMS) responses, ED visits and hospitalizations. The increase in rates has also increased transmission of infectious diseases such as Human Immunodeficiency Virus (HIV) and Hepatitis C infection (HCV) through intravenous drug use (Larney, Peacock, Mathers, et al, 2017).
DOH-Broward, through the OD2A grant from the CDC, coordinates a multi-pronged, multi-sector approach to access high quality, complete and timely data on opioid prescribing and overdoses through enhanced surveillance activities and uses that data to inform targeted and effective prevention and response through integrated planning and partnerships. Among many activities, DOH-Broward's OD2A program has hired a hospital coordinator who works closely with Broward County's 16 acute care hospital EDs and four free-standing EDs, which report to ESSENCE, in order to do the following: Increase the accuracy of their reporting, collaborate on the development of innovative testing approaches and comprehensive screening of nonfatal overdoses using the seven-drug toxicology screening, review existing protocols and policies in EDs to guide referrals and linkages to care for overdose patients, and to monitor the effectiveness of revised protocols and policies. In addition, the hospital coordinator works with EDs to increase the access and availability of naloxone to all patients admitted to EDs for opioid-related overdoses as well as MAT based on the patient's evaluation of need in the ED in order to promote harm reduction. Lastly, the hospital coordinator collaborates with Broward County's 18 EMS providers in order to increase the timeliness and transparency of their data and improve drug overdose surveillance.
DOH-Broward engaged in partnerships with non-profits SFWN and Fellowship Living to expand peer recovery support services for individuals with substance use disorders in Broward County hospital EDs, jails, treatment centers, and other community sites. Currently in Broward County, three hospital EDs (Memorial Healthcare System, Broward Health, and Holy Cross Hospital) are staffed with four PRS each; the PRS's are funded by the OD2A program through DOH-Broward. The EDs serve as an ideal location to intervene with an individual who has just been revived from an opioid overdose, and immediately connect them with appropriate services and support, including MAT. According to a literature review, peer support workers can efficiently connect individuals suffering from opioid use disorder with proper treatment and recovery interventions, often to greater effect than primary care or clinical behavioral health staff. PRS assist people with substance use disorders in developing the necessary skills for resiliency, in navigating resources vital to recovery, and in creating long-term recovery plans. Data collected by peer recovery specialists is shared with DOH-Broward and include statistics on the number of opioid overdose admissions where a peer recovery specialist has intervened, the number of opioid overdose deaths in the EDs, the number of overdose survivors who have engaged in recovery supports after discharge, the number of survivors who have declined recovery support services, and the number of those seen in EDs multiple times.
DOH-Broward worked with tax assisted hospitals and one non-tax assisted hospital in establishing protocols and policies in emergency departments to guide referrals and linkages for persons who have experienced overdose. This occurred in two ways, through incentivizing the hospitals and through peer-specialists.
The incentivized approach was based upon Florida's Baby Steps to Baby Friendly, which provides hospitals with mini grants to achieve milestones along the continuum to receiving Baby Friendly Hospital Designation. DOH-Broward developed a process to incentivize hospitals to establish protocols and policies in the ED which were modeled after national best practices of ED protocols and include components related to universal screening, naloxone access, referrals to treatment, and use of non-clinical personnel.
Previously, three hospital EDs (Memorial HealthCare System (MHS), Broward Health and Holy Cross Hospital) were staffed with five peer navigators and/or specialists.
MHS employed two PRS in one of its' five hospital emergency departments. This program provided an additional two PRS to provide services in two additional MHS hospitals with high emergency department utilization rates. MHS expanded its successful ED program to two other hospitals and provides bedside interventions for patients that present with any evidence of an opioid use disorder (cellulitis due to using unclean needles, etc.).
MHS uses a multidisciplinary team in the ED that includes Physicians, Pharmacists, Behavioral Health Nurses as well as Peers that intervene on any patient that comes in presenting with an opioid overdose as well as any patient that has a potential opioid use disorder. MHS utilizes Motivational Interviewing to engage the patient in treatment, if the patient agrees and is a candidate, they can start them on buprenorphine the same day or following day depending on the clinical presentation. The patient is started on MAT and monitored while the team transitions them to an outpatient service in which they can obtain more intensive individual, group, ongoing medication management and any needed case management services to address their psychosocial needs (stable housing, employment, transportation, etc.).
In 18 months (thru March 22, 2019) MHS screened 993 patients and initiated 243 buprenorphine inductions in the ED setting. This is a 25% conversion rate, there are patients that reach out post ED intervention and enter the MAT program. Of the patients that initiate the induction out of the ED there is an approximate 40% drop out after the first two weeks. Many of these patients come back and re-enter the program as relapse is part of the course of the disease of opioid use disorder (OUD). Ultimately these patients transition to the Outpatient MAT program. In 18 months 290 patients have been treated in the outpatient MAT program and there are currently 61 active MAT patients. Of the patients that are in the program at 6 months, 65% are drug free. Adding additional peers will allow for more aggressive follow up for those patients that initially decline the program or drop out with in the first two weeks and would assist in increasing the conversion and retention rate of individuals suffering from OUD.
Using the successful model that Holy Cross Hospital in Broward County developed, Broward Health began a similar program in the busiest of its five EDs. This program expanded PRS to four at two additional EDs. The goal of the program was to reduce opioid-overdoses seen in the emergency department and link patients to treatment services. Certified PRS from SFWN and Fellowship Living respond to overdose calls filtered by Henderson Behavioral Health from the Emergency Department. Certified PRS have life experiences and are in recovery from alcohol or other drug use disorders. They drive the program as they intervene bedside with patients who have just experienced an overdose. The idea is to have PRSs provide the critical support or link to the services and supports that a person needs to achieve and sustain recovery. A growing body of knowledge/evidence suggests that peer support workers can efficiently connect individuals suffering from opioid use disorder with proper treatment and recovery interventions, often to greater effect than primary care or clinical behavioral health staff. Having immediate support when crisis occurs is a high priority for effective engagement with treatment. Certified PRSs are available 24/7 to respond and engage patient's bedside. It is expected that based on the Holy Cross model, that 30% of patients who will meet with a Certified PRS accept treatment. Of the overdose patients that accepted treatment, 82% will have a 30-day follow-up conversation with their Certified PRS. A follow-up with the patients will occur for further engagement in the recovery process and treatment plan or if additional services are needed. Of those who accepted services, 30% were female and 70% male.
The SFWN, a peer-run recovery organization, known as a leader in peer support services, works to combat rampant opioid use in Broward County, Florida, and around the state by implementing Building Communities of Recovery in Florida. They will serve as Subject Matter Experts to provide guidance in the expansion of PRS Services for individuals experiencing substance misuse, introduce innovative wellness activities, enhance Recovery Community Organizations (RCOs) and networks, and advance public education. SFWN will build skills for recovery, resiliency and strength for diverse people with substance misuse and addiction, particularly from opioids, in Broward County jails, hospital emergency departments after overdose, treatment centers, and at community sites, focusing on peer support services and quick navigation to resources vital to recovery. SFWN's Wellness Center will offer innovative mindfulness activities, training, and support groups to enhance recovery. The project expanded the capacity for PRS Services and provided training and technical assistance to emerging RCOs, conducted a Building Communities meeting, and an annual PRS training. The project included public education to improve understanding and reduce stigma about substance addiction by using social media, a video, and community presentations.
The addition of PRS has been considered a success by all involved hospitals but reports of demand for PRS outweighing availability have become commonplace among Broward County hospitals, leading to the conclusion that additional funding is necessary to meet this demand. Additionally, while protocols and procedures developed and implemented by Broward County hospitals has improved care of overdose patients, more changes are still possible to continue to improve the care overdose patients receive in EDs.
Overarching goals for the PRS Program were: 1) Prevent overdose deaths in ambulatory care and in ED; 2) Arrival of PRS within 30 minutes from ED initial phone call; 3) Increase patient's success of recovery through on-site treatment and/or referral treatment; 4) Continual access to care and services through recovery support for up to 90 days; and, 5) Preventing readmission to ED.
DOH-Broward incorporated key best practices into this program including:
1. Incorporation of Peer Recovery Specialist in the Emergency Department or primary care settings to increase successful engagement in treatment for individuals presenting with substance abuse disorder (Coordinating Clinical and Public Health Responses to Opioid Overdoses Treated in Emergency Departments).
2. Access and availability of NARCAN to ambulatory care, ED, and to all patients admitted to the ED for an opioid-related overdose to promote harm reduction. Nearly every opioid overdose death is preventative with naloxone (Coordinating Clinical and Public Health Responses to Opioid Overdoses Treated in Emergency Departments).
3. Access and availability of Medication-Assisted Treatment (especially medication for opioid use disorder (MOUD)) based on patient's evaluation of need in the ED. Medication-Assisted Treatment lowers the risk of both relapse and death. (Coordinating Clinical and Public Health Responses to Opioid Overdoses Treated in Emergency Departments).
4. Long-term evaluation of contact with survivors in coordination from Peer Recovery Specialist with ED up to 90 days. All patient treated for addiction must have a long-term recovery plan (Coordinating Clinical and Public Health Responses to Opioid Overdoses Treated in Emergency Departments).