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Hospital, County Mount Robust Effort to Tackle Opioid Abuse

Task Force Works to Turn Tide on Overdose Deaths in County

Despite this progress, Calvert County is eighth in the state for opioid deaths as a percent of the population. According to the Calvert County Health Department, every 11 days there is an overdose death in our community. In 2019, the average age of those who died was 34 and it is believed half of those who died had children at home.

“We quickly realized that in order to tackle the problem in a comprehensive way, we needed all stakeholders to be involved,” said Dr. Stephanie Dabulis, Chair Department of Emergency Medicine.

“We can get blinded by statistics, but this is a human story, not just a human health crisis,” said Dr. Drew Fuller, former assistant director of CalvertHealth’s Emergency Department (ED). “We need all-hands-on-deck and we need transformational approaches.”

After working on the CalvertHealth task force, Dr. Fuller transitioned to the Calvert County Health Department as medical director for the Mobile Crisis Team, which consists of a physician/nurse practitioner, a nurse, a licensed counselor and a peer counselor. Working with the hospital and first responders, the team engages persons with opioid crisis throughout the county.

Emerging Problem Identified

“We were seeing a dramatic increase in overdose-related deaths and injuries as well as narcotic-dependent behavior in patients that were coming into the ED and community practices,” said Dr. Fuller.

“We didn’t know how to start the discussion or who should be involved, but we knew, as a community hospital, we had to do something about the overdose deaths,” said CalvertHealth Pharmacy Director, Kara Harrer, PharmD.

What evolved from that first meeting in 2015 was the Opioid Stewardship Task Force encompassing a multidisciplinary committee from CHMC as well as representatives from the Calvert County Health Department.

Setting Goals and Protocols

The task force set goals in 2016 to formalize opioid prescribing policy and guidelines, promote alternatives to opioids, work to become a ‘Dilaudid®- free ED,’ track and report prescribing practices, and develop a referral network for persons with opioid misuse disorder.

When used appropriately, opioids provide pain relief by altering the way normal healthy nerves process pain. Unfortunately, opioids change the chemistry of the brain and lead to drug tolerance. If used for an extended period of time, opioids produce dependence such that when people stop taking them, they have physical and psychological symptoms of withdrawal.

“The great majority of people who develop an opioid addiction start with pills,” according to Dr. Fuller. “We felt it was our duty to make sure we were using the best evidence-based practices for prescribing opioids and that we had the highest level of accountability, which is why we adopted protocols and committed ourselves to measurement and to transparency.”

“If we can avoid the possibility of patients becoming dependent on opioids, then we will see a decrease in the misuse of opioids, fewer overdoses and deaths,” said Dr. Harrer.

The Opioid Stewardship Task Force is a multidisciplinary committee with representatives from CHMC, the Calvert County Health Department and the Calvert County Sheriff’s Office.

Reducing Opioids in the ED

When the task force looked at data from the first year, they realized their plan to address the over-use of opioids was working -- and continues to work. By educating doctors and nurses on pain management alternatives, the ED has:

  • Reduced intravenous Dilaudid® orders by 94 percent
  • Decreased the number of prescriptions written for controlled substances by 95 percent
  • Decreased the number of opioid prescribing exceeding three days by 95 percent
“When people come to the ER in severe pain – of course our doctors and nurses work to get their pain under control as quickly and safely as possible and that may be through use of opioids,” said. Dr. Dabulis. “If a patient needs continued access to pain relief while at home, we try to limit doses for just the period of time until they can get in to see their doctor or specialist.”

Addressing Patients Who Are Opioid Dependent

Equally important to reducing opioids prescribed by physicians, the Stewardship Team looked at protocols to address patients who arrived in the ED or other CalvertHealth System locations with an opioid dependence.

According to Dr. Dabulis, the Stewardship Team worked to lay the infrastructure for trying to help substance abuse patients before they were discharged.

“That infrastructure includes education, empathy, NARCAN® kits, peer counselors and getting them set up with the health department that day or the next day,” Dr. Dabulis said.

Unlike a patient who is treated in the ED and told to follow up with their primary care physician within 10 days, opioiddependent patients don’t have 10 days to wait for follow-up treatment. There is a near 100-percent certainty that if these patients are not in treatment within 24 hours, they will use again, according to Dr. Fuller.

From Emergency Response to Treatment to Recovery

The Task Force developed protocols in line with the Substance Abuse and Mental Health Sciences Administration (SAMHSA) of the National Institutes of Health.

“It has been shown that if someone in crisis gets a dose of a medication-assisted treatment (MAT) in the ED, meets with a peer counselor and is linked up with a MAT provider such as the health department, they are twice as likely to follow up and stay in a recovery program,” said Dr. Fuller.

“A peer counselor is not some judgmental person coming in to fix someone, and is not even a social worker. He or she is someone who has been down the same road, and has been through multiple treatment facilities – sometimes multiple treatment options – until they have been successful in overcoming opioid addiction, and now, they want to help others understand treatment options so they can be successful, too,” said Dr. Dabulis. Peer counselors can usually get to the ED in less than an hour but patients have to want to see a counselor. According to Dr. Harrer, the percentage of patients who accept being seen by a peer counselor has risen, and this is great news because it shows that patients want help before they are discharged, she said.

MAT is shown to decrease deaths by 80 percent and the Calvert County Health Department has tripled its capacity in the last two years to take care of MAT patients.

“There is close collaboration between the health department and ED. We can see people the same day in the health department or the following morning seven days a week,” said Dr. Fuller.

Continued Education and Outreach

One of the initial goals of the Stewardship Team was to serve as a resource -- locally, statewide and nationally – by engaging in outreach and education opportunities. To that end, education initiatives started within the Emergency Department will continue and will expand to all areas of the CalvertHealth System, and to local physician and dental practices. A sheriff’s department representative has been added to the task force to provide input on trends and what law enforcement is seeing outside of the county.

“All of these efforts are to continue the robust collaboration we started in Calvert County and show how the successes we’ve had can be possible throughout the state and the nation,” said Dr. Harrer.

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