Opioid Overdose and Addiction Treatment: A Collaborative Model of Compassion, Patience, and Respect

Abstract

Purpose

The purpose of this article is to describe the creation and outcomes of a collaborative model and care facility for opioid overdose and addiction treatment based on compassion, patience, and respect: The Maryhaven Addiction Stabilization Center (MASC).

Approach

MASC was created with the vision to serve clients who have recently overdosed on opioids. In this article, the research, planning, building, and implementation of an opioid treatment center composed of an admission and triage unit, inpatient withdrawal management unit, and inpatient residential unit are described. A multi‐agency and multi‐disciplinary approach were used to immediately engage patients and connect them to treatment for opioid addiction.

Findings

Implementation of a collaborative model of care offers patients who overdose on opioids with immediate access to admission for treatment. This has resulted in significantly higher numbers of patients seeking and staying in treatment.

Conclusions

Through multi‐agency collaboration and a shared commitment to addressing the challenges of the opioid epidemic in innovative ways, more patients who are struggling with addiction have increased opportunities to engage in treatment and move towards recovery.

Clinical Relevance

Clinicians, first responders, and communities can employ MASC principles to guide their approaches to serve patients who have recently overdosed on opioids or who are in active addiction.

The increasing incidence of opioid overdose has had devastating consequences, affecting the health and social welfare of populations. Opioid overdose and addiction has recently been deemed an epidemic and national emergency in the United States (Jones et al., 2018). Srivaslava and Gold (2018) described the opioid epidemic as currently the most serious public health crisis, and the U.S. Department of Health & Human Services (HHS, 2019) declared the National Opioid Crisis as a Public Health Alert. The National Institute on Drug Abuse (NIDA, 2019) indicated that more than 2 million Americans misuse opioids and more than 130 die every day by opioid overdose. Accordingly, emergency department visits related to opioid overdoses increased by approximately 30% from July 2016 through September 2017 (Centers for Disease Control & Prevention, 2018).

Equally important, opioid overdose is not only an American concern, but a global concern. The United Nations Office on Drugs & Crime (2018) reported that the global opiate (poppy derivative) market is increasing, with 34 million users of opioids (poppy derivative or synthetic analogs) and 19 million users of opiates in 2016. Similarly, the World Health Organization (WHO, 2018) estimated that 69,000 people die annually from opioid overdose, even though a medication, naloxone, can reverse the effects of the overdose.

Whereas the prevalence of the opioid overdose crisis is well documented, available treatment is less so, and may consist of a drop off to the emergency room followed by a quick exit. The Substance Abuse & Mental Health Services Administration (SAMHSA, 2018) found that the majority of those with substance use disorders did not access treatment for help towards recovery for a variety of reasons, including costs and inability to find a treatment program. The WHO (2018) indicated that less than 10% of people who need treatment receive it. Furthermore, most addiction treatment facilities do not offer medication‐assisted treatment (MAT) for opioid use disorder despite evidence as a possible intervention (Mojtabai, Mauro, Wall, Barry, & Olfson, 2019). The Recovery Research Institute (2019) noted that MAT can help reduce the risk for overdose and increase treatment retention. In response to the need for treatment, the HHS (2019) has identified promotion of overdose reversal medications as well as access to treatment and recovery as priorities.

The increase in opioid overdoses coupled with a lack of inpatient treatment options has had a devastating effect in central Ohio. Ohio is second in the United States in opioid overdose deaths according to NIDA (2019). Additionally, patients who have experienced a nonfatal overdose are at high risk for experiencing another (Olfson, Wall, Wang, Crystal, & Blanco, 2018). First responders, emergency room nurses and physicians, and patients experience the helplessness and hopelessness of the overdose and reversal cycle. Availability of MAT programs specific to opioid use is sparse (Morgan, Schackman, Weinstein, Walley, & Linas, 2019); there are four certified opioid treatment programs listed for Columbus, Ohio, by SAMHSA (2019).

In response to the current epidemic and lack of immediate access to treatment in central Ohio, a coalition of professionals embarked to investigate the possibilities of using a collaborative model of caring to improve recovery rates. The initial coalition included the Alcohol, Drug, and Mental Health Board of Franklin County (ADAMH) and representatives from the police and fire departments.

Community Assessment

The transition began in 2012 with a decision to prioritize finding a treatment solution instead of focusing on the causes, pathways, and criminalization of addiction. Police officers were dismayed at watching people overdose and die while waiting for emergency medical services (EMS) and often saw the same patient overdose multiple times in one day. At least 20% of patients who overdosed refused transport to the hospital. Arrests and quick trips to the emergency room were proving ineffective solutions, and the problem was growing.

The coalition realized the focus had been on public safety instead of public health and began reaching out to the Health Department, Health Commissioner, and hospitals for data. In 2014, the assistant fire chief brought a nursing background to the department as an emergency room nurse and started collecting and viewing data from a medical viewpoint while questioning outcomes. In October 2015, the Ohio legislature enacted the Ohio Revised Code section 2925.61 permitting administration of naloxone by police officers. By 2016, discussions confirmed the massive scope of the problem and the tendency to focus on preservation of life with handoffs to emergency departments. Unfortunately, elopement rates from emergency departments indicated few patients were receiving treatment to specifically address opioid addiction. As a result, many patients immediately returned to opioid use.

In an effort to steer people into treatment, a letter offering care options was crafted by community health officials and sent to anyone who had suffered multiple overdoses. Despite numerous mailings, one person responded. This only served to highlight the mismatch of current approaches to opioid addiction and treatment.

Developing Collaborative Approaches

In 2015, the police had responded to 2,885 overdose calls and 11,572 drug‐related calls (Lieutenant Jeffrey, personal communication, October 2, 2019). It was clear that arrests were not the way to solve this problem. To expand administration of naloxone, the coalition reviewed the two ZIP Code areas where police responded to the most drug‐related calls (n = 1,468), and offered voluntary naloxone training to officers assigned there. These two ZIP Code areas had 25% of the total known naloxone administration in the city. In an effort to promote a culture of acceptance, the Columbus Police Department began voluntary training on the use of naloxone for police officers. Despite the voluntary aspect, naloxone administration by police officers grew from 58 in 2016, to 281 in 2017, and to 473 in 2018 (Lieutenant Jeffrey, personal communication, October 2, 2019).

During this time, the police department began to emphasize the need to address addiction as one of many mental, medical, and social concerns for those experiencing opioid overdose. This led to more holistic engagement strategies. Many of the officers and supervisors began Crisis Intervention Team (CIT; CIT International, 2019) training in an effort to improve collaboration with healthcare providers and divert people in mental health crisis from incarceration to treatment when appropriate. The CIT curriculum includes signs and symptoms of mental illness, treatment options, and de‐escalation techniques. Trained officers felt more confident differentiating between medical and legal emergencies, but the historical and continued use of involuntary admission or emergency department care was repeatedly proving ineffective for opioid overdose. The treatment void specific to opioid overdose continued, and the coalition reached out to community mental health partners for help.

The call for help prompted the development of the Rapid Response Emergency Addiction and Crisis Team (RREACT) in 2017 (Columbus Division of Fire, 2018). The Columbus Division of Fire, ADAMH, and Southeast Healthcare Services, Inc. formed a partnership to provide rapid response and care to residents who have overdosed on opioids. The Columbus Division of Police also partnered with RREACT, providing CIT police officers to accompany paramedics during follow‐up visits to patients treated for opioid overdose. This multi‐organizational collaboration of paramedics, social workers, and police officers helps connect patients who have received naloxone for opioid overdose to treatment providers and other social services in hopes of providing support that can lead to recovery. When an opioid‐related call is received, dispatch requests RREACT.

Initially, the approach was to meet with patients who had overdosed shortly after arriving at the emergency department to share treatment options. It was thought that patients having a near death experience might be more interested in recovery. The widespread use of naloxone, however, has changed the pathway, with many opioid users refusing transport to the emergency department or other treatment facility once revived. As a result, RREACT provides follow‐up visits to patients within 24 to 48 hr after experiencing an overdose and refusing transport to the emergency department. These follow‐up visits often occur at the address of the overdose site or at the last known address of the patient. Additional grant money has further enhanced services with the ability to add a project manager, case manager, and social workers for further outreach when offers for treatment are refused. The collaboration has grown to include social workers from Franklin County Family and Children First Council, and the Central Ohio Area Agency on Aging. The plan is to offer more service coordination, including trauma counseling and care for exploited or abused children and families impacted by opioid use.

Early RREACT Team interventions in the emergency department with patients who had overdosed resulted in a 50% outpatient services referral rate. RREACT was showing significant patient engagement, but the number of overdoses was exceeding the team capacity, and the major deficit was a lack of inpatient treatment specific for opioid addiction. First responders had become more versed in methods to divert patients from the criminal justice system into treatment, but the team could not keep up with the demand for inpatient services.

At this stage, the coalition still had two challenges: availability of treatment options and engagement of patients who overdose. As such, with continued collaboration, the coalition developed an innovative idea for an inpatient opioid treatment center in an effort to address the two challenges. Planning for the Maryhaven Addiction Stabilization Center (MASC) began with the goal to provide a facility dedicated to immediate treatment for opioid addiction.

New Inpatient Facility

With a long history of expertise in addiction care, the Maryhaven staff and key collaborator, ADAMH, were well suited to research, plan, build, and administer an innovative model of access and treatment to address the opioid crisis. In an effort to find a location, it was decided to identify the ZIP Code with the most naloxone administrations by first responders. Use of first responder naloxone administration and ZIP Code is an imperfect measure of opioid overdose and use, because it misses personal administration and deaths by overdose without administration. Nevertheless, the findings correlated with experiences and expert advice from coalition members. Step two was finding a location and building within the ZIP Code.

Building and Design

Coincidentally, a building existed in the identified ZIP Code area where Maryhaven was already renting space. Maryhaven staff examined the possibilities of renovating the building to make it suitable for triage and inpatient treatment. It was estimated that $1.4 million would be needed. A request for funding a new inpatient facility, MASC, was presented to ADAMH in April 2017 and approved in July 2017. Public and private funding supported the renovation of two floors of the building.

Next, a challenging step was convincing the neighborhood that the facility would be an asset to the community. There were difficult conversations about safety, fear, and lifestyle. Neighbors voiced worries over patients leaving against medical advice, increased drug activities, and loitering around the facility. Maryhaven staff shared first responder data indicating the prevalence of opioid use and overdose in the ZIP Code area. In an effort to address neighborhood concerns, MASC contracted with Columbus Police Department for one CIT‐trained special duty officer to be present in the facility 24 hr per day. Additionally, a “no walk off” policy was implemented. This meant that all patients discharged from MASC would be transported off site via taxi.

As a result of efforts to work together and a sense of urgency, along with the support of ADAMH, renovations began the month following approval in August 2017, with completion in November 2017, followed by opening in January 2018. From idea proposal to opening, the timeframe was 8 months.

MASC opened as a 57‐bed facility with three levels of care: admission and triage (7 beds); withdrawal management (20 beds); and residential treatment (30 beds). From the beginning, priority admission was given to patients transported by first responders or those referred from emergency departments by RREACT. If capacity permitted, walk‐in admissions were accepted. The original program design as depicted in Figure S1 included plans for other admission sources. However, within 6 months a full census was reached. Since then, MASC has operated at or near full patient capacity, precluding many other sources of admission (Figure S2). During the first few months, the majority of admissions walked in to be admitted, but over time the volume from other referral sources increased, as depicted in Figure S3.

Admission Protocols

The majority of patients admitted have a history of opioid overdose and naloxone administration. Medical and nursing leadership from EMS and MASC carefully designed a protocol for determining appropriate transport, as shown in Figure S4. Since MASC is considered a subacute facility rather than a complex acute hospital, it is imperative to move patients to appropriate levels of care so their needs are safely met. To promote understanding and collaboration prior to opening, EMS performed numerous mock patient hand‐offs. Additionally, MASC staff accompanied EMS on actual emergency calls to observe first‐hand the encounters between patients and first responders. To facilitate admissions, an EMS dispatch radio was placed in the MASC Triage Unit for staff to stay abreast of current situations likely warranting admissions. Initial radio interactions between nursing staff and first responders were cumbersome, and it was apparent that the nursing staff required training in radio protocols for smoother communications. As a result of careful planning, a new treatment path emerged: overdose, naloxone, and patient transported to MASC or the emergency department.

Mission and Philosophy

Along with transportation and admission protocols, MASC leadership developed a mission and philosophy, treatment protocols, and policies and procedures with a goal to meet patients where they are in the process of recovery without judgment. The core mission of MASC was defined as follows: “We embrace the opportunity to serve as agents of change by activating hope and empowering our community to honor the equality, worth, and dignity of every individual.” The philosophy of caring was developed by the nurse administrator and centers on compassion, patience, and respect.

Compassion for patients is vital because of the stigma that is attached to addiction, as well as the shame that many of the patients highlight when discussing their pasts. It is not for staff to judge them based on their transgressions, but rather to provide a safe space for listening and facilitating the processing of their experiences. The focus is to emphasize the importance of the present moment. The factors leading up to the present moment are less important than the next steps patients take towards their recovery. Compassion among staff and self is also vital because the addiction and recovery environment can be emotionally overwhelming. To refresh and remind staff of the core philosophy, the nurse administrator presents the CPR (compassion, patience, respect) Award each month to the staff member who best exemplifies the MASC philosophy of caring.

Patience is another essential aspect of the treatment model. Patients often speak and act in a manner that can be offensive when experiencing withdrawal. It is preferable to speak to disruptive patients one on one in a private area and allow them to verbalize, or attempt to verbalize, their current emotions as part of building rapport for the recovery process. There can be a tendency for the patient and staff to have a sense of urgency when dealing with the recovery process. However, it is important to realize that the addiction and behavior of the patient often have been reinforced over a period of many years. Patience is a form of wisdom, and the recovery process for the patient will unfold over a period of unspecified time.

Respect is manifested by actively listening to what patients have to say. It is expected that staff lead with respect regardless of patient behavior. The act of showing respect to everyone in the facility has empowered patients and shown them a different way to be treated than they have been accustomed to. It is important to remember these patients have chosen to engage in treatment.

The focus of compassion, patience, and respect is to reach out to those battling substance use disorders with unconditional positive regard. The goal is to instill hope and belief that this may be the day they begin their recovery. In the event a patient relapses and is readmitted, there is emphasis on embracing the patient and clearly communicating a new opportunity for recovery.

Inpatient Protocols

Admission and triage unit

When patients present to the Admission and Triage Unit, they are greeted by a special duty CIT‐certified police officer for security screening. Then the nurse practitioner or nurse performs an initial health assessment with a focus on the patient's desire to stay and appropriateness of patient condition for admission. Patients remain in triage between 4 and 23 hr. MASC is secured from the outside and open from the inside, meaning people enter with permission only but may sign themselves out against medical advice at any time. As such, there are not forced admissions based on danger to self or others. This has had perhaps a surprising, but important, impact on patients' understanding of personal responsibility for their health and well‐being, as well as comradery and support of each other when tempted to leave treatment prematurely.

Patients who elect MAT typically receive an initial dose of buprenorphine on this unit, though some patients receive an initial dose on the Withdrawal Management Unit as determined by their Clinical Opiate Withdrawal Scale (Wesson & Ling, 2003) score.

Withdrawal Management Unit

Once patients are deemed stable, they are transferred to the second level of care, the Withdrawal Management Unit, where the average stay has been 5 to 7 days. While 25% of the patients in the Withdrawal Management Unit are on a 7‐day buprenorphine taper, the remaining 75% are on a maintenance dose with the intent of linkage to an independent buprenorphine provider or outpatient clinic following discharge. Approximately 90% of patients utilize buprenorphine as their primary withdrawal management medication. The remaining 10% utilize comfort medications such as clonidine, hydroxyzine, acetaminophen, and/or ibuprofen, often with a goal of a quicker pathway to naltrexone induction.

While specific programing is scheduled for the Withdrawal Management and Residential Units, there is a soft encouragement when patients are in withdrawal, since they can feel too sick to participate. An important intervention is tolerance for patients during this period of withdrawal. The withdrawal management process consists of assessment, stabilization, and fostering readiness for the next step in recovery.

Residential Unit

Following withdrawal management, the third level of care is residential, where the patient stay is approximately 2 weeks, and up to 30 days, especially if waiting to secure longer term recovery housing. Programming includes education, yoga, pet therapy, journaling, and a variety of group and individual counseling. Peer recovery groups, led by peer recovery support specialists (PRSs), are an essential element of programming. PRSs began as Maryhaven patient care assistants prior to training and certification by the Department of Mental Health and Addiction Services. After residential, a major barrier to continuation of treatment is the lack of recovery housing allowing MAT in the state.

Operating MASC

After establishing the location, building, and equipment, MASC recruited 106 full‐time equivalent employees. The overall annual budget for MASC is approximately $6.6 million, supported in part by public and private funders. Patient billing is coordinated by a utilization review team, and most patients receive Medicaid benefits. Staff comprises a major part of the budget and includes customary roles such as nurses and counselors, with the addition of others specific to MASC, such as special duty police and PRSs. The medical director is board certified in addiction and family medicine, and the nurse practitioners have prescribing authority for buprenorphine for opioid use disorder. Although the medical director is always available for consultation, the nurses and nurse practitioners coordinate and lead patient care as the primary decision makers. With only 3.17% of nurse practitioners in the United States having prescribing authority for buprenorphine (Spetz, Toretsky, Chapman, Phoenix, & Tierney, 2019), the role of the nurse practitioner is advantageous at MASC.

Leaders in MASC began and continue an inclusive campaign to build community support and sustainability by engaging with partners on a local, state, and national level. Major goals are to reduce stigma, dispel myths regarding MAT, and increase awareness of treatment and recovery options. MASC works closely with local colleges and universities, and offers clinical learning experiences for students in undergraduate nursing, nurse practitioner, social worker, and counseling programs of study. To date, 400 nursing students have had opportunities to engage with patients experiencing substance use disorder. Additionally, under the guidance of the medical director, MASC has partnered with a local hospital to offer medical fellowships, and two physicians are currently participating.

New Pathway to Admission

In June 2018, a new route of admission to MASC emerged when the Whitehall Division of Fire, Whitehall Division of Police, and Heart of Ohio Family Health Center joined efforts to implement the Stop Addiction for Everyone (SAFE) Station. Anyone in crisis related to opioids or other substances can arrive at the fire station designated as a SAFE Station and ask for help related to their addition. Leaders from MASC worked closely with SAFE Station leaders to develop a screening tool to ensure appropriate referrals for treatment. Individuals walk in knowing they will be welcomed with respect as well as coffee and snacks. Often, this is followed by a warm hand off to treatment without fear of incarceration. Since opening and up through October 2019, the SAFE Station has made 827 referrals to MASC, which was 22% of the total referrals in that timeframe.

Outcomes

The nurse administrator of outcomes and community engagement collects demographic and descriptive data related to patients referred, admitted, and discharged from MASC. The scope of the opioid problem and extent of interdisciplinary community involvement has elicited interest in these statistics for community planning. Statistics for the period of January 19, 2018, to October 31, 2019, are depicted in Table S1. There were an average of 5.74 daily admissions from 31 different counties across Ohio, and 35.6% of patients have had two or more admissions highlighting the necessity of multiple attempts at recovery for many patients. The majority of patients were male at 58.9%, with females at 41.1%. Patients identifying as homeless comprised 28.6% of the patient population. There were 82 patients known to be pregnant who received services over 116 treatment episodes. The majority of patients were 20 to 39 years of age, but patient ages ranged from 18 to 79 years of age.

In addition, referral sources, admission rates, and completion rates are used to assess outcomes. There were 3,780 referrals in 22 months, highlighting the role of MASC serving patients in need of inpatient treatment. Of those referrals, 93.1% agreed to be admitted for treatment, followed by 76.9% agreeing to transfer to the Withdrawal Management Unit after triage. While the majority of patients agreed to admission and entered the Withdrawal Management Unit, 9.3% left triage within their first 23 hr against medical advice, and 1.5% completed triage and were referred out. Another 6.9% declined admission for personal reasons or were deemed not medically appropriate due to the drug of choice or needing a higher level of psychiatric or medical care. As a result, there have been 2,907 admissions to the Withdrawal Management Unit, with a 63.5% completion rate, followed by 1,080 transfers to the Residential Unit, with a completion rate of 73.4%. Conclusions drawn from the outcome data indicate that MASC is serving significant numbers of patients seeking immediate access to treatment for opioid addiction. Another significant outcome measure is violence prevention. While special duty police presence was initially a concession to the community, it appears to have enhanced the no violence policy at MASC. There have been no incidents of violence towards staff, and there have only been a few patients discharged for threatening violence towards another patient.

While numerical descriptive data were used in assessment of outcomes, the narrative descriptive data have significant meaning for the staff at MASC. Numerous interactions in the community with former patients remind staff of the impact of their caring. As part of treatment programming, former patients return to MASC to share their recovery stories with current patients. Further, building on the importance of community and shared experiences, a MASC alumni group began meeting monthly in August 2019 to create an avenue for continued dialog among staff and those in recovery. MASC exists without signage or advertising, instead relying on strong referral partnerships and former patients sharing their treatment experiences at MASC with others in need of recovery.

Limitations

A limitation of the information and outcome data is that it is descriptive over a short time frame, since the facility is new. Another limitation is the difficulty in comparing outcomes, since there is not another opioid‐specific inpatient provider in the service area that works predominantly with patients who are uninsured or receiving Medicaid. Longer term data collection and statistical comparisons are needed and may reveal different outcomes. Further, despite our nursing experience and expertise in addiction treatment models, we have been involved in the assessment of the quality and impact of MASC and therefore may have been subject to biases affecting our descriptions. Another challenge is the difficulty in collecting data once patients are discharged due to homelessness, frequent address changes, unreliable transportation, and returning to opioid use or overdose. As a smaller non‐profit agency, resources for data collection are sparse, and the nurse administrator is responsible for data collection and reports to stakeholders in addition to performing community engagement responsibilities and oversight of nursing care.

Challenges

There are challenges in operating MASC. Since the opening, sufficient nurses have been difficult to obtain, necessitating some agency nurse staffing. Despite taking measures to address the effects of vicarious trauma on staff, the intensity of the opioid epidemic and its impact on individuals and the community can be overwhelming. Space is limited, and times of full occupancy necessitate use of a diversion policy. The entire treatment program is indoors without any outdoor space available. The referral‐out process is often challenging due to insufficient housing availability, particularly for those on MAT. The referral‐in process can be confusing and frustrating to those who do not understand the scope of the facility or what is deemed medically appropriate for inpatient addiction treatment. The drugs patients use, such as fentanyl and fentanyl analogs, are showing increased lethality (NIDA, 2018) which decreases opportunities for engagement at MASC.

Conclusions

It is clear there is a need for focused treatment for opioid use and overdose. As the first alternative to the emergency department in the area, 3,780 patients experiencing opioid overdose and/or use were referred to MASC in the first 22 months of operation, with 93.1% consenting to treatment. The service area encompassed 35% of the counties in the state. Emergency room nurses, physicians, and social workers, as well as first responders, describe relief and hope as they refer patients to MASC. Equally important, the MASC treatment model is showing initial success, with completion rates of 63.5% for withdrawal management and 73.4% for residential.

The design and opening of MASC as a collaborative model for treatment of opioid addiction and overdose prompted many to wonder at times if the plans were too risky. During the first 48 hr, two patients were admitted, but on the third day, five patients were admitted, and worry about risk began to abate. Now typically near full occupancy, MASC has become a new center of hope for recovery from opioid addiction. The resources, partnerships, processes, procedures, and data collections for implementing the MASC model may be replicated in other communities striving to combat the opioid epidemic with compassion, patience, and respect.

Supporting information

Figure S1. Maryhaven Addiction Stabilization Center program design.

Figure S2. Admissions per month January 2018 – October 2019.

Figure S3. Referral sources to Maryhaven Addiction Stabilization Center January 19, 2018 – October 31, 2019.

Figure S4. Emergency medical services protocol for transporting patients to the Maryhaven Addiction Stabilization Center.

Table S1. Descriptive Outcome Data January 19, 2018 – October 31, 2019.