The Opioid Crisis: A Multidisciplinary Perspective on Effective Management - Episode 14
Experts discuss the need for and impact of peer-to-peer discussion initiatives, as well as the impact telemedicine utilization has had on the opioid crisis.
Theresa Mallick-Searle, MS, RN-BC, ANP-BC: I would love to see an initiative to have peer-to-peer discussions. You might have patients who do not want to talk to their health care provider because of stigma, for a whole host of reasons. But I would love to see a movement where a person misusing these drugs, or an individual who is on the street, or a homeless person who is at high risk could experience some kind of peer-to-peer discussion. It could be just like AA [Alcoholics Anonymous] or other groups like that, where there is that discussion to normalize and safely use naloxone and also discuss what these medications mean.
Jeffrey Bratberg, PharmD, FAPhA: We have that. We innovated that in Rhode Island; I keep mentioning that.
Theresa Mallick-Searle, MS, RN-BC, ANP-BC: I love Rhode Island.
Jeffrey Bratberg, PharmD, FAPhA: Maybe that is why I am here; anyway, we have peer recovery specialists, and they are trained folks. They are people in recovery themselves, and we adopted this program. I think the easiest way to think about it is that when the doctor, the provider in the white coat, comes in and says, “I’m going to give you naloxone,” the patient is going to say, “Whoa, people like you have not treated me well.” If the person comes in and says, “I’ve been where you have; I was saved by naloxone.” About 90% of people, when they're told, “I was saved by naloxone,” take naloxone and get into treatment. We need people to tell them that there is life after this, that they should not leave against medical advice, or whatever that is. That is a really important point.
Joshua Lynch, DO, EMT-P, FAAEM, FACEP: I think attaching patients to peers is underutilized. There are a lot of folks who could be peers out there who probably want to take on that role, and just have trouble. We wanted to lower the barrier when pairing patients to peers. We started a text for naloxone program where, instead of calling, which is also awkward, you can just send a text message. This is on billboards, too. You send a text message with an address, and we will mail you naloxone. We will also text back and ask if you want to talk to somebody about this. If patients say no, that is totally cool. If they say yes, it is even better, and that somebody the patient will talk to is a peer. That peer is well aware of our emergency department referral program, and often, as Jeff had mentioned, patients are much more willing to talk to somebody in that category than someone with a shirt and tie on.
Peter Salgo, MD: We are in the middle of the COVID-19 crisis, and that means we are doing an awful lot of telemedicine. It is one thing to be in the same room, to be peer-to-peer, and to reach out. It is another to do this behind a screen. Does it work as well? What are the techniques people are using in telemedicine?
Theresa Mallick-Searle, MS, RN-BC, ANP-BC: I’ve found it very challenging because, when I have this discussion with patients, I feel that I need to give them time. Even though you are eye to eye—sometimes it may be eye to forehead, sometimes eye to sky—when you are on a computer, being able to sit there and hold their hand and have this discussion in person is a lot more earnest. And I think I get more patient compliance. For me, in my practice, even though we’ve made it work, it has been very challenging to start these discussions.
Joshua Lynch, DO, EMT-P, FAAEM, FACEP: We have taken a look at it from a different angle. We see this as the creation of virtual emergency departments; these are patients we would not have seen. I think we would all prefer an in-person encounter, but the way we look at it, in regard to the emergency department, is that these are patients who would not have come to the hospital. So we try to create a market where if you are not feeling safe or you do not want to be in person, you can use this virtual emergency department.
We have taken it one step further to better help those with substance use disorder. We have given cellular-based iPads to police departments, and if they run into somebody with opioid use disorder or a substance disorder on the street, they can do a telemedicine visit from the side of a road or the back of a police car with an emergency provider. That provider can run them through a quick assessment, and then the treatment and referral program. That is a link to a peer; that is a 14-day script for buprenorphine, all provided while they’re sitting in their kitchen. That is a link to care; that is mailing a naloxone box. I think telemedicine is something that has been simmering for years in a lot of different areas of health care and society in general. This has just forced us to find innovative ways to fast track the rollout of this. I think, for substance use disorder, telemedicine is a perfect fit. Is it ideal? No. Does it allow us to treat patients we would not normally treat? For sure it does.
Peter Salgo, MD: There is a bit of a silver lining in the midst of this entire pandemic?
Jeremy Adler, DMSc, PA-C, DFAAPA: I would say that, in some respects, it is a little more than a sliver. I think that patients are sometimes more comfortable in their own homes, looking at a screen and having this conversation virtually rather than actually being in front of us in a room. Plus, we can ask patients, “How do you keep your medicines at home? What would you do if…?” It creates an environment, in some respects, of safety for them when we have this kind of conversation. I do not do emergency care; I do chronic pain management. Our population is a little different than who might be in the [emergency department]. It is amazing what is being done here out in the community to address some of these substance misuse problems. That is pretty exciting. In our practice, I think there are some patients with whom we have connected who respond better when discussing these issues at home, rather than in the office where there is a lot of distraction and a lot of other things occurring simultaneously.
Jeffrey Bratberg, PharmD, FAPhA: I think the interesting thing about telehealth too is, again, social determinants of health. Transportation is a huge issue when you need to go to your treatment visit, your urine toxicology screening, your chronic pain specialist, or to see a specialist. If you are in a rural area and there are no pain specialists, or there are no buprenorphine prescribers. We have seen what these temporary regulation releases from SAMHSA [the Substance Abuse and Mental Health Services Administration] and DEA [Drug Enforcement Administration] allow. We have a buprenorphine hotline in Rhode Island; it is 24/7. You call a waiver provider; they’ll call in a script to a pharmacy, and we’ve flipped that. I am part of a federal grant where you can walk into a pharmacy and say, “I want to treat my withdrawal,” or “I would like to start treatment,” and in an hour, they leave with no scheduled induction, or home induction that day. We have done 4 of them. It is amazing.
Transcript Edited for Clarity