Joint Webinar - Vital Signs Town Hall Teleconference and COCA Call Coordinating Clinical and Public Health Responses to Opioid Overdoses Treated in Emergency Departments
Moderator: Ibad Khan
Presenters: Rear Admiral Anne Schuchat, MD (USPHS); Vice Admiral Jerome M. Adams, MD, MPH (USPHS); Alana Vivolo Kantor, PhD, MPH; Elizabeth Samuels, MD, MPH; Meghan McCormick, MPH
Date/Time: March 13, 2018, 2:00 – 3:00 pm ET
Ibad Khan:
Good Afternoon.
I’m Commander Ibad Khan, and I’m representing the Clinician
Outreach and Communication Activity, COCA, with
the Emergency Risk Communication Branch
at the Centers for Disease Control and Prevention.
I would like to welcome you
to the first ever joint CDC Vital Signs Town Hall
and COCA Call, Coordinating Clinical
and Public Health Responses to Opioid Overdoses Treated
in Emergency Departments.
This webinar is hosted by both CDC’s COCA program
and the Office for State, Tribal, Local,
and Territorial Health to join clinicians and public health professionals
in a discussion on how they can work together
in coordinating a more robust response
to the opioid overdose epidemic.
You may participate in today’s presentation via webinar,
or you may download the slides if you are unable
to access the webinar.
The PowerPoint slides and the webinar link can be found
on our COCA webpage at emergency.cdc.gov/coca.
Again, the web address is emergency.cdc.gov/coca.
You can also access the presentation on the Office
for State, Tribal, Local, and Territorial Health webpage,
www.cdc.gov/stltpublichealth.
Again, that’s www.cdc.gov/stltpublichealth.
Click on the Vital Signs Town Hall Teleconference button
on that page.
Free continued education is offered for this webinar. Instructions on how to earn continued education will be
provided at the end of the call.
In compliance with continuing education requirements, CDC,
our planners, our presenters, and their spouses/ partners wish
to disclose they have no financial interest
or other relationships with the manufacturers
of commercial products,
suppliers of commercial services,
or commercial supporters.
Planners have reviewed content to insure there is no bias.
Content will not include any discussion of the unlabeled use
of a product, or a product under investigational use.
After the speakers have presented,
you will have the opportunity to ask questions.
You may submit questions at anytime
through the webinar system by clicking the Q&A button
at the bottom of your screen, and then typing your question.
For those of you who may have media questions,
please contact CDC Media Relations at 404-639-3286,
or send an email to media@cdc.gov.
If you are a patient, please refer your questions
to your healthcare provider.
At the conclusion of the session
the participants will be able to accomplish the following.
Explain the latest epidemiological data
around opioid related morbidity within emergency departments.
Describe ways that public health
and emergency departments can collaborate
to advance prevention and treatment efforts related
to opioid overdoses. Identify steps that can be taken
to establish protocols within emergency departments
to prevent future opioid overdoses.
It is my honor and privilege
to now introduce the acting director for the Centers
for Disease Control and Prevention,
and Acting Administrator for the Agency for Toxic Substances
and Disease Registry, Rear Admiral Anne Schuchat.
Dr. Schuchat previously served
as CDC’s Principal Deputy Director,
a role she has held since September 2015.
She joined CDC as an Epidemic Intelligent Service Officer
in 1988.
She was Director of CDC’s National Center for Immunization
and Respiratory Diseases from 2006 to 2015.
Dr. Schuchat played key roles in many CDC emergency responses,
including the 2009 H1N1 pandemic influenza response,
the 2003 SARS outbreak in Beijing,
and the 2001 bioterrorist anthrax response.
Globally, she has worked on meningitis, pneumonia,
and Ebola vaccine trials in West Africa,
and conducted surveillance
and prevention projects in South Africa.
Dr. Schuchat graduated from Swarthmore College
and Dartmouth School of Medicine,
and completed her residency and chief residency
in internal medicine at NYU’s Manhattan VA Hospital.
She was promoted to Rear Admiral in the Commission Core
of the U.S. Public Health Service in 2006,
and earned a second star in 2010.
Rear Admiral Schuchat will provide the agency perspective
on this urgent public health issue,
and introduce our first esteemed presenter,
the US Surgeon General.
Welcome Rear Admiral Schuchat.
Anne Schuchat:
Thank you so much Commander Khan, and thank you all
for joining this webinar
to discuss CDC’s most recent Vital Signs report
on Increasing Opioid Overdoses Treated
in Emergency Departments.
As acting Director of CDC,
I have seen this fast-moving opioid overdose epidemic does
not distinguish between age, gender, state, or county,
and it is still increasing
in every region in the United States.
The Vital Signs we released last week had alarming data
from emergency department visits,
and you’ll hear much more about that from today’s speakers.
It will take coordinated efforts by communities,
medical professionals, public health, law enforcement,
and government to combat this epidemic.
At CDC, we work closely with partners, states,
and other federal agencies to prevent opioid overdoses,
as well as the other negative health effects of this epidemic.
Including, addiction, neonatal abstinence syndrome,
and the infectious diseases associated
with injection drug use, such as hepatitis C and HIV.
This is a problem for all of us, wherever we work
and whatever we do, and it’s a great privilege to get
to host this Vital Signs joining a Town Hall and Coca Call.
I’m personally honored to be able to introduce a champion
that we have joined forces with in this fight,
the 20th Surgeon General of the United States of America,
Vice Admiral Jerome Adams, who, as you will hear,
has a personal connection to this epidemic.
As Surgeon General, Dr. Adams has pledged to lead with science
and facilitate locally lead solutions
to the nation’s most difficult health problems.
He’s committed to maintaining strong relationships
with the clinical and public health communities,
and strengthening partnerships with nontraditional partners.
He is a tremendous champion for the public
and the public’s health, and it’s been a great privilege
to get to know him.
He is a great friend and colleague to CDC,
and it’s an honor to get to have him join our Town Hall.
Dr. Adams, thank you again for speaking
with our community today,
and let me turn things over to you now.
Jerome Adams:
Thank you so much Rear Admiral,
and Dr. Anne Schuchat.
Thank you, Commander Khan.
For those who aren’t aware, they are both excellent clinicians
and members of the United States Public Health Service,
and they’re protecting and promoting our country’s health.
As the nation’s doctor, I’m grateful
for CDC’s extremely important work
on the opioid overdose epidemic.
I have encountered the complexities of dealing
with addiction, not only professionally
as a Physician Anesthesiologist, as a state health commissioner,
and as the Surgeon General, but also personally.
As some of you may know,
my younger brother, Philip, has struggled with addiction
for decades, and I often contemplate the fact
that it could have been me.
My brother and I grew up in the same house,
with the same parents, same advantages, and same challenges.
But today, he’s in state prison for crimes committed as a result
of untreated mental illness and substance use disorder,
and I’m the Surgeon general.
Where did things go wrong?
What more could we have done?
Could I have done?
And if I, given my education and influence, wasn’t able
to change his course, I think it demonstrates
that without a fundamental change in our attitudes,
our environment, and our resources, we can expect more
of the same for many more Americans.
My family, like many other families in America,
have witnessed firsthand, the pain that comes
from opioid use disorder,
which is commonly referred to as addiction.
As I’ve traveled across the country visiting communities
impacted by the opioid epidemic, I’ve met many individuals
who have either lost a love one to this epidemic,
or who are struggling with addiction.
Meeting families, community members, and those most effected
by loss or addiction
has helped shape my office’s work on this issue.
I want us to work together to prevent addiction,
and get community members who need treatment, our friends,
our family members, connected with treatment that works.
It’s why the theme of my time as Surgeon General is better helped
through better partnerships, because only
by working together, can we overcome this epidemic.
The White House is working to strengthen vulnerable families
and communities, and working to build and grow a stronger,
healthier, and drug-free society.
The administration’s priorities are saving lives,
reducing demand, and reducing supply.
As your Surgeon General, I’m particularly focused
on three key aspects of the opioid crisis, Naloxone,
education, and prevention.
First, I’m focused on putting Naloxone in the hands
of first responders and community members.
We must, let me say this again, we must get Naloxone
into the hands of more first responders and community members,
so that they can help save lives,
and then provide a warm handoff to connect individuals
to effective treatment.
Recently, when I traveled to Rhode Island,
I had the opportunity to meet a person
in recovery named Jonathan.
Unfortunately, Jonathan lost both his brother and his father
to an opioid overdose, and Jonathan was struggling
with addiction himself.
Naloxone saved Jonathan’s life.
He will tell you, his recovery turning point was a trip
to the emergency room and a warm handoff to a recovery coach.
Now, I’m proud to say, Jonathan is working to help others reach
and maintain their own recovery.
Second, I’m working to educate the public about the severity
of the epidemic and working with our communities
to reduce negative attitudes and discrimination towards people
with substance use disorder.
Despite a person dying about every twelve minutes
from an opioid overdose, a recent New England Journal
of Medicine article revealed less than 40%
of the public sees the opioid epidemic as a problem
in their communities, and less
than 20% consider it an emergency.
We need to help the public understand substance use
disorder is a chronic disease that must be treated
with the same skill, compassion, and the same urgency
that we treat conditions like diabetes or heart disease.
Stay tuned, as we are working on a series of initiatives
that will help Americans understand the severity
of the epidemic better and the roles
that everyone can play in overcoming it.
Third, we must prevent addiction before it starts.
We are working with healthcare professionals
to improve prescribing practices.
We need patients to understand the benefits
of opioid alternatives, as well as how to safely, use, store,
and dispose of prescription opioids.
To successfully combat this epidemic,
all of us as clinicians
and healthcare professionals have an extremely important role
to play.
We need to do our point to end stigma, and make no mistake
about it, it exists amongst our colleagues
as well as amongst the general public.
I’ve seen it in my practice, and in my day to day life.
Help everyone, especially patients and families,
understand that this is a chronic illness
and it impacts the brain.
Recovery is possible, as is recurrence,
and we need to insure we have the supports for it,
and can help people recover along the spectrum
of their recovery journey.
All healthcare professionals, including divisions,
division assistants, nurses, nurse practitioners, dentists,
social workers, therapists, pharmacists, and more,
can play a role in addressing substance misuse
and substance use disorders.
Not only by directly providing healthcare services,
but also by promoting prevention strategies,
and supporting the infrastructure change if needed
to better integrate care for substance use disorders
and to general healthcare and other treatment settings.
Additionally, we need the support treatment and recovery,
and I mean really support treatment and recovery.
As healthcare professionals, you’re an important source
of information for your patients about what works.
I’m calling upon you to know
and make sure your colleagues know the warning signs
of addiction, individuals
with opioid use disorder often cross your paths
for non-opioid related reasons.
And also, asking you to provide MAT,
or help connect patients to MAT.
Make sure you’re aware
of the evidence-based treatment programs and recovery supports
in your community, because we know that you can’t do it alone,
and don’t expect that you can do it alone, but we do expect
that you can refer individuals to appropriate resources
in their communities to help them recover.
Unfortunately, only about one
in three specialty addiction treatment facilities offers
medication assisted treatment as an option for patients
with opioid use disorder, despite the fact
that science tells us MAT works.
If you are referring a patient or a family member to care,
be informed and make sure they’re going
to a reputable provider.
Briefly, here is what they should look
for in a treatment provider.
Personal diagnosis assessment and treatment planning. W
e know that one size does not fit all
and treatment should be tailored
to the individual and their family.
Access to FDA-approved medications.
Effective behavioral interventions delivered
by trained professionals.
Long-term disease management.
Again, we know addiction is a chronic disease of the brain
with the potential for both recovery and recurrence,
and long-term outpatient care is the key
to long-term successful recovery.
Coordinated care for other co-occurring diseases
and disorders, such as HIV, such as Hepatitis, such as diabetes.
And recovery support services, such as mutual aid groups
and community services that can provide continuing emotional
and practical support for the recovery.
It’s not just about getting the individual the specialized care
and treatment that they need for their addiction,
but it’s about wrapping them around with services
that can help them stay successful
in their recovery, long-term.
Finally, I implore all of you to think about prevention,
start low and go slow when prescribing.
Make sure you’re familiar with and that all
of your colleagues are familiar with
and are utilizing the CDC guidelines.
They really are the best practice, and they’re a key
to helping us overcome this opioid epidemic.
But unfortunately, there is still far too many
of our colleagues, of the individuals who we work
with on a day-to-day basis
who aren’t utilizing those best practices.
Be cautious of prescribing opioids and benzodiazepines,
and other medications and alcohol
that can cause respiratory depression.
Increase use of PDMP by pharmacists,
physicians, and other providers.
And unfortunately, I know I’m speaking to the choir
on this phone call, likely, but again, the statistics tell us
that many of our colleagues are not utilizing the PDMP
on a consistent basis to help identify individuals who are
at risk for opioid misuse.
Make sure patients know how to safely monitor, store,
and dispose of their unused opioid painkillers.
We know that far too many teenagers say they got their
first pill from a loved one’s medicine cabinet.
Recognize there is a duel crisis of pain and opioids
that both need to be addressed.
One of the most common concerns or complaints I get
when I speak is amongst the chronic pain community saying,
we don’t need to over-swing the pendulum.
And my answer to them is that I completely agree.
We all need to be part of addressing chronic pain
in a more holistic way, in a better way, because ultimately,
that’s what led us down this pathway
of opioid overuse and misuse.
And fourth, I need your help in preventing overdose death.
Yeah, I need you to help me educated the community
about the warning signs of opioid overdose, raise awareness
of the availability of Naloxone, both injector and nasal,
by standing order or prescription.
In your own practice, offer to co-prescribe Naloxone
to those taking opioids to manage chronic pain,
and to those who may be at risk, or who know someone
at risk for opioid overdose.
Make sure you are aware of the standing order laws
and legal protections for physician prescribers
and bystanders, otherwise known as Good Samaritans,
who administer Naloxone
when encountering an overdose situation in your state.
Far too often we hear unfortunate stories
about someone overdosing and dying,
while many bystanders are there witnessing it,
and it’s because they don’t know how to access Naloxone,
or they’re worried about the ramifications
to themselves personally, if they intervene.
You can help us tremendously
by helping folks become better educated
about what the laws are,
and what the availability looks like in your state.
In order to successfully tackle the opioid epidemic,
we need your help.
In summary, we need you to help us educate and end stigma.
Address substance use related health issues
with the same sensitivity, and care, and urgency, as you would
with any other chronic health condition.
Support treatment and recovery.
Support warm hand offs and high-quality treatment
for substance use disorders.
This includes considering providing
or starting MAT yourself.
And I really want to give a shout out to the individuals
out there who have taken that next step
of becoming MAT providers themselves
or instituting programs in their emergency rooms
where they can start individuals on MAT directly
after an overdose. It really does make a difference
and saves lives.
Think prevention.
Promote primary prevention using evidence based prescribing
practices and understanding alternatives for acute
and chronic pain management.
We don’t want to over-swing the pendulum and we don’t want
to leave individuals with legitimate chronic pain
out in the cold as we respond
to this opioid overdose epidemic.
And finally, stop overdose deaths.
Increase awareness around Naloxone, what it is,
how to use it, how to get it, and what to do afterwards.
Thank you for your continued leadership on this issue.
Please, don’t let this conversation be another one
where we’re preaching to the choir.
Please, use your voices to go out into the community to speak
with your colleagues, with your friends,
with your community members, about the steps we all can take
to help us prevent this unfortunate epidemic
where we’re losing a life about every twelve minutes.
I’ll now turn it back over to Dr. Schuchat.
Ibad Khan:
Thank you, Vice Admiral Adams, for sharing such a wealth
of information with our audience,
and your passionate call to action.
We appreciate your time and value your public health
in clinical insights in this matter.
Thank you also, for setting the stage
for the rest of our presenters.
At this time, we would like to welcome our remaining
three presenters.
Presenting next, will be Dr. Alana Vivolo Kantor.
Dr. Vivolo Kantor is the lead author
on the March 6th Vital Signs Report,
Trends in Emergency Department Visits
for Suspected Opioid Overdoses the United States, July 2016
to 2017.
She’s a Behavioral Health Scientist in the Division
of Unintentional Injury at the Centers for Disease Control
and Prevention, and will be giving an overview
of the main findings of the Vital Signs Report.
Following Dr. Vivolo Kantor will be Dr.
Elizabeth Samuels.
Dr. Samuels is a Postdoctoral Fellow
with the Yale National Scholars Program.
She’s the Implementation Lead for Levels of Care
for Rhode Island Emergency Departments and Hospitals
for Treating Overdose and Opioid Use Disorders.
Today’s final presenter is Ms. Meghan McCormick.
Ms. McCormick is a Public Health Epidemiologist
with the Drug Overdose Prevention Program
in the Division of Community Health and Equity
at the Rhode Island Department of Health.
Dr. Samuels and Ms. McCormick will be providing an
example from their experiences in Rhode Island of what it looks
like to coordinate opioid overdoes responses
between emergency and public health departments,
and the positive impact it can have on community.
At this time, I would like to welcome Dr. Alana
Vivolo Kantor.
Dr. Vivolo Kantor, please proceed.
Alana Vivolo Kantor:
Thank you so much and good afternoon everyone,
thank you for joining this call.
As mentioned, my name is Alana Vivolo Kantor,
I am a Behavioral Scientist who has been working
over the last few years
on Opioid Overdose Surveillance Activities at CDC.
Before we hear from our experts and clinicians from Rhode Island,
I’m going to give an overview
of our recent CDC Vital Signs publication
on Opioid Overdoses Treated in Emergency Departments.
Next slide.
The overall purpose of this new report is
to examine the timeliest data available to CDC
on emergency department visits for suspected opioid overdoses
across multiple states.
As part of this report, we also note the central role of state
and local health departments in coordinating responses
to opioid overdoses in collaboration
with emergency department staff,
mental health treatment providers,
community-based organizations, law enforcement,
and community members.
Next slide.
This report uses data from two separate data sources
that both include emergency department data.
The first includes data
from CDC’s National Syndromic Surveillance Program or NSSP,
also known as ESSENCE or BioSense Platform.
This data source includes approximately 60%
of emergency department visits from fifty-two jurisdictions,
representing forty-five states across the U.S. In this data,
we can look at emergency department visits
for suspected opioid overdose by U.S. region, age group, and sex.
To get a more local perspective,
we use data from sixteen states funded
by CDC’s Enhanced State Opioid Overdose Surveillance Program,
or ESOOS.
With this data we can provide state level estimates
and can also look at level of county urbanization.
The time frame used for both data sources includes quarter
three of 2016, through quarter three of 2017,
which spans from July 1st, 2016, through September 30th, 2017.
Next slide.
Over all, using the National Syndromic Surveillance Program
data, we found that emergency department visits
for suspected opioid overdose increased 30% across the U.S.
from July 1st, 2016, through September 30th, 2017.
In addition, though all regions witness increases
over this time period,
the Midwest saw the largest increases, about 70%.
Using our ESOOS data in sixteen states, we found some urban
and rural differences, as well as state differences.
For example, large central metropolitan areas saw a 54%
increase from July 1st, 2016, through September 30th, 2017.
Next slide.
Specifically using the National Syndromic Surveillance Program
data, opioid overdoses increased for both men and women,
about 30% for men, and 24% for woman.
And all of the adult age groups saw large increases.
The largest increase was for the thirty-five
to fifty-four-year-old age group, and as you can see here,
it was a 36% increase.
As mentioned previously,
the National Syndromic Surveillance Program data showed
a 30% increase on average across all states,
and a 70% increase in the Midwest.
The West also experienced a 40% increase, and the Southwest
and Northwest both experienced approximately 21% increase.
The Southeast saw a 14% increase.
Next slide.
As mention, using the ESOOS data in sixteen states,
we also saw continued rises in cities and towns of all types.
The highest rate increases, which were 54% were
in large central metropolitan areas,
which include a population of one million or more,
and covering a large principal city.
But, as you can see, rural areas,
including the non-core all the way to left on this slide,
and the metropolitan areas right next to the non-core,
also saw increases of 21% or higher, which was similar
to fringe metropolitan areas.
The small and medium metropolitan areas witnessed 37%
and 43% increases, respectively, over this time period.
Next slide.
Lastly, using our ESOOS data in the sixteen states, we were able
to look at state level changes.
The overall purpose of ESOOS is to improve the timeliness
of reporting of both fatal and nonfatal overdoses.
And across these sixteen states, we say increases averaging 35%.
Ten out of these sixteen states saw significant increases during
this time period.
The largest increases were in Wisconsin at 109%,
which means the rate more than doubled.
A similar rise in Delaware was 105%.
Pennsylvania and Illinois, also had large increases
of 81% and 65% respectively.
These states are noted in the dark blue on this slide.
Consistent with the data
in the National Syndromic Surveillance Program,
all of our ESOOS Midwestern states experienced large
and significant increases.
However, there was variation among states
in the Northeast and Southeast.
In the Northeast, for example,
while Delaware’s opioid overdose emergency department visits more
than doubled, other states like Massachusetts, New Hampshire,
and Rhode Island, showed modest decreases
that were not statistically significant.
The largest decrease was actually in Kentucky,
which saw a decrease of 15%.
In that region, West Virginia also decreased,
but not significantly.
Though North Carolina had a significant 31% increase.
Next slide.
So, with all of this data and all of this analysis
that we’ve presented, there are many things that we can do,
and that different responders can do, to come together
and prevent opioid overdoses and death.
Specifically, health departments are central
to the coordinated outreach among many players.
They can use emergency department data
to alert the community and help inform action plans
for a timely response.
For example, health departments can make sure there is enough
supply of Naloxone in the hands of emergency responders,
or friends and family of those patients
with opioid use disorder in accordance
with state and local policies.
Local emergency departments are also key players
for surveillance, because they have direct access to patients
who have had overdoses.
They can provide Naloxone to take home
to prevent future overdoses and give training on how to use it.
They can also link patients to follow-up treatment
for opioid use disorder.
Emergency departments can link these patients to mental health
and substance abuse treatment providers, which can assist them
in gaining access to medication assisted treatment, or MAT.
MAT combines behavioral therapy and medications
to treat substance use disorder.
Innovative emergency departments are actually initiating MAT
in that emergency department themselves.
Public safety and law enforcement also play a key role
in this response, as they can quickly identify changes
in the illicit drug supply of an area, and can quickly respond
and coordinate with local partners,
like public health departments.
Community-based organizations can assist
in mobilizing a community response to those most at risk.
For example, providing resources to reduce harm associated
with injection drugs, such as facilitating screening for HIV
and hepatitis B and C, as well as, referrals to treatment
and Naloxone prevision.
And finally, but perhaps most importantly,
the community members, and family, and friends,
and those who’ve overdosed, and those who use opioids,
can help bridge the gap by connecting with organizations
that provide public health
and medical services supporting people in treatment
and recovery, and working
to increase Naloxone distribution and use.
Next slide.
With all that said, there is also a role
for the federal government.
One of the initiatives that we are undertaking is ESOOS,
where we are tracking overdose trends to better understand
and more quickly respond to the opioid overdose epidemic.
Currently, ESOOS is funding thirty-two states,
in addition to the District of Columbia, to do this work.
We’re also improving access to opioid use disorder treatment,
such as MAT, and overdose reducing drugs,
such as Naloxone.
We are also educating healthcare providers and the public
about opioid use disorder and opioid overdose,
and providing guidance on safe and effective pain management.
It’s also very important to equip states with resources
to implement and evaluate safe prescribing
and the federal government is working towards that goal.
We’re also coordinating actions to reduce productions
and impacts of the elicit opioid supply in the United State
through our work with the High Intensity Drug Trafficking Area
program, or HIDTA.
Finally, we are supporting cutting edge research
to improve pain management and opioid use disorder treatment.
Final slide.
Thank you so much for allowing me
to present the results our March Vital Signs on Opioid Overdoses
in Emergency Departments.
The two following links bring you to the Vital Signs webpage,
and specifically to the opioid overdose description at CDC.
Thank you so much, and I turn it back over so that you can hear
from our partners in Rhode Island.
Elizabeth Samuels:
Thank you, Dr. Vivolo Kantor.
Good afternoon everyone, my name Elizabeth Samuels,
and as Dr. Khan mentioned, I’m an Emergency Physician
and Health Services Researcher that has been working
over the last year with the Rhode Island Department
of Health to implement state-wide hospital
and emergency department standards for the treatment
of opioid use disorder, and opioid overdose.
Today, I’m going to give you an overview
of Rhode Island’s state-wide standards of care,
and discuss some implementation barriers and facilitators.
Next slide.
Although small in square millage, Rhode Island has one
of the highest rates of opioid overdose deaths
in the United States.
In 2015, Governor Raimondo assembled an overdose prevention
and intervention task force to address the epidemic,
and in 2015, they released a strategic plan.
Next slide.
This strategy has four key components.
First, is prevention, through trying
to reduce risky opioid prescribing practices.
Rescue, expanding access to Naloxone for overdose reversal.
Treatment, expanding access to medication assisted treatment,
and initiation in medication assisted treatment
through venues like the emergency department.
And recovery, expanding access to pay recovery services
and support to help people continue engagement
in addiction treatment, and prevent relapse
of opioid use disorder.
Next slide, please.
Recognizing the unique and vital role of hospitals
and emergency departments.
In 2017, the Rhode Island Department of Health,
and the Rhode Island Department of Behavioral Healthcare,
Developmental Disabilities and Hospitals, released levels
of care for Rhode Island emergency department
and hospital for treating overdose
and opioid use disorder.
Next slide.
The levels of care outline three different tiers of services
for hospitals and emergency departments to provide care
for patients with opioid use disorder
and after having had an opioid overdose.
So here, you see the three levels of care.
Level three is the basic level that hospitals should provide.
We have a discharge planning law that’s mandated throughout the
state, which includes contacting a patient’s emergency contact
and primary care provider.
Level three also includes standardized substance use
disorder screening, educating patients on safe opioids storage
and disposal, Naloxone distribution and, or dispensing
or prescribing, peer recovery support consultation,
referral to community substance use treatment providers,
48-hour reporting of opioid overdoses
to the Rhode Island Department of Health, and drug screening
of fentanyl for all overdose patients.
Components one through seven of this list are actually part
of the emergency department regulations,
so they are mandated through all hospitals in Rhode Island.
Level two facilities who meet this criteria,
meet all the criteria of level three, but then,
also have availability of addiction specialists
who can conduct comprehensive substance use assessments
and treatment plans.
And level one facilities meet both criteria of level two
and level three, and are able to initiate, stabilize,
and maintain patients on medication assisted treatment.
This includes emergency department
buprenorphine induction.
Next slide.
The 48-Hour Reporting is a key component
of Rhode Island’s surveillance and response system
to the overdose epidemic, Meghan will get
into this in greater detail.
But, mandatory reporting was actually initiated in April 2014
by Department of Health Emergency regulations,
and subsequently passed
by the State Legislature in October of 2014.
Reporting takes place with use of this online tool,
which you see here, which has been iterably revised
to improve data quality, accuracy,
and usability for surveillance.
Next slide.
48-hour reporting data
and additional resources are available on a public dashboard,
preventoverdoseri.org, which is maintained
by Dr. Brandon Marshall and his colleagues
at the Brown School of Public Health.
Next slide.
On this dashboard you can view aggregate reports
from 48-hour overdose reporting, including monthly changes
in emergency department utilization for overdose,
reported Naloxone distribution, and prevision
of onsite counseling at time of the E.D. visit.
Next slide.
In July 2017, I joined the Department of Health
to implement the levels of care
at hospitals throughout Rhode Island.
There are twelve licensed facilities in Rhode Island.
As of today, nine hospitals are now certified,
seven hospitals have achieved level one certification,
two have achieved level three.
We had an addition site certified as level two,
but unfortunately that hospital has since closed.
There are only three remaining hospitals to certify,
two level three applications are currently under review,
and one is in process.
Next slide.
There has been some implementation challenges,
as one might expect.
The first being stakeholder engagement.
The levels of care initially were an external policy not
written by emergency department or hospital clinicians,
who would be implementing the described tasks.
Through the implementation process,
each hospital really did demonstrate dedication
to integrating the policy requirements
into their work flow, improving the standard of care given
to this patient population, and reducing opioid overdose deaths.
Given the high prevalence of deaths,
it’s very common for people to have, you know,
either their own personal lives touched by lose of a love one,
or know someone who had unfortunately lost a loved one.
So, people were truly motivated to try
to make something different,
and be able to provide innovative, comprehensive care
to patients with opioid use disorder.
And through the implementation process,
true partnerships developed between the Department of Health
and these hospital sites, where the Department
of Health was able to provide support
to enhance existing good work by emergency departments
and elevate the standard of care state wide.
48-hour reporting, which has been vital to the Department
of Health’s ability to do surveillance
in response to the epidemic.
It’s also challenging for hospitals especially smaller,
less resourced institutions.
It is, you know, requires manual extraction of data,
and manual filling out the form, which is quite a bit of,
not specifically onerous in itself,
but does take staff time to complete.
We’ve been trying to minimize this and streamline this effort
by narrowing down the data that we need for response
to the epidemic, and are exploring some other ways
to streamline the data transmission process.
Naloxone cost.
As many of you are probably aware,
the cost of Naloxone has risen considerably
over the last five years.
Some hospitals have been able to decrease costs
through bulk purchasing, acquisition of grants,
or the goodwill of their hospital administration.
Naloxone is covered by insurance,
so bedside pharmacy delivery is possible, as it can be delivered
as an outpatient medication.
But, hospitals who have been unable
to provide Naloxone physically at the time of the E.D. visit,
at a minimum, still provide patients with a prescription.
Availability of Medication Assisted Treatment,
or perceived availability.
So, this is an issue with emergency department
and hospital initiated MAT.
Often, it’s related to hours of operation.
MAT clinics generally operate on “banker’s hours”.
But, in the emergency department we treat patients
with opioid use disorder any time of day or night,
most overdoses come in in the evening hours.
So, really what’s been successful in hospitals
when they’ve implemented E.D. buprenorphine initiation is a
development of clear protocols, with clear roots
of acquiring an appointment or drop in hours the next day,
or something like that at partnering MAT providers
to ensure that patients do have follow up after the E.D. visit
and not be able to utilize that encounter
to initiate medication assisted treatment
for people who are interested.
And finally, stigma.
So, as was discussed earlier in the call,
this has really been the largest barrier to policy implementation
and services utilization.
And I would say, this is both, among staff and when it comes
to medication assisted treatment, some patients.
Sites who’ve been implementing the policies have been doing a
great job at doing additional staff training on the disease
of addiction and what evidence based treatments are available.
Next slide.
And where there are challenges, there are also facilitators.
The presence of local champions has made a huge difference
on policy implementation.
This has been a different person on each site.
Its been emergency department directors,
its been emergency department clinicians, social workers,
nursing leadership, pharmacists, and hospital administrators.
Community hospitals in particular, have been,
have done a great job at leveraging their department
of social work and pharmacy, really working
up for their full scope of practice and taking leadership
on policy implementation.
Advance.
They’ve also done some very innovative work leveraging
their electronic medical records to improve services utilization
by providers, and reduce time and labor for reporting.
And finally, partnerships, both external.
Advance a little bit.
Between the hospitals and the Department of Health,
the Rhode Island Department
of Behavioral Healthcare Developmental Disabilities
and hospitals, Anchor Recovery Community Center,
community based organizations.
And then, internally, within the hospital, the partnerships
between departments of social work, pharmacy,
emergency medicine, and psychiatry, have been essential
to successful implementation.
Advance, advance, advance.
[laughter] Again, great.
Without these partnerships,
implementation would have failed.
Next slide.
So, next steps of what’s, in terms of what going
to happen in Rhode Island.
So, one of our biggest goals is to improve the efficiency
and timeliness of data surveillance.
This really does help us in state wide public health efforts
in addressing the epidemic.
Implementation, we are almost there.
We only have three sites remaining, which is,
I think quite good, given that we’ve been working
on this a little bit less than a year.
And then, ultimately, evaluation.
Both in terms of the evaluation of services
that are being offered by the patients we are trying to serve,
the patients with opioid use disorder
and who are being treated after and opioid overdose,
but also the impact on mortality,
recurrent overdose, incarceration, and
whether they’ve initiated medication assisted treatment.
Next slide.
And I’m going to hand it over to Meghan.
I’m happy to answer any questions at the end.
Meghan McCormick:
Thank you Dr. Samuels.
Hello, I’m Meghan McCormick, I am the Lead Epidemiologist
for the Drug Overdose Prevention Program
at the Rhode Island Department of Health.
Next slide.
Our Surveillance Response Intervention Team is a
collaboration between staff at Rhode Island Department
of Health, Department
of Behavioral Healthcare Developmental Disabilities
and hospitals, and the Rhode Island Fusion Center.
Next slide.
We began weekly meetings in April of 2017,
in response to an increase in overdose activity
in a specific area of our state.
We meet every Tuesday to review the past weeks overdose data.
Recommendations based on emerging trends are made
and stakeholders are alerted to any increased overdose activity.
Next slide.
We review multiple data sources on these calls,
including toxicology reports from our laboratory,
law enforcement alerts, and EMS data.
The majority of our response however,
is based on our 48-hour reporting system.
In this system, hospitals are regulated
to report any suspected opioid overdose
to the Rhode Island Department of Health within 48-hours.
Next slide.
This graph shows the number of overdose reports
from emergency rooms per week in 2017.
There is a fair amount of variation in number of overdoses
in a week, but we average about thirty-four reports a week.
Next slide.
In 2017, 65% of reported overdoses were discharged home
and just about 2.5% did not survive.
Prior to development of this reporting system,
most of our information about people
who overdosed were based on fatal overdoses.
But, a very small percent of overdoses resulted in fatality.
This system allows us to learn more about nonfatal overdoses
and possibly prevent a subsequent overdose death.
Next slide.
One of the lessons we have learned
through this reporting system
and our weekly SRI team meeting is
that even though we are a very small state, different areas
of the state experience increased overdose activity
at different times.
This graph shows the average number of weekly overdoses
for three cities based on baseline data,
and the actual number of overdoses in those cities
for a four-month period of time in 2017.
There are weeks where all three cities are
over average activity, such as week nine.
But, there are also weeks, like weeks three and four,
where one city is well below average,
and the other two cities are experiencing increased activity.
Next slide.
As a result of these regional differences,
we divided the state into eleven regions based on a year
and a half of 48-hour reporting data.
Thresholds for normal overdose activity were set based
on two standard deviations away
from the weekly average for that region.
If a region goes over that threshold,
we send out a public health advisory to stakeholders
and to community partners to alert them
of increase overdose activity in their area.
Next slide.
This is the map of our eleven regions.
Thresholds range from ten overdoses in one week
in Providence, our largest city, to three overdoses in one week
in some of the less populated areas.
Next slide.
And this is a real advisory that was recently sent
out in response to an increase in overdoses in one region.
In December, we brought in stakeholders from every city
and town in the state and helped them to think about development
of an emergency response plan specific
to the overdose epidemic.
We received recently, letters of intent
from thirty-one municipalities
planning to complete the emergency response plan.
We have continued with technical assistance calls
with these municipalities
and are expecting completed emergency response plans in May.
This is meant to help municipalities respond
when they receive a public health advisory regarding
overdoses, as well as long-term planning
to prevent overdoses in the future.
Next slide.
I really appreciate having a chance to talk to you today
about some of Rhode Island’s overdose work.
My contact information is included
if you have any follow up questions.
Thank you.
Ibad Khan:
Thank you, presenters, for providing our COCA OSTLTS
and Vital Signs audience with a wealth of information.
We will now commence with our Q&A session.
Please remember that you may submit questions
through the webinar system by clicking the Q&A button
at the bottom of your screen and the type in your question.
In some instances, this Q&A button might be
at the top of your screen.
If for any reason you are unable to access the Q&A system
at this time, please note that you can email your questions
to coca@cdc.gov, and they will be answered
by our presenters upon conclusion of this presentation.
I ask our experts to please identify yourself
as you answer todays questions.
Our first question is regarding the Naloxone
and opioid overdose responses.
The question states, are all the opioid overdoses responding
to Naloxone treatment?
Or are there other treatments available?
Elizabeth Samuels:
This is Liz Samuels from Rhode Island.
In terms of the overdose, I’m assuming I took
that question meaning, Naloxone is the general agent
that is used, the primary agent that is used
for overdose reversal.
The main issue that we’re seeing,
especially in Rhode Island is that there is quite a bit
of fentanyl that is in the heroin supply
or is being pressed as counterfeit pills,
and it requires significantly large amounts
of Naloxone for reversal.
Ibad Khan:
Thank you.
Our next question also has to do with the local experience.
The question states, we are hearing increased reports
of suspect overdose patients who are treated by first responders
that refuse transport to hospitals.
Do you have any strategies or recommendations
that we can utilize to better prepare for this?
Meghan McCormick:
We’ve recently looked at our EMS data here in Rhode Island
to look at how many suspected overdoses were refusing
transport to hospitals, and we have found that it was about,
it was less than 2% of calls for overdoses,
then refused transport.
So, from a data standpoint, this has not been a particular area
that we have focused on.
Jerome Adams:
And this is Surgeon General Adams, it’s one of the places
where it’s important again to make sure you’re partnering
with, involving local law enforcement.
I would completely agree that this is not
as common an occurrence as you would think, but we don’t want
to lose any touch point for an opportunity to intervene.
Some folks are exploring legal remedies,
such as emergency detentions.
And looking at what the legal environment looks like to try
to compel folks to come in and be evaluated,
be held for a certain amount of time.
I’m not saying that that’s a good thing or a bad thing,
but I’m saying that in answer to your question,
that that’s one thing that folks are exploring.
One thing that I would encourage folks to do,
and I did during my initial comments, was to know your laws
in your states and in your local areas,
and make sure everyone else knows them,
because standing orders, Good Samaritan Laws,
making sure folks feel like they can go in and get treatment
without automatically being incarcerated, or that meaning
that they’re going to be subsequently incarcerated,
will definitely increase someone’s chance of wanting
to go in and get treatment.
A lot of those individuals are resuscitated, and they’re scared
that if you take them to the E.R., the next stop is going
to be automatically to jail.
And so, helping them understand what the laws say
and what they don’t say, and again,
partnering with your law enforcement
so it isn’t an automatic hand over to the jail can help folks feel better about coming in and being evaluated,
and getting connected to treatment and care,
as opposed to just being simply thrown into jail.
Elizabeth Samuels:
This is Liz Samuels.
One other thing I would just add to that,
is that there are municipalities
who have developed some innovative responses
to that problem, all though it is low frequency.
In Rhode Island, we actually did trial EMS consultation
of a recovery coach prior to the E.D. arrival.
But again, this is a very low incidence event for us.
Other places have partnered with local police to do follow
up wellness checks or EMS to do follow up wellness checks.
There have been some trials or programs like that.
But, in terms of, you know, mandating treatment,
I think we really want to, we want people
to feel comfortable coming to the emergency department
and other sites of like low threshold care,
so they have increased willingness
to enter into treatment.
You don’t know where someone may be in their stage
of change, mandating treatment
for them isn’t necessarily effective,
and they may actually avoid seeking care
if they think they’re going to receive repercussions.
If you are interested in knowing what your states policies are,
in terms of Good Samaritan Legislation or Naloxone access,
a good resource is lawatlas.org.
Its just l-a-w-a-t-l-a-s-dot-o-r-g,
and that will let you know what the legal restrictions are
in your state.
Ibad Khan:
Thank you very much.
The next question comes to us regarding evaluation
of intervention programs.
It’s a couple of questions that I’m summing up as an inquiry
about what actual indicators that you plan on evaluating
when evaluating program interventions?
Meghan McCormick:
I can speak to that briefly about what we’re planning
on doing in Rhode Island.
And so, in Rhode Island, we’re planning on doing, you know,
two levels of evaluations.
So, one, being from the people we’re caring for themselves,
the question being, you know, we have come up with a list
of policies, and programs, interventions,
that we think will help reduce death
and that will meet peoples needs.
But, checking in and making sure that we are on track
with what their priorities are
and what actually will help them live self-sustaining lives,
where they can take care of themselves,
have solid relationships, and be in treatment
for opioid use disorder.
Secondly, in terms of like, larger population studies,
important indicators we have discussed evaluating,
obviously, death is a huge one, which we all talk about,
quality of life I think is an important one, incarceration,
repeat overdose, and engagement
in evidence-based treatment, like buprenorphine.
Ibad Khan:
Thank you.
The next question is about the tracking system
that was mentioned.
The question states, does the system track unique cases?
i.e., can you tell how many times one person has entered the
E.D. for overdose?
Alana Vivolo Kantor:
Hi, this is Alana Vivolo Kantor from CDC.
Before I let my Rhode Island folks jump in,
so with what we’ve captured and used in analysis
for the Vital Signs, we cannot track unique cases.
Our ESOOS states provide us either access
to line level data or aggregate data, that doesn’t allow us
to have any identifiable information
where we can understand if it was a repeat overdose or not.
However, specific data
at the state level may have that capability.
Meghan McCormick:
For our 48-hour reporting system here in Rhode Island,
we chose to make it not identifiable.
We do collect a lot of personal information,
but we don’t collect a name or Social Security Number,
or anything to that extent.
What we do collect is medical record number, so we can see
if the same person has gone
to the same hospital multiple times.
We are able to track that in our system, but if that person goes
to a different hospital,
they would have a different medical record number
and our system would not capture that.
Ibad Khan:
Thank you.
The next question is about communication
and awareness strategies.
The question states, what information
or materials were utilized for bringing awareness to the signs
and symptoms of opioid overdose?
The inquirer is interested in any materials
that they could be directed to,
so that they could also replicate the success
in their community.
Elizabeth Samuels:
Like for general patient education
and provider education?
Ibad Khan:
The question does not specify specifically.
Elizabeth Samuels:
Well, there’s lots of online resources available.
In terms of the levels of care policies,
it’s an overarching policy.
And then, each individual site, develops some
of their own materials, many of which were adapted
from prescribetoprevent.org, which is a good resource,
both in terms of patient education materials,
and provider education materials.
Meghan McCormick:
Additionally, all of Rhode Island’s communication efforts
are housed on the preventoverdoseri.org website.
I don’t remember specifically under where you have to go
to find it, but I believe there’s a media campaign
and there are several communication campaigns
on that website.
Jerome Adams:
And on the federal level, if you go to SAMHASA website,
if you, S-A-M-H-A-S-A, for those who don’t know how to spell it.
It’s www.samhasa.gov, and if you do a search
for the Opioid Overdose Prevention toolkit,
there’s a lot of great information there
on a national level to help equip healthcare providers,
communities, and local governments with the material
to develop practices and policies
to help prevent opioid related overdoses and deaths.
Ibad Khan:
Thank you.
Also on the federal level, there’s a question that,
has there been any discussion
around allowing clinical pharmacist the ability
to get a NADEAN, such as nurse practitioners
and PA’s with CARA?
We face many challenges in our highly rural state, Alaska,
with access to MAT and are looking at ways
to increase the number of medical providers
that can provide that care.
Jerome Adams:
This is Surgeon General Adams.
That doesn’t fall directly under my offices perview,
but can tell you that on a federal level, we are looking
at many different ways to increase our number
of individuals who can prescribe MAT and to increase our reach.
No option is off the table.
And I would continue to work
with your federal representatives, your senators,
and your representatives, and help make them aware
of the challenges in your state,
and also to reach out to us directly.
I will take that information directly back
to the folks here on a federal level.
But, know that we continue to hear those concerns,
particularly in rural areas, and are continuing
to make sure we’re doing everything we can
to take full advantage of all of our providers across the gamut,
and not just the physicians.
Ibad Khan:
Thank you, Sir.
Our next question is regarding exposure to,
exposure for, first responders and E.D. department employees.
Can you please comment on this?
And this is secondary exposure.
Are you seeing secondary exposure?
Elizabeth Samuels:
This is Elizabeth Samuels.
This is, that has been something that has come up as a concern,
but I believe it is not a, it is not something that is occurring.
I know that there has been a lot of, I have seen people worried
about it, but I have never seen a case
where someone has overdosed from touching a powder or something
like that, or some kind of secondary exposure.
Jerome Adams:
This is Surgeon General Adams, and I’m speaking based
on my experience as Indiana State Health Commissioner.
Again, we convened law enforcement
and health professionals around this very issue.
The times when it has occurred, there have been instances
of Police dogs who’ve been exposed
and of law enforcement officials.
I haven’t heard of any health officials who have been exposed,
because we tend to take precautions and tend
to be more anticipatory.
But, it’s an important place to have discussions,
it’s not happening commonly, but it is, for a lot of people,
a reason for them to not want to intervene.
And what we don’t want is for someone to not intervene
and watch someone die in front of them because of a fear
of being exposed themselves.
So, it’s a place where it’s important
to have those discussions, and for the clinicians
and the healthcare folks on the phone, it’s important
that you talk to your law enforcement individuals
in your states and localities about how to protect themselves
with basic precautions, such as gloves.
Help them understand the risk that they do, or don’t face,
so that again, we can protect lives, both individuals
who are overdosing and the individuals who are responding.
Ibad Khan:
Thank you, Sir.
Our next question is one regarding strategy.
What strategy do you propose that epidemiologists
at a local health department employ
to work more closely in collaboration and coordination
with hospitals in their areas to collectively address this issue?
Meghan McCormick:
That is a great question.
So, I have worked very closely with all
of the hospitals specific to the 48-hour reporting system.
Because they’re regulated to report, I am able to go
and make sure that they are following the regulation
and that they’re reporting
and they’re reporting on a timely basis.
But, that also gets space time and a foot in the door
into the emergency room to talk to people
about the epidemic in general.
So, that’s been a way that I have done it,
but of course I have regulations saying
that they have to report data to me.
Without that regulation, I do think that that relationship
between an epidemiologist
and a hospital is still very important,
and perhaps that kind of relationship building,
so that open communication could be,
could move forward from there.
Ibad Khan:
Thank you.
The next question is, are there any evidence-based models
for peer to peer based recovery interventions or support systems
that you are currently employing?
Elizabeth Samuels:
So, Rhode Island has a very strong,
several very strong peer recovery coach organizations,
and I would say one of the corner stones of the levels
of care for obviously level three,
but for all of the levels is consultation
of peer recovery coach.
So, peer recovery coaches are being used increasingly
around the country, there are models in New York,
models in Ohio, other places.
And they, one of the great benefits
of using peer recovery coaches is one – they really know
where the person has been, they can provide ongoing counseling
and follow up and support beyond the E.D. clinical encounter,
and can provide navigation,
in terms of services out in the community.
We started using them at a hospital I was worked
at in Rhode Island in 2014, and they’ve been used,
now are available in all of the hospitals in Rhode Island.
It’s very, they’ve developed a great system.
You know, they come to the emergency department
within about thirty minutes of being called,
and they provide follow up for at least ninety days.
Ibad Khan:
Thank you.
Jerome Adams:
This is Surgeon General Adams.
I would say, I’d go as far as to say
that it is clearly a best practice
to have peer recovery coaches.
The challenges that we continue to see around staffing
and availability, and again, payment structure,
if you’re going have a payment structure
to help compensate those individuals.
And so, it’s important again, that the folks
in the emergency room have relationships
with the individuals in the community
and the community organizations
where peer recovery coaches often coalesce in our house,
so that you can figure out how you provide services,
not just from nine to five, but at two a.m. in the morning
when you are just as likely or more likely
to need their services.
Ibad Khan:
Thank you, Sir.
Our next question comes from a local perspective.
In our region, rescue breaths are not being administered,
only Naloxone, we are encouraging both.
Do you agree?
If so, it would be helpful
to provide perspective from your experience.
Thank you.
Elizabeth Samuels:
So, I primarily take care of patients after
and overdose once they’ve arrived
in the emergency department, and we obviously,
provide supplemental oxygen at that time.
But, in the field we recommend everyone do rescue breathing,
I support your approach.
And NMS or Naloxone, especially in these cases
where fentanyl is being,
is the drug that someone is overdosed on.
The Naloxone, the bystander Naloxone dosage they have might
not be sufficient.
So, doing rescue breathing, initiating CPR, calling 911,
giving Naloxone, those are all the things everyone should
be doing.
Nothing has changed in terms of that algorithm of care
that we’ve been teaching people in Rhode Island.
Ibad Khan:
Thank you.
The next question is regarding the talk as a whole.
The question is, is it possible that the increase
in opioid overdoses seized in E.D.’s is a reflection
of detection bias and not a real increase?
Meaning, are we seeing increases because we are able
to track it better with this new surveillance system
or is it a real increase?
Alana Vivolo Kantor:
This is Alana Vivolo Kantor from CDC.
I think that that’s a valid question and one that we need
to consider and look into a little bit more.
One thing to note is that as data quality increases,
so the specificity of drugs in the chief complaint field
in which we’re using for emergency departments.
As that data gets better, as medical billing coders learn
and use the ICD-10-CM diagnosis codes
and they get more acquainted with the many codes they have
to understand and decode, we are going to see some changes.
But, the nice thing about what we’re doing with ESOOS is
that we have data going back right now through 2016,
so we are going to at least, through 2016 and forward,
able to track what is happening, whether,
and whether they’re true increases.
One thing that I would note is that all of the data
that we collect for emergency departments,
we talk to our states about triangulating
with other data sources to validate
or collaborate what they’re finding.
So, we look at emergency medical service transports data,
we look at hospital billing data,
if your states are using emergency departments
data, we look at mortality data.
And I think, one of the things that can help answer
that question is if you’re seeing increases
in multiple data sources, then it’s likely
that it could be a que increase.
However, we do need to look at this a little bit closer
as we move forward in capturing this data.
Jerome Adams:
And this is Surgeon General Adams.
I will say that I agree with everything
that the CDC has just said.
I will say that based on my work around the country,
we are anecdotally talking to a lot more people
who are being affected.
A lot more people are coming to me, as mothers, as fathers,
as family members of people who have died.
And additionally, if you look on the law enforcement side,
there’s a lot more fentanyl being confiscated
than ever before.
And when you look at the laboratory data that is
out there in regard to which drugs are being found
in individuals who have overdosed,
where we do have the ability to delineate, we are seeing more
and more fentanyl, which we know is deadlier.
So, while we can’t say with 100% certainty
that it’s one verses the other, I will say to you
that it is my strong opinion that it’s a little bit
of additional reporting and a whole lot of additional fentanyl
out there that is causing a real and significant increase
in the number of people who are dying as a result
to this evolving opioid epidemic.
Ibad Khan:
Thank you.
Our next questions are regarding the hospitals
and facilities in Rhode Island.
The first part of the question is, what percentage of hospitals
in Rhode Island are level two, or level one facilities?
And the second part is, do the hospitals submit data directly
from their electronic health records?
Elizabeth Samuels:
I can speak to those.
So, of the hospitals that have been certified,
so there are twelve licensed acute care facilities
in Rhode Island.
Currently, in terms of percentages,
I can’t give you, do quick math.
But, two of them are level three.
The site that had been certified as a level two,
unfortunately is no longer open.
And then, most sites are level one.
So, as you’ll be able to see when you download the slides,
seven of them are actually level one facilities.
So, that’s seven of the twelve.
And two of, there are two current applications that are
in process for level three, and one in process for level one,
which would make eight of the twelve level one
at the completion of implementation.
Now, sites that have been certified
as level three can later expand their services
and become level one, that is our hope.
And what was the second part of the question?
Could you please, repeat it?
Ibad Khan:
Yes, the second part of the question pertained
to how do hospitals submit data?
Do they submit it directly from their electronic health records?
Elizabeth Samuels:
Meghan, do you want to address that?
Meghan McCormick:
Yes, absolutely.
So, the 48-hour reporting system is a web based system.
It does require that someone actually manually enter the
information into the web-based form.
Some hospitals have set up queries within their EHR
that allow them to pull out the cases that need to be reported,
and have all of the information that we ask for, already pulled
from their EHR, but that still requires someone
to manually enter it into the web based form.
Ibad Khan:
Thank you for that clarification.
Our next question involves a category of clinicians we have
yet to discuss, however could pertain to the situation.
The question states, can you discuss the role of dentists,
if any, in the opioid overdose response.
Is there any data reports about opioids
and opioid use during dental emergencies?
Jerome Adams:
This is Surgeon General Adams.
I actually had a very informative
and productive meeting with leaders of the dental society
and in dental field, just a few weeks ago in Massachusetts.
And we know that there are a number of individuals,
including dentists who have a part to play
in us digging ourselves out from the hole that we are
in right now, in regards to the opioid epidemic.
We know that a lot of the prescribing to youth
of opioids is through oral health procedures
and encounters.
And we know that the dental community knows this
and is doing a lot to try to address prescribing,
and to try to look at alternatives.
And also, to make sure they are utilizing best practices
for acute prescribing.
So, to answer your question in a nutshell, yes,
dentists are an important part of this, and to the extent
that you and your communities can make sure you invite them
to be part of this conversation, you will help prevent the start
of the pathway for a lot of folks.
As I mentioned earlier, we’re seeing this evolve
into a fentanyl epidemic, but the fact is,
there is still a large number of individuals
who are getting their start through prescription opioid.
And unfortunately, far too many are being prescribed those
opioids for acute pain, not in accordance with CDC guidelines,
and that’s leading to them ultimately going
down an addiction pathway.
Ibad Khan:
Thank you, Sir.
We have time for one last question,
so I would like to propose this to all our presenters.
What are some specific examples of planning
that an emergency department can undertake
to better prepare themselves
for these increasing rates of opioid overdoses?
Jerome Adams:
Well, I’ll kick things off.
This is Surgeon General Adams.
You’ve just got to talk about it, you’ve got to be willing
to have the conversation, you’ve got to be willing to bring
in partners, both traditional and nontraditional.
One of the unfortunate, well, one of the things that’s come
out of this unfortunate tragedy, is that folks are willing
to come and sit down and talk, but we need to use our roles
as clinicians, as public health leaders,
to have that conversation.
To have our epidemiologist in the room sharing the data.
To have our ER doctors in the room sharing their concerns
and their obstacles in regard to connecting people to care.
To have our first responders in the room,
including law enforcement,
talking about what they’re seeing in the field.
And by doing so, by taking advantage
of the unfortunate opportunity
that the opioid epidemic has provided us to better partner,
we can achieve better health, we can turn this thing around.
And we know we can, because you saw the data earlier
in Rhode Island, in Massachusetts, in New Hampshire.
And hopefully, it will also hold true in West Virginia
and in Kentucky, that we’re seeing the ability
to at least stop the increase in death from overdoses
if you have a process that includes multiple partners,
and takes into account, everyone’s needs, everyone’s,
everyone’s obstacles, and everyone’s assets.
Elizabeth Samuels
I would just like to echo that.
I think that community partnerships and partnerships
with Departments of Health are key, both in terms of coming
up with a plan and coordinating, implementing that plan.
And also, being able to monitor, you know,
how changes in overdose are happening, how that,
what that means for directing interventions in the community,
and what kinds of resource considerations need to be taken,
need to be considered when you’re thinking
about resource allocation.
Whether it’s about access to treatment or Naloxone, etc. But,
I think for emergency departments, you know, this is,
this is well within our scope of practice, you know,
you stabilize and treat unstable conditions, we do,
we diagnose patients in times of uncertainty.
And certainly, either diagnosing substance use disorder
or altered mental status, well within our scope of practice.
But, we also have a key public health role to play,
and we have a key opportunity to link patients into treatment,
and initiate medication assisted treatment
at the time of the E.D. visit.
Or, if they’re not ready at the time of the E.D. visit,
then to help lay some of the ground work until they are ready
to engage in treatment, in keeping an open door,
low threshold, nonjudgmental environment,
where people know they can come and seek help.
Ibad Khan:
Thank you very much.
This concludes our Q&A session for today’s presentations.
If we did not get to your question, please feel free
to email coca@cdc.gov, and we will get you the answer.
Again, the email address is coca@cdc.gov.
On behalf of COCA, OSTLTS, The Division
of Unintentional Injury, and Vital Signs,
I would like to thank everyone for joining us today.
But, a special thank you to our presenters,
Rear Admiral Anne Schuchat, Vice Admiral Jerome Adams,
Dr. Alana Vivolo Kantor, Dr. Elizabeth Samuels,
and Ms. Meghan McCormick.
The recording of this call and the transcript will be posted
within the next few days on the COCA website
at emergency.cdc.gov/coca.
Again, the web address is emergency.cdc.goc/coca.
All continuing education for COCA calls are issued online
through TCE online, the CDC Training
and Continuing Education online system at www.cdc.gov/tceonline.
Those who participated in today’s COCA call and would
like to receive continuing education,
should complete the online evaluation by April 16th, 2018,
and use course code WC2922.
Those who would review the call on demand,
and would like to receive continuing education,
should complete the online evaluation between March 13th,
2018 and April 17th, 2020, and use course code WD2922.
Please join us for our next COCA call,
where the discussion will be on the new shingles vaccine.
This call will be held on Tuesday, March 27th,
from two to three p.m. Eastern time.
Please join us for the next Vital Signs Town Hall
Teleconference on April 10th,
where we will discuss antibiotic resistance.
Please stay connected with the Vital Signs Town
Hall Teleconferences.
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Again, all these links are available
at emergency.cdc.gov/coca.
More information of opioid overdose prevention can be found
at www.cdc.gov/drugoverdose.
This Vital Signs, including the mortality
and mortality weekly report, consumer factsheet,
and other communication products,
along with the previous issues of Vital Signs, can be found
at www.cdc.gov/vitalsigns.
Finally, a companion editorial, titled Opportunities
for Prevention and Intervention of Opioid Overdose
in Emergency Department, written by CDC’s Director
of the National Center for Injury Prevention and Control,
Dr. Vivolo Kantor and other CDC opioid experts,
is available online.
You can find this by directing your browser
to emergency.cdc.gov/coca to today’s COCA call and clicking
on additional resources.
Again, thank you all for being a part
of the first ever joint Vital Signs,
OSTLTS Town Hall, Coca call.
Have a great day.
END