Coordinated Opioid Recovery (CORe): Florida MAT Program

All right, welcome, Everybody. It is 2 o' clock Eastern Time on June 8, 2023.

I'm very excited about today's speaker and the topic. Just a little bit of background. I've been very blessed to know Houston park when I became a medical director at Palm Beach County Fire Rescue.

Houston was there for over 30 years as a captain. And he came to Dr. Schepke with something that sounded crazy at the time, which was, hey, why aren't we treating these folks who had opioid use disorder? Why aren't we treating them instead of just having them do that circular door from the emergency department back to the street, back to the emergency department? He came up with the idea. He. He came up with the program, and it's been so successful that he's now up at the state of Florida at the Department of Health, and it's titled as the community Paramedicine Coordinator for the State of Florida for the Department of Health. And I asked him, I said, houston, can you come on and talk about what we're doing in the state of Florida with the Florida's core program? And so, Houston, thank you so much for joining us. If you wanted to make any further introduction and then if you want to share your screen and take it away, thank you so much for joining us.

Well, great. Thank you, Dr. And Tevi, I feel really privileged to have this opportunity to be able to join everybody here. I recognize quite a few names that are popping up. And just to begin with, if, as I share my screen, are you able to still see everything right now?

Yes, perfect.

Okay, great. So, yeah, it's really exciting to work with Dr. Entebbe and just a little bit of feedback. So when Dr. Entebbe came on board with Palm Beach County, I think it was right around 2016 to 2017.

He was the pediatric specialist that came on board. And.

My passion was HAZMAT toxicology. And the reason I'm bringing that up to begin with is there's a connection to that and what we're talking about today. And so my passion was I wanted to know everything that I could about toxicology, specifically that as it pertained to hazmat response or the new realm, which was wmd, which is really just a nicer way of saying hazmat response. But I had created a series of protocols for antidotes for toxicology associated with WMD and hazmat and handed that off to Dr. And Tevi, and of course, he switched that to make sense with hand TEVI model. And so that we had to Immediately be able to look at something that made sense with calculating drug dosages for pediatrics that would fit into our realm of toxicology. So it worked out really well. And the reason I bring that up is because of the connection with my interest in toxicology. And we were just inundated with patients coming in and out of the hospital systems up in Palm beach county at that time, as was the state and the rest of the nation with overdoses, particularly those of opioids. During that timeframe, Palm beach county led the state of Florida with the most known deaths and overdoses opioid related. And so I wanted to find out what can we do to change this. And I started doing a little bit of research and I found that there had been a study done and had been verified through Yale and Harvard where they were looking at the utilization of buprenorphine through some clinics. And these were walk in clinics where individuals were given the opportunity to self medicate or at least self direct for treatment on buprenorphine to get off of their dependencies to opioids.

The statistics back then showed that There was a 90% success rate on these individuals getting off with success of not needing to use any more opioids. When I read that, I thought there's no way that this could be possible. But I read it and researched it a little bit more. I presented it to Dr. Schepke and he at the time was our medical director and also working at JFK Medical center, and he was receptive to it. And so we created a program which really led us into.

The development of community paramedicine as it has become within Palm Beach County Fire Rescue. And it also was the catalyst to developing a program for treating patients that have opioid use disorder and has now expanded into not only opioid use disorder, but substance use disorder as well.

Unfortunately, that came at the end of my career and so I worked a few more years on it with a passion. And I must say that doing 30 plus years in EMS, I did start down in Miramar Fire Rescue.

I developed a passion for the fire service and particularly ems. But the most rewarding thing that I have ever done in my entire career was focused on working with patients with substance use disorder.

I have never seen anything like this. It reignited that fire of wanting to help people and seeing success in helping people by doing that.

I created this program with the help and support of so many other agencies and the willingness for doctors to go out on a limit and look at this and agree to it. And it works. And so.

About two years ago, Dr. Schuppke asked if I wanted to come on board with the state at the Department of Health to help reproduce what we had done in Palm beach county statewide. And.

The obvious answer was, yes, I'd be happy to do that. So I'm really excited to tell you that we are actively working on implementing the same program, but with a little bit different roadmap statewide. Currently, we have 13 counties on board following this program. We're about to bring on another 12. Ultimately, we will have 65 counties on board statewide that will have a coordinated opioid response program. What that is, is it is coordinating the efforts of fhir, ems.

The hospital systems, the behavioral health providers, and the federally qualified health centers statewide, the Department of Health, dcf, bringing everybody together, bringing them to the table, and establishing a system of care that is long term care. And so I'm going to go into that. I don't want to do death by PowerPoint. So I'll get through the slides fairly quickly and then there'll be a couple of points where I'm going to bring in some of the newest things that we're looking at doing, implementation of some of these new programs. And then what I would really encourage is upon the end of this presentation is having some open dialogue, encouraging anybody that wants to discuss what they have, what they think, what they see or what they need, because that's where we're headed. Can everybody hear me? Okay?

Loud and clear, Houston.

All right, very good. Okay. So it's a network of addiction care. And I'm going to be cautious on using the word addiction care. One thing that I did learn when I stepped into this arena is the words we choose and how we speak to individuals that have substance use disorder is critical.

What I learned is how you talk to individuals that you're trying to treat.

If you choose the wrong words or you choose the wrong way to speak to individuals that have these challenges, you will not get very far.

I've learned how to change my behavior, to select my words properly, and to reengage with compassion and care.

When we hear people refer to individuals as addicts, that's not a very nice way to refer to individuals that have a medical disease.

I do want to encourage the thought process to change and that we recognize anybody that does have a substance use disorder and that it is truly a medical disease. It is diagnosed and it is now known in the medical community that it is a disease. Basically, it's a network of care for fire and ems, and it's how to blend them together within the emergency services to the hospitals and then onto a system of care beyond that.

Already kind of said who I was.

A little bit further. More information on it. Again, it's through the Department of Health from Tallahassee with direct encouragement and support from the governor. Also, we work very closely with dcf. So an interesting thing about DCF is that right before I retired, I was working with this program with Palm Beach County. And then upon retirement, I was asked if I would help support DCF in helping maintain or develop this program statewide. And they actually created a program called the Bridge program. And so what this was was a program where they were working with emergency rooms and the emergency rooms were receiving patients that were being brought in by ems. And the Bridge program was a program to encourage the ER to facilitate induction of buprenorphine and then distribute or disperse the patients out to community behavioral health providers for long term care. So many of the Bridge programs are still in existence and those were funded through grants from the cdc. They continue to be funded at this point. So there's a lot of federal funds that come in. And in addition to that, we also work with the Health Care Administration. So it's really a very big umbrella of support at the federal and state level. The goal here is to have a standardized form of treatment for substance use disorder. And although we have some definitive treatment plans for opioid use disorder, there are also some other definitive treatment plans to involve medications for some of the other substance use disorders. And so we'll include those as well as we go through this program.

Here's kind of what it looks like if you were to put it into a diagram. You have an individual that overdoses emergency response and care navigation is provided. A model that's now being evaluated and utilized with success in Palm beach county is rescues. And I'm going to use the word rescue because that's a common term in South Florida. But in other parts of the state I'll use ambulance. They are bypassing the closest hospitals and they are transporting to designated hospitals ERs that have specialized care for patients with substance use disorder, with physicians that are trained specifically in.

Specifics to meeting the needs of patients that have addiction or addiction specialists so they're transported to those facilities. Not much different than what we see with the development of a trauma system or a stroke facility or cardiac facility. And that is becoming a trend. Although that's not necessarily something that has to be set up right now. It is becoming a trend. And an interesting thing about this and Dr. Schepke, he talks about this pretty frequently right now. And that is that when you look at the 911 system as we know it today.

It started in the 70s, the early 70s, as a result of car accidents, because there were so many frequent car accidents. It led to the development of trauma systems because they needed a system of care that was going to focus on the injury patterns associated with motor vehicle accidents. And that's how we got our trauma system established. Well, now opioid injuries and death has surpassed car accidents. So when we start thinking on a global view of this, we need to start looking at what is the best way to treat the leading cause of death, which is now opioids, which has far surpassed that of car accidents. We need to have a system of care or facilities that can provide the best care for that. So then we go from there. We stabilize the patient, we start the medications that are appropriate, and then we transfer them to specialty medical groups that can maintain that medical care and then focus in on the clinical side of that as well. Now, when I talk about specialty medical groups, it's not just about giving them the buprenorphine or the medical assisted treatment meds that are out there. It's addressing all of their needs. Do they need dental needs or do they have hepatitis, hepatitis C? Do they have hiv? Because a lot of these things come together. Are there codependencies that we can start to address and get those taken care of as well? We also start to address the behavioral health issues. Sometimes the behavioral health issues are the reason that they have the codependencies to the substances that they become dependent to. So this is a kind of a diagram that shows the direction in which we are, we are headed.

A little bit of terminology. For those that are not used to it, we will use the word sud, which is for substance use disorder. It's recurrent use of alcohol, alcohol and or drugs with a significant impairment. So somebody who experiments one time with a substance and ends up requesting or needing your services in EMS or the emergency room as an overdose doesn't necessarily have a substance use disorder. They had an overdose. And so what we want to look at is do they have a dependency where they're using it inappropriately? Do they have a dependency to needing the drug? And I'll talk a little bit about needing the drug. And once somebody becomes dependent to a substance, particularly opioids or some of these other drugs that we're going to talk about, they need the drug. And the reason they need the drug is because they don't want to feel the bad effects of not having the drug. And that's critical. We all have heard at some point or another in our career, oh, they keep taking the drugs because they want to feel that great high. Well, they lose that very soon. And particularly with the opioids, they use it, they have this great sensation, they get that dopamine effect. They feel like the best thing in the world. And then they come down off of that and they go into withdrawal. And that withdrawal feeling is so bad that they keep using the drug to get rid of that feeling and then all they do is chase that feeling of not going into withdrawal. So we'll talk a little bit more about that as it goes on. We'll also talk about oud, which is opioid use disorder. And I'll play a little bit on that a little bit later. And I'll talk about opioid use disease because I think we also need to look at it that way as an opioid use disease. And it's the misuse of prescribed opioids and also want to include on that the synthetics that are so prevalent now to the point now where, if you looked at the, the state coroner's death reports, we're not really seeing anybody who has death determination by heroin because it almost does not exist. It's almost completely synthetic, being that of the fentanyls that are out there. And they just keep redesigning the chemical chain of these analogs. And we're seeing less and less heroin and more and more of the synthetics, which is a challenge for us because many of these synthetics are less likely to respond to naloxone. And we'll talk a little bit about that as we get into it.

So here's some interesting studies that have done on the effects of the brain disease and how when you use.