A patient survives an overdose, but what`s next?

Recovery coaches who are peers—individuals in recovery—can go into hospital emergency departments (EDs) where patients have been rescued from opioid overdoses via naloxone, and provide hope and a path toward treatment. The first program of its kind in the country, Anchor ED, based in Providence, R.I., is making this happen and is being viewed as a model by other states.

The program uses peer recovery coaches who try to convince patients in the ED to get into recovery. The goal from the point of view of the state of Rhode Island, which is helping to fund the program, is to get every overdose survivor seen by a recovery coach.

Recovery coaches at Anchor do not steer patients toward any particular treatment program, or particular type of treatment, or even to treatment itself, says Deb Dettor, director of recovery support services at Anchor Recovery Community Centers, a recovery support component of The Providence Center community behavioral health organization.

“We give them the whole gamut of options,” Dettor says. “If they want recovery coaching, if they want [medication treatment], if they want an inpatient program—we will literally help them go where they want to go. If they say on the spot where they would like to go, we can get them there.”

The mindset of people when they have just been rescued from an opioid overdose is not conducive to thinking clearly about next steps, however. Moreover, that says nothing of the physical illness they are experiencing due to withdrawal symptoms. The naloxone (Narcan) that saves someone’s life also precipitates withdrawal in the opioid-dependent.

“You didn’t want to be here, you didn’t want to see any of us, you didn’t want to end up in the hospital with an OD being Narcan-ed back to life, you are physically sick because of being in withdrawal, you are angry,” says Dettor. “There are so many barriers to seeing anyone at that point. So when someone says to you, ‘Do you want to talk to a recovery coach?’, you say, ‘I don’t want to see anybody.’ That’s a real barrier.”

What is often keeping the patient from saying yes is shame, says Dettor. “This illness is just maddening in that way,” she says. “The level of shame, embarrassment, horror.”

She recalls the time when she went to the hospital with alcohol poisoning. “There you are covered in puke. You can’t believe your life has come to this place where you have no control,” she says.

Interpreting the early data

Anchor ED was under the gun back in the summer when a report revealed that 45% of patients recovering from overdoses in Rhode Island hospitals do not see a recovery coach. But Dettor says it is not accurate to say that 45% of overdose survivors refused intervention. Rather, 45% were not actually connected to treatment—perhaps because they declined to meet with a recovery coach, or because they were never offered the chance.

“All of the hospitals in Rhode Island are supposed to ask every person [who survives an overdose] if they want to see a recovery coach,” Dettor says. “Sometimes they don’t do that. Staff may not be trained.”

If the patient is offered the chance to meet with a recovery coach and turns it down, that can be addressed in several ways, Dettor says. For example, it might be better if the recovery coach could just talk to the person, instead of the hospital staffer first asking the patient if this is acceptable.

Anchor has started a pilot program in which every overdose survivor who says no to seeing a recovery coach will be asked if he/she could be contacted the next day. For this to work, the patient would have to sign a release form, allowing the hospital to give the patient’s information to Anchor ED, says Dettor.

Anchor also asks the hospitals to give information about their recovery coach to patients, although that leaves it up to the patient to reach out. “Often social workers who discharge patients say to contact us,” says Dettor.

Anchor's numbers show that of all people who were seen in the emergency department by a recovery coach, 86.8% did agree to engage in some kind of recovery plan, she says.

“We might see you in the emergency department, and not get you engaged, but then the outreach team may see you in the street, and approach you there,” adds Dettor. “Our goal is always about connecting you with resources to help you get into recovery.”

Rebecca Boss, the state substance abuse director in Rhode Island, has championed the Anchor ED program from an early stage, getting other single state authorities interested in how it works. “I know when Becky presented about this a couple years ago at our annual meeting there was a great deal of interest,” recalls Rob Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD). “Other states gravitated to her to talk about the mechanics.”

Anchor ED began with a conversation Boss had with people at Anchor, when she heard them say, “People just want to talk to somebody,” says Morrison. “That was the light bulb moment. They just want to talk to someone who’s been where they are.”

Law enforcement involvement

While some states may choose to have public safety officers, police or fire, involved in peer recovery interactions with overdose victims, that doesn’t happen in Rhode Island, says Dettor. “We have no connection with law enforcement,” she says. “In Pawtucket, where our primary recovery center is located, the police department is very supportive. … If we need help from them they’re right here, in a positive way.”

There have been concerns that police involvement could mean that the overdose victim will be asked about where the drugs were obtained; law enforcement has a legitimate mission to keep these drugs off the streets. But this also could have a chilling effect on patients’ willingness to be contacted by a police-related recovery coach.

“We don’t care where you got your drugs,” says Dettor. “We’re more interested in how we can get you into recovery.”

Dettor, who worked for two decades in treatment, has been working in recovery support since 2004. “To me, this is where the hope is,” she says. “We’re having a much bigger success with engagement.”

“I think it’s great that the police departments are trying this,” says Patty McCarthy Metcalf, executive director of Faces and Voices of Recovery. “But I think it’s a slippery slope. Unless they are guided by standards, then we’re creating something that could be a sideline, and not real recovery coaching.”

Standards for peer work include appropriate training for peers in ethics and boundaries, and supervision of peers by programs that understand the culture of peer recovery, says Metcalf.

At Anchor, all of the recovery coaches are in recovery from a substance use disorder (in some cases, from an opioid use disorder), and some have had the exact same experience of being rescued with naloxone. Others are in medication-assisted treatment. “Recovery coaches will use their own story when it’s appropriate to identify what they have gone through,” says Dettor.

The Anchor ED program, created by Anchor Recovery Community Centers, The Providence Center and the Rhode Island Department of Health, is part of a much larger system, including two recovery community centers where people can come in every day to receive a variety of support services. Anchor also houses recovery coaches in the state's prison facilities.

Debating peer qualifications

Does someone need to have professional training, a degree, or a license to be a peer recovery coach? “This is one of the debates,” says Kimberly A. Johnson, PhD, director of the federal Center for Substance Abuse Treatment (CSAT) under the Substance Abuse and Mental Health Services Administration (SAMHSA).

“Do you need to have a master’s degree to have that conversation? Many people have answered, ‘No, you don’t need to have a master’s degree to do motivational interviewing and get someone to engage in treatment,” Johnson says.

What she likes about Anchor is that its efforts are not tied to one treatment center. “They just ask if someone would be interested in different things that are out there,” she says.

At a time when someone has just gotten revived from an overdose, the peer “has a level of understanding of what that experience is like,” Johnson says. “It’s a very similar model to the rape crisis model, in which they send people who have had this experience. The peer model has been used for other emergencies, so it’s not an unknown.”

Another benefit of the Anchor model is that the overdose survivor doesn’t have to engage right then and there, in the emergency department. “A lot of people don’t decide on treatment at that time,” Johnson says. “So what Anchor does—following up over time—is critical.”

SAMHSA’s State Targeted Response (STR) to the Opioid Crisis grants, the two-year, $1 billion program authorized by the 21st Century Cures Act, is helping to fund new initiatives following in the footsteps of Anchor ED, says Johnson. New Jersey is using $3.5 million of its $13 million for each year for the Opioid Overdose Recovery Program, which was started before the grant but is being continued with its help. “We also have grants to start up peer recovery organizations,” says Johnson.

“This whole concept of trying to reach out and find people, and engage them in treatment, instead of just waiting for them to show up, is a good thing,” she adds. “There might be some issues with some of the models, but just the fact that people are realizing it’s not just about having an open door, that we need to take the next step and reach out to people and get them engaged. And when they say yes, we need to have treatment for them.” That treatment isn’t necessarily going to be a residential program for every person, she says.

“The nature of the crisis is forcing things to speed up so that different approaches are tried,” says NASADAD's Morrison. “They know it’s not always a slam-dunk the first time, but if there’s something done, other than walking out the door, that gives some level of hope.”

Alison Knopf is a freelance writer based in New York.

Peers' work can take a toll

Even as prescription opioid misuse is declining, opioid overdoses are continuing to rise, mainly as a result of illicit fentanyl. First responders now need to carry extra doses of naloxone, because more are needed if the overdose drug was fentanyl. “It’s heartbreaking to watch so many people die,” says Anchor Recovery Community Centers' Deb Dettor. “A lot of our staff are former heroin addicts. We’re all blown away by this.”

In recovery work, it’s important to be available, so that when someone is ready the help is there, says Dettor. “We keep doing the work knowing that a point comes when people are just ready,” she says. But she adds that even if someone might not be ready for recovery, that doesn’t mean he/she is ready to die.

“We don’t know if we’re doing hospice care or helping people on the road to recovery,” says Dettor. “We never know.”

Meanwhile, recovery staff have to support one another. “One of my brand new staff lost his first person last week,” says Dettor. The patient had overdosed and had been revived four times. The fifth and final time, he died.

“It’s like a war zone,” says Dettor. “We go to the emergency department over and over again.”

After a death, debriefing for staff is essential, she says. “For that young staffer, we pulled him off the street for that day, put him back in here with the other coaches,” she says. “We also refer staff to the Employee Assistance Program.”

Experimenting with service models

“There’s a lot of experimentation going on with the emergency room outreach right now,” says Kimberly Johnson of the Center for Substance Abuse Treatment (CSAT). “The Anchor program is one of the older programs, with well-established and clear protocols around engagement.”

What organizations need to think about in setting up these programs is clear protocols with the hospitals. “What does that engagement look like, who participates, how does the patient connect with the peer?” says Johnson. “Right now there is a lot of debate, but no good answers, about whether peers or other community health workers are the right people” to staff this outreach. “There’s not a lot of good research,” she adds.

In Ohio, law enforcement is doing the outreach. In New Hampshire, it’s the fire departments. Then there are the states where police departments are imitating the Police Assisted Addiction Recovery Initiative (PAARI) model, in which people can come in to police headquarters and ask for help, without fear of arrest.

It would be beneficial to find out if the results from law enforcement-related peer programs differ from those in programs run by health departments, such as Rhode Island’s, says Johnson. “That would be ripe for study,” she says, adding that she would mention this at the next national Clinical Trials Network meeting.