Situational Analysis
Like many communities across the country, St. Charles County has experienced an alarming trend over the past decade. Prescription opiate and heroin overdose call volume has increased dramatically during said timeframe, leaving paramedics, police officers, school officials, treatment providers, court systems, and a slew of others scrambling to get a handle on the epidemic. In our community, call volume has risen from sub-200 calls per year to more than 500 calls per year. St. Charles County Ambulance District (SCCAD) responded to the majority of these calls [426], with St. Charles City Fire Dept. responding to 127 calls.
2015 proved to be a watershed moment for St. Charles County Ambulance District Paramedic, Lisa Cassidy. In 2015, the District ended the year with a 41 percent opiate call volume increase over the prior year, leading Cassidy to dedicate herself into the development of programs aimed to curb this growing call volume. Cassidy’s efforts began as a public awareness campaign, but quickly grew more extensive. Today, the District’s heroin/opiate efforts focus on three core areas: public education and awareness, treatment referral, and training/resources for patients and families struggling with addiction.
Goals
The desired outcomes of SCCAD’s heroin/opiate program have evolved as we have added more components to the program. In the short-term, our project aims to:
- Increase acceptance among members of the public that heroin and opiate abuse is a major problem within our community.
- Alter behaviors among members of the public in regard to access, safeguarding, and proper use of opiate based, prescription pain medication.
- Create a sustainable system to link those successfully revived following an overdose with treatment options in their community.
Long-term our project aims to:
- Slow the rate of overdose call volume growth, and ultimately, reduce call volume in this segment of our operation.
Planning & Implementation
The three-pronged heroin/opiate program that SCCAD has today, did not begin all at once. The process of implementing and planning each component of our program has been detailed here.
AWARENESS/EDUCATION:
Initially, the District’s efforts were concentrated solely in the area of public education and awareness. Our team soon recognized a need for treatment and support services and began incorporating them into our program. Formally known as #StopHeroin, the awareness component of our campaign got underway in early 2016. Cassidy felt that she and the other Paramedics at her station had been running an increasing number of opiate-related overdoses, but did not know until the year-end figures from 2015 were recorded just how serious the issue had become. SCCAD Paramedics responded to 41 percent more opiate and heroin-related calls in 2015 than in 2014. Clearly, this was a public health emergency that requiring an intervention.
To begin, the District joined St. Charles County’s “Community Resources United to Stop Heroin” [CRUSH] coalition. CRUSH is a consortium of treatment providers, law enforcement, school districts, adult, and juvenile court employees, prosecuting attorneys, DEA officials, and others. CRUSH had been established two years prior, and its flagship initiative was (and continues to be) the Teen Drug Summit, an event held each autumn in our community that is attended by select sixth, seventh, and eighth graders.
After meeting Cassidy and other members of our team, the group decided that Paramedics could offer a fresh, unique perspective on the epidemic to the audience at the summit. The group charged the SCCAD with opening the summit by giving the youth in attendance a no-holds-barred look at how overdose calls often play out.
To accomplish our mission, SCCAD created a seven-minute video that begins with an actual 911 call for a heroin overdose. The video features a re-enactment that closely follows the events of the 911 overdose call. Despite the efforts of bystanders, law enforcement, and paramedics, the patient does not survive. The scene shows the victim’s mother begging emergency personnel to let her hold her son and police officers photographing the body for the Medical Examiner’s office. In short, it is a raw but accurate look at these tragic situations. SCCAD drew from the expertise of Paramedic Adam Hermann, who in a previous position worked extensively in video production.
A presentation featuring call volume statistics, video clips of emergency responders, and parents talking about their experiences with overdoses, was developed to accompany the re-enactment.
Concurrently, Cassidy and SCCAD Director of Community Relations, Kyle Gaines, developed a series of infographics that would be used on the SCCAD’s social media channels in the months leading up to the Teen Drug Summit presentation. The figures represented were a mix of local overdose death numbers and national statistics related to the opioid epidemic. Data was pulled from the Centers for Disease Control (CDC), National Council on Alcoholism and Drug Abuse (NCADA) and other highly-respected sources. The goal of the infographics was to break down the large volume of information into simple data points that anyone, regardless of age or education level, could understand.
Cassidy and Gaines also worked to create material that would outline the physiological effects of an overdose and prevention strategies in the form of simple, shareable content. During the social media campaign, the SCCAD’s Board of Directors authorized Paramedics to wear special #StopHeroin shirts purchased with uniform allowance to raise awareness within the community. The epidemic is near and dear to our six-member elected board. Tragically, one of our SCCAD board members lost a stepson to a heroin overdose several years ago.
At the Summit, Cassidy presented alongside Paramedic Ashley Pease. The presentation received positive reviews from students, parents, and others in attendance. Since then, Pease has remained active in presenting the information to our community, focusing primarily on youth audiences.
Following the Teen Drug Summit, Cassidy and Gaines created an adult-oriented version of the presentation. Once created, Cassidy and Gaines then leveraged established relationships with community leaders to reach the chamber of commerce, Rotary Clubs, church groups, and other civic organizations. Though initially aimed at a youth audience, adults are an essential component to our community education plan. For several years, St. Charles County was collectively unwilling to have a conversation about heroin and the problems it creates. The “it’s not in my town” sentiment was widespread. After seeing our presentation, the attitudes of many in the community are beginning to shift. Today, most will now admit that this epidemic has touched our community. The next hurdle is getting parents to admit that this epidemic could affect their family on a personal level.
Throughout the process, social, and traditional media have played important roles in the implementation of the educational and awareness campaign. Large-scale community awareness events hosted by school district partners are promoted heavily on Facebook and Twitter. Both print and digital media outlets have profiled the collaborative efforts to engage members of our community in this ongoing discussion.
March 2016
•Identification of issue
•Initial discussion of what awareness campaign may entail
•Joined CRUSH group to connect with other like-minded entities
May-June 2016
•#StopHeroin shirts designed, bid & procured
•Identification of key statistics & education points; creation of infographics
August 2016
•Infographics rolled out individually on social media throughout the month
•Select statistics compiled, included in Summer issue of SCCAD newsletter Pulse Points (mailed to 40,000 households in our county)
•#StopHeroin shirts worn throughout month by on-duty crews
September 2016
•Re-enactment video scripted, shot and edited
•Interviews with parents and emergency responders conducted, edited
•Presentation for Teen Drug Summit designed
November 2016
•Presentation given to 500+ at Teen Drug Summit
•Presentation delivered to first adult group (Cottleville/Weldon Spring Chamber of Commerce)
December 2016-Present
•Presentations delivered regularly to groups of youth and adults; to date, more than 5,000 individuals have attended a #StopHeroin presentation
TREATMENT:
The #StopHeroin campaign received strong support from the community shortly after its implementation in the Fall of 2016. This support lead SCCAD to investigate other programs to add in the response to the problem of heroin and opiates. Through networking and relationships with other first responders, Assistant Chief Dave Lewis learned of a program in Ohio that had EMS providers following up with patients resuscitated after an overdose to attempting to link them with treatment providers. Upon further research, SCCAD found a handful of agencies throughout the country operating similar programs, each of which tailored to meet the unique needs of their community.
Knowing that the model existed, Lewis and Cassidy began by connecting with NCADA to gauge their ability to partner on assessment, referral, and counseling. NCADA agreed, but encouraged us to bring other treatment providers into the fold as well. Providers with whom we’d connected with at CRUSH also agreed to support the initiative, and the St. Charles County Police Department agreed to provide officer standby if requested by the Paramedic (as it turns out, this service is very rarely required). The initiative was dubbed the Substance Use Recovery Response Team (SURRT).
Initially, our idea was for counselors from the treatment agencies to accompany a SCCAD mobile health Paramedic on the follow-up visits. This however would be logistically challenging and cost prohibitive for the agencies. SCCAD revamped the plan, settling on an assessment and referral-based model. This model enables our mobile health paramedics to connect patients interested in seeking treatment with a variety of resources throughout the metro area and state.
Working with our treatment partners, SCCAD developed a flow chart to demonstrate how best to link patients with the appropriate resources. Certain criteria qualify for immediate entry into treatment regardless of a patient’s ability to pay. The group works to ensure that patients meeting this criteria are caught early in order to expedite their entry into treatment.
Another key program partner in this endeavor is the St. Charles City Fire Department. The City of St. Charles is unique in that it receives shared EMS coverage between SCCAD and the fire department, which operates two ALS ambulances. In order to ensure the program reached all overdose patients, we connected with Fire leadership, who agreed to train their Firefighter/Paramedic staff on the program and process of obtaining consent. Obtaining consent is necessary to allow follow-ups, which are only conducted by SCCAD. This partnership ensures that all overdose victims in our community who are conscious, have the opportunity to consider a helping hand into treatment.
For purposes of clarification, the sequence of events in SURRT cases are as follows:
•Patient successfully revived with nalaxone, encouraged to go to hospital for evaluations.
•Regardless of whether patient consents to transport, he/she is provided a SURRT folder filled with treatment provider contacts in the area. The folder includes a waiver that allows the Paramedic on-scene to share the patient’s personal health information with the SCCAD SURRT Coordinator. The patient also may authorize SCCAD to discuss their case with specific family members.
•If patient gives consent, a SURRT team member (typically Cassidy, though we have added to the team to keep pace with demand) will call him/her in 24-48 hours, as this is the time frame during which they are most likely to relapse, according to our program partners.
•If patient agrees, SURRT team member will work to find a treatment option that meets the needs of the individual (in-patient vs. outpatient, capable of chemically-aided detox, in-area vs. out-of-area, etc.).
Thanks to the variety of treatment providers involved with CRUSH, Cassidy and Lewis had a broad base from which to draw on when developing the program. While some partners work exclusively with patients who have commercial insurance, others will provide treatment to uninsured clients. Thanks to industry conversation and media coverage, more treatment providers have learned about SURRT and have reached out to provide information on their programs. Today, SURRT not only refers to facilities in our region, but also to those in other areas of the state and country.
August 2016:
•Research of programs similar to SURRT
•Initial meeting with St. Charles County Police Department
September 2016:
•Initial meeting with NCADA to discuss concept
October 2016 – January 2017:
•Meetings with our ‘core’ treatment providers (Preferred Family Health, Bridgeway Behavioral Health, Crider, Center Pointe Hospital) to develop logistics plan, flow chart, and intake procedures for those referred via the SURRT program.
January 2017
•Leadership of St. Charles City Fire Department and SCCAD met to discuss partnership, Fire personnel agreed to explain program to overdose patients they revive.
•Filmed SURRT patient interaction video to be utilized in SCCAD and City Fire training.
February 2017:
•Training on SURRT program deployed to employees of SCCAD, St. Charles City Fire Department and program partners across the county.
March 2017:
•SURRT program launches at SCCAD and St. Charles City Fire Department.
FAMILY SUPPORT/NARCAN DISTRIBUTION:
After the successful partnerships with SCCAD on #StopHeroin and SURRT, NCADA approached SCCAD about becoming a distribution agency for Narcan. NCADA received their supply of Narcan via the Missouri Hope Grant through the Substance Abuse and Mental Health Services Administration (SAMHSA), and has been actively partnering with agencies to get it into the hands of family members who have a loved one struggling with addiction.
Per the grant parameters, in order to receive two doses of Narcan, an individual must go through a brief training on proper administration of the medication. Initially, we thought this responsibility would lie with our Mobile Integrated Health (MIH) Paramedics, but upon further reflection, we realized that all Paramedics should be trained, as those revived may relapse before an MIH Paramedic makes contact to discuss treatment options. Further, there are some patients who may refuse SURRT services, but may accept the Narcan. Thus, SCCAD Paramedics are now incorporating this training into their discussion after explaining the SURRT program.
This initiative is a bit different than the others, as we knew there might be some employees uncomfortable with the idea of ‘harm reduction’ by providing Narcan to those who are using opiates. To address this concern, we strategized with NCADA on ways to help our team better understand the rationale behind the program. Our partners answered by providing cost-free, on-duty training to all uniformed personnel. This training not only covered the distribution program, but also the addiction process and the science behind it.
Though a handful of employees are admittedly still unhappy that we made the decision to go this route, most have applauded the decision. Some employees who were initially on the fence later reported a noted shift in opinion on the topic because of the addiction training they received. It took a high-profile overdose or two, along with key influential employees seeing first-hand what a difference they could make by investing time and effort with family members, but things are moving in a positive direction.
April 2017:
•NCADA approaches SCCAD about becoming a Narcan distribution partner.
May 2017:
•Proposal goes through proper channels for approval internally.
June 2017:
•SCCAD uniformed personnel complete training not only on Narcan distribution, but opiate addiction in general. Training provided by NCADA.
July 2017:
•Narcan distribution program ‘goes live’
Results
SCCAD’s goal is for the programs implemented to deal with heroin and opiates to evolve over time as we incorporate new facets and ideas. When SCCAD embarked on this initiative just over a year ago, we wanted to increase acceptance that opiate abuse is a real issue in our community, modify storage and disposal behaviors among those prescribed opiates, and ultimately reduce call volume for these types of overdoses.
Quantified success is difficult to measure in regard to our first two goals. Our community is unquestionably more willing to discuss the epidemic that it was even two years ago. It would be unfair however, to solely attribute this shift in opinion to SCCAD’s efforts. Rather, this change in opinion is a likely combination of the presentations, and enhanced national and local media coverage on the topic, including segments highlighting the efforts of SCCAD (and Lisa Cassidy, in particular).
Behavior modification in regard to opiate storage and disposal is another area that is difficult (if not impossible) to fully track. In our adult-oriented presentations, SCCAD actively encourages the audience to keep opiate-based pain medication locked away and dispose of it safely when no longer needed. While most nod and seem to comprehend the rationale behind this recommendation, actually doing it when they get home is another story. Thanks to a partnership with the National Council on Alcoholism and Drug Abuse (NCADA), we’ve secured a (virtually) unlimited supply of drug neutralization bags that are given to anyone who asks at all SCCAD stations. This option is utilized moderately, with more individuals opting to drop medications off at police department drop boxes.
Call volume reduction is the one area that SCCAD has undeniable, quantitative data. Unfortunately, we have not yet seen the ‘downward turn’ in overdose call volume that we’ve been hoping for. As much as we may want it to be, we recognize that this not a sprint, but a marathon. Year-to-date in 2017, we’re up more than 20 percent over last year, and will likely eclipse 500 heroin or opiate overdose calls on our own this year.
Impact
In many ways, it’s hard to believe that SCCAD’s heroin and opiate program was introduced to our community only one year ago. Over the past 12 months, we’ve forged new partnerships with key agencies in our community, heightened understanding of the epidemic among the public, and have linked individuals and families struggling with addiction with treatment and resources to aid in their recovery.
In addition, these initiatives has led to a wonderful new level of partnership between the Ambulance District and our County Health Department. Never before have we shared this level of data with one another, something we hope to continue doing on future projects.
Though SCCAD is proud of what our team has accomplished by taking a collaborative approach, there is undeniably more work to do in our community. In the coming years, we will cultivate new relationships with treatment agencies and other strategic partners, while strengthening already existing relationships with agencies who have been with us since the program’s inception.
#StopHeroin (August 2016-present)
Number of individuals reached by #StopHeroin presentations: 5,000+
Number of YouTube views of re-enactment video: 10,910
SURRT (March 1 – August 31)
Number conscious following revivial: 197
Number consented to follow-up: 100
Number who entered treatment: 55
Family support/Narcan training (July 1 – August 31)
Number of bags distributed: 39
Budget
Given the impact that SCCAD’s heroin and opiate programs have had on our community, the financial investment has been minimal from the District’s perspective.
From a manpower perspective, Cassidy has worked 28 hours of overtime, on average, per month since the program kicked off in August 2016. This calculates to $1,068.20 per month, or $12,818.40 total. Cassidy has also invested many volunteer hours into this initiative as well.
Other (potential) expenses have been kept to a minimum thanks to our employees’s willingness to volunteer their time to help further the mission.
Occasionally, the District incurs minor expenses to support the programs (printing of SURRT release waivers, for instance), but these expenditures are infrequent and have very little impact on our overall department budget. It is worth noting the fact that the CRUSH group, to which District belongs, underwrites the cost of the SURRT folders ($1 a folder).
URL: https://www.youtube.com/watch?v=czXBu3N2qKs&t=9s
Files: 75 percent heroin users 01.jpg, Common opioids 01.jpg, Community News Lisa.pdf, KSDK video.pdf, More likely 01.jpg, OFallon Chamber Stop Heroin video removed.pptm, Overdose Calls 01.jpg, Overdose Deaths 01.jpg, Paramedics lead community efforts to stop heroin opioid abuse.pdf, WEB Heroin and Drug Bags cropped.pdf, WEB Heroin page.pdf, bp heart failure 01.jpg, drop boxes 01.jpg, forms of heroin 01.jpg, locked cabinet 01.jpg, opioid to heroin 01.jpg, respiratory failure 01.jpg
