Building a Use Case for Community-Based Peer Support in the Emergent Management of Opioid Overdose

Since 2014, the Centers for Disease Control (CDC) has recognized a significant uptick in the incident and prevalence of opioid overdose deaths related to synthetic opiates [1,2]. Prior to the Covid pandemic, multiple efforts were initiated to try and address the opioid epidemic through care provision changes, policy interventions, community awareness and medication management practices [3]. Immediately prior to the Covid outbreak, the National Center for Health Statistics at the Centers for Disease Control found that there was a slight reduction in the incident and prevalence of opioid overdose noted in multiple states, and the community of providers seeking to address the opioid epidemic were hopeful that interventions were starting to bend the curve of opioid management. Unfortunately, the Covid pandemic re-engaged many of the underlined dynamics that fueled the opioid epidemic and subsequent data has demonstrated that the trend towards opioid overdose and death has returned to pre-pandemic levels, and in some cases continues to exceed those trends [4,5]. Based on the daunting task of arresting the trajectory of opioid death related to overdose, novel interventions are required to try and stem the tide. 

One area where advances are being explored in the management of Opioid Use Disorder (OUD) is integrated services in primarily medical settings. One technique being used in a variety of emergency departments across the United States is the introduction of Certified Peer Recovery Specialist (CPRS) as an adjunct to the medical management of acute opioid overdose [6,7]. Multiple emergency departments have indicated the use of CPRS in this capacity. Some of these programs employ CPRS as members of the hospital team in care provision while others have sought to link with community-based organizations that provide peer support specialists in their community [8-10]. Whether the CPRS are native to the hospital team or are collaborative partners from the community, the end goal is the same. These programs strive to provide additional services and resources to complex patients in need of comprehensive care in the emergency departments. They also serve as a conduit to ongoing treatment and care. In that conduit role, these clinics are seen as a “bridge” to Care. 

This article seeks to explore the efforts of the Hennepin County Medical Center (HCMC) emergency department. HCMC serves the Minneapolis community as a Level I trauma center (adult and pediatric) and as a safety net hospital for Minneapolis and the surrounding Hennepin County. HCMC engaged with a community provider (YourPath) in the provision of peer support service connections to care for individuals who present with opioid overdose concerns. In this article, we will review the structure and function of the collaborative effort, we will review the preliminary outcomes from pilot data, and we will discuss the impact of this program on the ongoing management of complex patients with opioid use disorders.

The HCMC - YourPath partnership was designed to work with patients with substance use concerns in the Emergency department and in the Acute Psychiatric Services (APS) department, a 15-bed unit for individuals in acute crisis. The goal of the program is to engage patients in these settings with concerns related to use of any substance through the unique skillset and approach offered by Certified Peer Recovery Specialists (CPRS). A CPRS is a person who has experienced issues related to substance use and recovery, has completed the requisite allotment of training hours related to non-clinical recovery supports, and has passed the state recovery exam or another exam with reciprocity. 

The focus of this pilot project was to develop and improve the care stream for targeted HCMC patients seen in the emergency department/APS with a known overdose from opioids in the community. Peers can engage in a manner that is unique within healthcare, using their lived experience to connect and relate to the individual seeking assistance. In addition to their CPRS training, the YourPath staff in this environment have many of the same experiences that the patients served have had - non-fatal overdoses, incarceration, trauma and abuse, and repeated treatment episodes. Through their presence in this setting, the program can engage an underserved and particularly vulnerable population in a manner that appears to be more effective with some patients. 

The peers are consulted via other members of the hospital staff through the electronic medical record or through direct communication. Any member of the care team can submit a consultation, and every effort is made for the peer staff to work within the existing workflow. Peers are co-located within the hospital, which allows for near-immediate response times. This program relies heavily on the use of the Health Insurance Portability and Accountability Act (HIPAA) compliant YourPath technology platform. Peers have a tablet that can be handed to the patient, or used with the patient to: 

• Complete forms and assessments
• Register for the YourPath care platform, which helps engage patients post-discharge
• Identify relevant local and community resources for issues related to treatment, wellness, and social determinants of health and make referrals/intake appointments
• Live chat with integrated medical and clinical staff if needed
• Complete video visits for medical and clinical appointments as needed 

The platform allows patients to connect with virtual, integrated clinical and medical services offered by YourPath via a tablet, but the program leads with the engagement of the peer in a face-to-face, physical setting to increase engagement and improve the patient experience. As outcomes for people of color in Minnesota continue to be far worse than their white counterparts, it is especially important to offer patients connection and culturally specific programs. Staff are well-versed in options for care for Somali and East African immigrant and refugee populations, African American or Black populations, and Native American populations. As the program continues to expand, the program will focus on recruiting and retaining peers that reflect the population served. 

After the peer is consulted and initiates the engagement, the patient can discuss what services they might be interested in. Once the patient communicates that they are interested in the next steps in the process, the patient can complete the screening and onboarding on the tablet. This assessment identifies appropriate next steps, which can include virtual services via YourPath. These virtual services can be offered on demand in this setting and are designed to augment services within the larger hospital system, never replacing or duplicating services that are already on offer. The services include: 

• Comprehensive SUD assessments, which allow licensed alcohol and drug counselors to help with program placement for patients interested in residential or outpatient specialty SUD treatment
• Initiation of medications for opioid use disorder, including buprenorphine. This is often helpful if appointments with the hospital’s robust addiction medicine or psychiatric clinic are more than a few days out
• Other treatment coordination activities, including connection to detoxification and withdrawal management programs, direct connections to residential treatment, and referral to other services 

After these services are provided, the patient is cleared via the standard process within the emergency department and prepares for discharge. As a part of this process, they are enrolled on the YourPath platform which allows for HIPAA- and the Confidentiality of Substance Use Disorder Patient Records (CFR 42 part 2) compliant text, email, and chat follow-up once the patient returns to the community. Patients are educated on the potential use of the platform and the way that it works, allowing them potential options for responsive, Substance Use Disorder (SUD) focused care in the future. The platform is available to the public and functions in the same manner outside of the hospital system as it does in it, allowing for immediate connection to assistance for issues related to SUD. 

As the program matures, it may be possible to include this peer-initiated, hybrid response model in other parts of the system. Some potential areas of focus include community-based emergency medical services and paramedicine; services within inpatient medical surgical units; outpatient psychiatry; within the treatments offered in the Hennepin County Jail that are delivered by HCMC; and within the invite-only coordinated care clinic, a clinic focused on individuals who have frequent hospitalizations that are often correlated with substance use and worsened by housing instability. Our hope is that this model provides an innovative framework for hybrid models of care that help improve our systemic efforts to support people with issues related to substance use.

Traditional emergency medicine and emergency nursing training leaves Emergency Department (ED) providers and ED nurses underprepared for the delicate and nuanced conversations required for effective engagement of individuals with SUD, including Opioid Use Disorder (OUD). While the education of medical management and nursing care of patients with opioid overdose has grown in recent years, there is often less importance placed on how to navigate conversations with patients about treatment options and next steps, or how to provide counseling and motivational interviewing about use patterns and overdose risks. This lack of experience combined with limited time on shift due to busy emergency departments greatly challenges the ability to have meaningful connections with patients after they suffer an overdose. 

Moreover, the historical complexity surrounding buprenorphine and the risk of precipitated withdrawal has made its induction intimidating for both providers and patients. As such, ED care has primarily focused on medical observation after an overdose and providing naloxone at discharge. While there has been a shift towards initiating buprenorphine for those in withdrawal, many patients who arrive at the ED with an opioid overdose do not leave with a prescription for buprenorphine or other medications for Opioid Use Disorder (MOUD). Our lack of intervention and ability to engage these patients only contributes to the moral injury that has become ubiquitous to emergency care for both providers and nurses. 

It is important to note that the one-year mortality rate after an opioid overdose is akin to that of a ST-Elevation Myocardial Infarction (STEMI) or heart attack [11]. A patient who suffers from a STEMI has countless resources and medical expertise poured into their care. While a patient who suffers an opioid overdose frequently receives minimal care and resources. Recognizing the need for more comprehensive and compassionate care, the Emergency Department at Hennepin County Medical Center introduced peer recovery specialists into the primary workflow to engage patients with OUD. The inclusion of peer recovery specialists, viewed as essential consultants akin to other medical specialties, has proved successful. CPRS have lived experiences and dedicated resources which allow them to navigate the intricacies of OUD conversations with patience and empathy, while instilling hope and enhancing engagement. Their presence allows for extended engagement to address the unique needs of each patient, a task often challenging for ED providers and nurses during hectic shifts. Since the program’s implementation, the cross pollination of organizations has increased the working knowledge regarding the scope of service and capacity to promote change in the staff from both organizations and this growth bodes well for the continued management of future patients. Similarly, there has been notable growth in patient engagement, highlighting the vital role played by peer recovery specialists in addressing the unique needs of individuals with OUD in the fast-paced ED setting.

The unfortunate return of skyrocketing incidents of opioid related overdoses and deaths continues to stress the healthcare system. Novel approaches to address this concern must include integrated and interdisciplinary efforts to care for the complex needs of individuals suffering with opioid use disorder. This pilot study showed the potential efficacy of a peer-supported specialist-driven intervention to facilitate care for individuals with OUD-related concerns in the emergency department/APS. Efforts like the HCMC pilot project show opportunities to improve outcomes at the facility level, community level, and patient level. 

At the facility level, emergency departments are often constrained by utilization concerns, and limited resources to care for the needs of patients. Efforts like the HCMC partnership help create more efficient processes to care for complex patients who require additional services to ensure safe and timely discharge for follow-up care. The use of CPRS as an adjunct to the medical team can provide novel opportunities to increase access to transitional treatments as well as provide psychosocial support at the point of care which can assist in navigating the complex treatment options available for an individual suffering from addiction related concerns. 

At the community level, the HCMC partnership serves as a model for cross collaboration between institutions. This collaborative effort can help facilitate communication and ensure increased knowledge about the care continuum, which bolsters the opportunities for individuals in that community to receive coordinated care. The literature on Recovery-Oriented Systems of Care (ROSC) speaks to the essential nature of cross collaborative communications [12]. A ROSC seeks to find inflection opportunities where care providers speak with and work with one another on the management of complex patients and this bridge clinic serves as an excellent expression of a ROSC in the Minneapolis and Hennepin County communities. 

The literature on patient centered care (PCC) is clear. When institutions and communities work to ensure care is coordinated and delivered with patients as active participants in their treatment, patient level outcomes improve [13,14]. PCC related outcomes include improved clinical management, reduced length of stay and enhanced patient safety. The HCMC partnership is an example of a PCC approach to the delivery of OUD related treatments in an emergency department. By bringing the peer support specialist from the community into the emergency department team, the HCMC pilot project creates a care environment for patient inclusion in treatment and peer support specialist facilitated assertive linkage with warm handoffs to ongoing service lines both within the HCMC continuum and the broader Hennepin County community. Efforts such as the HCMC collaboration serve as excellent examples of integrated treatment approaches to try and address the epidemic of opioid use disorder related overdose and death and continued research on these efforts is highly encouraged.

The authors wish to thank the CPRS members and leadership team at YourPath for their collegiality in care delivery and the HCMC leadership and ED care team for the tireless effort they bring to the compassionate care offered to the citizens of Hennepin County.

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