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Robin Kish (Host):  The number of opioid related deaths skyrocketed in Palm Beach County in 2016 to over 600, a community in crisis, banding together to launch an innovative approach to addiction treatment. Restoring Lives on this edition of Here For Your Health.

Welcome to the Health Care District of Palm Beach County’s podcast Here For Your Health. I’m your host Robin Kish. The Health Care District is a unique healthcare system located in Palm Beach County Florida. We provide county residents access to Primary Care, Hospital and School Health services, Skilled Nursing and Long Term Care and lifesaving Trauma and Air Ambulance services. Through all of these programs, the Health Care District focuses on filling the gaps in the healthcare delivery system and being the healthcare safety net for Palm Beach County. On this edition of Here For Your Health, we’ll discuss an innovative response to a community crisis, the opioid epidemic. Our guest today is Dr. Belma Andric, Chief Medical Officer, Vice President and Executive Director of Clinical Services with the Health Care District of Palm Beach County, and C. L. Brumback Primary Care Clinics. The C. L. Brumback Primary Care Clinics are federally qualified health centers also known as FQHCs that provide primary care, dental and behavioral health services to adults and children at nine locations around the county. Welcome Dr. Andric.

Belma Andric, MD, MPH (Guest):  Thank you. It’s good to be here.

Host:  Dr. Andric in 2016, Palm Beach County found itself an epicenter of a nationwide opioid overdose crisis. How has this crisis impacted the work that you do for the Health Care District and the C. L. Brumback Primary Care Clinics?

Dr. Andric:  It changed everything. The Health Care District involvement and immediate response in early 2017 delivered positive results to the overdose crisis that we were dealing with. What started as a pilot program with 30 patients through a partnership with Fire Rescue and local hospital and the Health Care District of course now has become a comprehensive outpatient based medication assisted treatment clinic. And since that time, we had over 600 patients that went through our program.

Host:  Wow. Dr. Andric maybe you can explain how this pilot program helped to address what really had become revolving door in some hospital emergency rooms with repeated opioid overdoses even to the same patients overdosing more than once on the same day.

Dr. Andric:  Yes, the pilot program tested and confirmed the success found in 2015 by Yale University researchers and in that model, we tried to copy their best practices of emergency room initiation of substance use disorder treatments. So, in this pilot, our local hospital initiated medication assisted treatment in emergency room and warm hand off of them to our outpatient clinic where the patient received treatment on a continuing basis and as long as it was needed. And some of those patients are with us even to date receiving treatment for their substance use disorder in their medical home that our clinics are for them.

Host:  And they had to commit to this program?

Dr. Andric:  They have to commit to this program, and they use that as a one-stop shop. They receive their mental health, addiction treatments, psychiatric services as well as primary care services, lab services and medications as well in our clinics.

Host:  So, it sounds like this pilot program was the key to opening the door to this innovative approach. Who was involved?

Dr. Andric:  Local Palm Beach Country Fire Rescue transported those patients to the JFK Medical Center Emergency Department. Upon discharge, Fire Rescue would bring the suboxone medication to the patient’s home for the first seven days. That was what was necessary for the pilot. But since that time, Fire Rescue just transports them to the Emergency Room and as I said, treatment is initiated in the Emergency Room and then a warm hand off to outpatient treatment.

Host:  You mentioned that there are still patients who are involved in this program today. How successful was the pilot program overall?

Dr. Andric:  Roughly 50% of the patients are still three years after the initiation of the treatment in some type of treatment in our clinics. So, that goes in line with literature supported outcomes. So, it might sound that only 50% of the patients are still compliant with the treatment but compared to traditional abstinence only programs that don’t have more than 10 to 15% long term compliance; we interpret that as success.

Host:  And this program utilizes suboxone you mentioned. How does that medication work and what does it do to help patients progress without relapsing?

Dr. Andric:  Suboxone is a medication that satisfies the brain receptors that desire opioids like heroin, but it does so without necessarily the euphoric high the opioids provide. A patient also has no risk of overdose with suboxone. So suboxone enables the patient to avoid negative effects of withdrawal which often leads to relapse and allows the patient to be sober so they can start putting their lives together and start working with the counselors to reach the sustained road to recovery.

Host:  So, there is more than just medication in this approach. There has to be you mentioned counseling, group, individual as well?

Dr. Andric:  That’s why it’s called medication assisted treatment. This is very comprehensive treatment for addiction and those patients receive one on one counseling, they go for the group counseling. They also have to see their primary care. We treat them for infectious diseases such as hepatitis C or HIV and this is very comprehensive approach to this very complex medical condition.

Host:  Once you saw the success of the pilot program; what came next?

Dr. Andric:  You’re right. Building upon the success of the outpatient treatment clinic; the Health Care District saw to develop a sustainable approach to addiction care and access to treatment. Borrowing elements from the nationally recognized satellite receiving facility approaches for overdose care and evidence-based solutions found in MAT models; they actually sought to develop response that will leverage the best elements of each model to create our unique Palm Beach County approach. Palm Beach County was fortunate to have ideal partners in the community that come together including the Health Care District, Fire Rescue, JFK Medical Center and the county government.

The Health Care District worked with JFK Medical Center, actually the North Campus of this hospital to develop the idea of addiction stabilization unit as the entry point of care combined with readily available outpatient treatment. What does that actually mean? Instead of traditional central receiving facility, often developed as ER or jail diversion programs; this unit functions as a regular emergency room with clinical staff who have additional training in addiction. The team consists of addiction trained ER physicians, nurses, EMTs, hospitalists, psychiatrists on staff all along with the other medical professionals trained on MAT treatment and addiction treatment in general.

The MAT treatment focuses offered to the patients throughout their stay at the hospital including doing admissions for medical or mental health reasons on the floor. This is still a field of medicine that we are all learning in medical field. So, that’s why it was important for us that very similar to a model that we have in trauma or stroke or heart attacks, hospital has expertise for this very complex lifelong illness. So, that’s what we try to do here.

Host:  And it’s working?

Dr. Andric:  Well we are open for a few months. Similar to regional centers of excellence that address other complex conditions as I said, it requires a high level of expertise such as found in trauma, heart, stroke and cancer care. Palm Beach County now has that first of its kind specialized center for addiction care. We don’t have benchmarks. We didn’t find that anybody is trying to do anything similar, so we don’t know if it’s still working in longer time to follow the outcomes but what we accomplished is to provide that treatment for most acute phase of this illness. So, medical professionals are ready 24/7 for patients to arrive. The trained team is comfortable treating addiction as well as any other medical conditions patients may have.

This specialized ED also functions similar as I said, to trauma centers where EMS and ambulance services prioritize over those patients to bring them directly to this unit. And basically, bypass the closest emergency rooms very similar what we do for trauma for example. This direct access assures the patients arrives in a not only timely manner in the emergency room that is specialized for this condition but also this hospital has developed warm hand off mechanisms that upon discharge, they care connected directly to continue in outpatient treatment instead of just treat them and street them like we do traditionally in addiction. We really do those extra steps to connect them for the most appropriate higher or lower level of treatment as appropriate.

Host:  So, the addiction stabilization unit has been open since the end of October and has been busy.

Dr. Andric:  Yes, you’re right. To our surprise. Not only that the Fire Rescue transfer patients here but also, we have a lot of walk ins and actually roughly 50% of the patients are walk in patients here. But I believe since the opening until the end of January, there are 340 patients treated in addiction stabilization unit and we are working on data, how many of them were connected to the higher or lower level of care as I speak. As I said, we need a little bit more time to compile our initial data. But it is very well received and anecdotally what we hear from the patients and the employees that work both in the inpatient and outpatient partners; it is very well received.

Host:  So, this centralized and specialized approach seems very promising since discharge does not mean the end of the patient’s care. What’s the next step in their treatment?

Dr. Andric:  As I already said, once treated and stabilized in this addiction stabilization unit, the patients are discharged using warm hand off. The personal referral is made with the patient directly to the clinic and you can very often see the nurse from the unit literally walks the patient across the parking lot to the outpatient medical building where the clinic is located. The majority of the patients qualify for outpatient treatment but some of them might need high level of care and then from the clinic, they are connected to the higher level of inpatient addiction treatment but that even short assessment in outpatient clinic is very important because those patients will be discharged from the higher level of care at some point of care but they already have established relationship with outpatient clinic for their illness.

No different than when we have a heart attack, at some point of our recovery, we are referred to our primary care that further coordinates our care for our heart disease for the rest of our lives. So, that’s kind of what we are trying to medicalize addiction as an illness and give any opportunity for those patients to establish medical home for their addiction needs. No different than any other medical needs that they might have in their future long term.

Host:  We talked about this effort being a community approach. How many community partners have been involved?

Dr. Andric:  There have been many. I’m very proud of this project because this is public and private partners coming together and took us a while to reach that. We had many obstacles to overcome but as I said, in time of crisis, this was the best example how community comes together as I said, private and publicly funded partners. We already mentioned Palm Beach County Fire Rescue, JFK Medical Center, Palm Beach County; those are all partners as they come together to put this project together.

Host:  So, it’s a public private approach to an epidemic.

Dr. Andric:  Absolutely. This crisis touches all. And the only way that we could do some innovative approach in treatment because old ones don’t necessarily work the way that we want them to work. We have to come with something new and as I said, we still need time to prove that this works but it makes sense. And everybody put a lot of efforts for this to come together and to try to do something differently in our community.

Host:  And Doctor, you’ve seen personally the difference that this innovative approach has made in the patient’s lives.

Dr. Andric:  I think that we need, as I said, again, we wanted to do something different because many people were dying and still are dying. We have many successful stories but what I’m most excited about is that we provide very valuable access to care for people who because of the nature of the illness, many of them run out of the other resources. Initial results show that more than 80% of those patients do not have any type of insurance and there are not really many doors that they could open in our community to initiate the treatment once they are ready or once they overdose and in that most motivational moment of their illness, we want them to have an opportunity to have access to care and we work really hard to provide that continuum of care in that medical model like any other illness. So, we have patients who on a daily basis, tell us that this access to care really changed their lives and gives them a long seeking opportunity to at least try to reach their recovery. This is a relapsing illness. Many of them relapse on that road to recovery but at least they have door to knock any time when they relapse.

And by treating this addiction illness as any other medical condition, we don’t interpret relapse as a failure. In many aspects that means just more treatment and more access to different kinds of treatments. So, that’s why I think patients get very positive impressions about a program like this because they can always come back.

Host:  And the financial commitment from the county over a million dollars there, the fact that the federally qualified health centers, the Brumback clinics see all patients with or without insurance. There is a commitment there to support those who would not be able to afford this type of care in other facilities.

Dr. Andric:  That’s absolutely right. And our federally qualified health centers will be medical homes for addiction treatment of those patients, no different than any other chronic condition and this is a chronic condition.

Host:  And these patients have come back to say thank you?

Dr. Andric:  Those patients come to say thank you on a daily basis.

Host:  It must be gratifying to see the difference from when they first start to the progress that they’ve made. What do you see in their ability to interact with their families, with the community, with professions?

Dr. Andric:  That is something that is very important to us. We have many successful stories that the patients share with us on a daily basis in the clinic. But we also try to measure that like in any other illness in medicine, we try to measure outcomes and long term outcomes and ongoing measuring is very important in the clinic. And every three months, all our patients that come in the clinic, we ask them to complete something that we call BAM tool. What it stands for is Brief Addiction Monitoring tool. That’s one of the evidence-based tools of how you measure the long-term outcomes of your addiction treatment programs and because addiction is not necessarily only measured by decreasing number of overdoses or yes, I’m using drugs or no I’m not using drugs but we also monitor did they find a job, did they reestablish relationships with their families, are they living more productive lives in society and are they not engaging in criminal activities anymore.

So, those are the things that during the time that we measure, and I’m pleased to say that our program has that more protective factors during the time in treatment, the longer they are in treatment there is upwards trend of those outcomes and decreasing risk factors. Every three months, they are asked to complete this by which we monitor then those BAM outcomes. We are trying to benchmark ourselves but as I said, there is not a lot of literature that you can benchmark yourself necessarily but the more we all medicalize this illness, the more we will publish and the more we will have benchmarks. But so far, we are pleased to share that we have expected trends and that is kind of in essence proof that we are on a good track.

Host:  And seeing that the patients are getting on with productive lives is the reward.

Dr. Andric:  Absolutely.

Host:  Well, Dr. Andric, thanks so much for joining us. You’ve provided our listeners with excellent information about the opioid crisis, the importance of evidence-based care for substance use disorders and the Health Care District’s response in Palm Beach County.

Dr. Andric:  Thank you.

Host:  Thanks to all of our listeners. Please check out our other Health Care District podcasts on health topics you won’t want to miss at www.healthcaredistrictpodcasts.org. Today’s podcast is brought to you by the Health Care District of Palm Beach County, C. L Brumback Primary Care Clinics. The C. L. Brumback Primary Care Clinics offer medication assisted treatment for patients with substance use disorders as well as primary care, dental services, behavioral health and pharmacy services for adults and children. The Brumback clinics have locations throughout Palm Beach County as well a mobile health clinic serving the homeless. If you or someone you know could benefit from medication assisted treatment or other services offered by the Brumback clinics, please call 561-642-1000 to make an appointment or visit www.brumbackclinics.org.