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Robin Kish: Before the COVID-19 pandemic, Palm Beach County, Florida, like the rest of the country, was waging a war against a deadly opioid epidemic. Thanks to an innovative public private partnership, last year, JFK Medical Center North opened a specialized emergency room called the Addiction Stabilization Unit or ASU. Patients across the county who overdose are now transported to the ASU for evidence-based care.

The hospital partnered with Palm beach County government, fire rescue agencies and the Health Care District of Palm Beach County to help break the cycle of addiction in many cases, by offering these patients a warm handoff to the healthcare district's medication-assisted treatment program located right on the hospital's campus.

Today, two physicians on the front lines of these programs share how this unique approach is working one year later 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. Our guests today are Dr. Courtney Phillips-Rowling, the healthcare district's Director of Behavioral Health and Dr. Steven Keehn, Medical Director of Emergency Services at JFK Medical Center North.

The Addiction Stabilization Unit or ASU opened its doors a year ago in February of 2020. So I'll direct this question to both of you. First, Dr. Keehn, why does this model where emergency medical services or EMS in the county bypassing other hospitals to bring overdose patients to a specialized facility like the ASU works so well?

Dr. Steven Keehn: You know, EMS, a lot of times will see the same patient multiple times in one shift that has substance abuse. I know in the ER, I've seen multiple patients, the same patient multiple times. To my knowledge, we're the only emergency department that actually has an addiction unit. We take patients from all over the county. EMS brings us patients from all over the county to our unit. They come to our emergency department and then we bring them over to our addiction unit and we have social workers. We have our ER nurses that are especially trained to help with addiction. And we've teamed up with healthcare district to be able to help give them the proper care they need to stabilize them. And we've had a lot of success.

Courtney Phillips-Rowling: We now have a place where a patient can go after hours in crisis, in the ASU. Frequently, emergency rooms never had a place to discharge patients to or, if they did, they had to wait a week. And during that week, the patient may change their mind, they may have an overdose. So they've also benefited from knowing there's a place where these patients can go as soon as we're done with the acute piece of their care.

Dr. Steven Keehn: Dr. Rowling and I are using the Yale protocol, which was used up in obviously Connecticut, and we adopted that to help with the best practice. The evidence-based medicine is truly the best way to treat patients. And we used that to come up with our own style and help the patients in the community.

Robin Kish: You mentioned and adopting Yale University protocols. In 2017, Yale University researchers found that starting opioid addiction treatment in the emergency department with medication to reduce cravings and withdrawal leads to better outcomes and is also cost-effective. Now, in its first year of operation, the Addiction Stabilization Unit served over 1400 patients. Dr. Keehn, some of these patients are in dire condition when they arrive at the ASU, aren't they?

Dr. Steven Keehn: Definitely. Some of them have just overdosed. Some of them needed to be resuscitated, be bagged, et cetera. Some have aspiration pneumonia or sepsis. Some of them are suicidal and needed to be Baker acted. But the majority of patients needed to be stabilized with medication. And that's what we do and we do it with dignity.

We have our nurses checking a COWS score and seeing what level they are withdrawing. And we have different medications we use to stabilize them. Obviously, Suboxone is the medication we start them on. We'd use different criteria to start them on the medication to hopefully prevent precipitated withdrawal, which I know is a huge concern in the community. And we have our social workers see them. And it's a multidisciplinary team that helps these patients because it's not just one level they need help with.

Robin Kish: Are you both seeing patients from all walks of life?

Dr. Steven Keehn: I am. I have people, you know, unfortunately that are homeless and I have people that have successful careers. Addiction affects everybody. It's not just one person. It unfortunately affects everybody and people need help with it. And addiction is a disease. It's an illness and it's not just because of they have maybe bad morals. This is an unfortunate disease and needs to be treated like that. Diabetics aren't told to go cold turkey off their diabetic meds. In addiction, people with opiod abuse shouldn't be told, "Go cold Turkey off of opiates, and you'll be better." That's incorrect thinking. And we are treating people properly by stabilizing them, stabilizing their brain on Suboxone and it helps them long-term.

Courtney Phillips-Rowling: In our clinic, actually, our typical patient is between the age of 20 and 50. Typically, they've been in and out of detox and rehabs, have had maybe some smaller stints with sobriety, but never really been able to manage their addiction or substance use disorder in a real-world setting. So typically they do okay when they're sort of in a place that's structured. As soon as they get into the real world setting, they seem to struggle.

I would say about 40% of our patients are homeless when they first walk through the door. They may not have been, they may have been executives at some point, but that's where they've come to. And most of them are pretty bright. They've had education and careers, but they just fell off the wagon because of what they're dealing with. And we do see a lot of difficult situations with human trafficking, people in, you know, domestic violence situations, people who've never really had a fair shot. So we see a lot of patients who both parents were substance users and now they've become as well. A lot of our patients have had a lot of challenges that have made it hard to set up for an easier way of living. Amazingly though, we do see a lot of patients with quite a bit of resilience.

Robin Kish: The healthcare district's medication-assisted treatment program is located in the medical building that's adjacent to JFK Medical Center North in Mangonia Park. Dr. Keene, how helpful is it for the healthcare district's outpatient MAT program to be just steps away from the ASU?

Dr. Steven Keehn: Our warm handoff is paramount to the success of our program. One of our social workers or the healthcare district's care coordinator will personally walk the patient from our ASU unit over to the healthcare district. We don't want someone to walk out of here and not know that they're getting the definitive care that they need.

In general, in the ER, when I say, "Please follow up with this doctor," you hope that they follow up with the doctor, but we're not guaranteed that they're going to actually get there. Maybe they don't know how to get there. Maybe there is different concerns. So this is great that they actually get there and the health district is ready for that patient to take care of them for definitive care, for long-term care, such as their comorbid conditions, diabetes, hypertension, maybe they have dental issues, maybe they have psychiatric illness that all needs to be taken care of.

Robin Kish: Because the MAT program is part of the healthcare district's CL Brumback Primary Care Clinics, patients also have access to medical, behavioral health, dental, and pharmacy services. Dr. Phillips-Rowling, how has your partnership with the ASU helped improve access to care for these patients?

Courtney Phillips-Rowling: So up to date, since our opening about a year and a month ago, we've had about 300 patients get a warm handoff to our clinic, which means specifically that as soon as they're discharged from the emergency room or the floor or the psychiatric unit, if they have a dual diagnosis program, they're not just scheduled for the next day, they actually can be walked over and start their care that same time.

I think what makes this program special is the passion behind most people who work here, that's the first thing. And the desire to provide evidence-based care and give substance use disorders what they've never received, which is respect and a good quality care. It's been forgotten for years by the medical community and it needs to be treated with the respect it deserves so that we can address it.

The second thing that makes it unique is when you come here, it's a one-stop shop program. So while you're here, you get your medical care. You get full psychiatric care. You're assigned a therapist and there's even somebody who can help you with getting back on your feet financially, with housing supports, with transportation supports and other social determinants of health. So we really pride ourselves in being somewhere where you can get it all taken care of in one place. And that multidisciplinary approach really makes it more successful.

Robin Kish: Dr. Phillips-Rowling, in the MAT program for disorders involving opioids like heroin and the more potent synthetic narcotic, fentanyl, what type of medications are used in treatment?

Courtney Phillips-Rowling: Sure. For opiate use disorders, there's quite a few options in terms of medication and then there's also abstinence-based, which is driven by patients and physicians making that decision together. But the medications available are buprenorphine, which is a blocker and an opiate, and methadone, which we don't provide here at the healthcare district, but we work with community partners. We also here provide something called Vivitrol, which is just a blocker.

So patients have multiple options for medications and there's different reasons for choosing those medications for these patients. They need to come in more frequently because in the beginning, there's a lot going on with the illness that's not just "I'm using." We believe strongly here that they need to tie the medication treatment to therapy and to something we call care coordinators, who help them get back on their feet in terms of housing and those social determinants of health.

So in the beginning they come weekly and they're welcome to come more than that if they need to. As time goes on, as they get better and they start to get things adjusted, they can go up to two or three weeks. But in the beginning, we certainly pair it. And regardless of where they're at with their medication, they have to see their therapist weekly.

Robin Kish: According to local news reports from January to August 2020, there were 361 overdose deaths in Palm Beach County, a nearly 50% increase compared to 2019. Overall, more Americans are dying from drug overdoses during the pandemic. The Centers For Disease Control and Prevention reports that more than 81,000 died in the 12 months ending in May of last year, the highest number of overdose deaths ever recorded in a 12-month period. I'll ask you both starting with Dr. Keehn, how has the COVID-19 pandemic impacted your patients and the need for treatment?

Dr. Steven Keehn: With COVID, we are seeing more patients with psychiatric illness, more patients with overdose situations and that's multifactorial. People are losing their jobs. They're homeless. They are lonely from isolation. That is probably the biggest thing I've seen from COVID, is people being down in their luck and being depressed. And because they're depressed, they're using drugs more often.

Courtney Phillips-Rowling: I think it's had a huge impact. I think that there's been multiple factors and, overtime, we'll understand this better. But I think we stayed open the entire time during the pandemic. We had some more teleservices than we used to, but we still had a live component. And for a lot of our patients, you know, one thing was substance use disorders, psychologically it's a very isolating illness. So COVID is also very isolating. And I think that at times we were a touchstone for those patients who had nobody to interact with. And I think a lot of patients feel in some ways that, "This is my substance use family. And I can come here when I need services." So being available to them was huge.

So about three or four months after the shutdown, we have seen a surge in overdoses. The ASU has gotten busier and we've seen more than ever that it's very important that we're available to these patients because many of them are also going through more mental health crisises.

Finally, one thing that's been notable is that alcohol use disorders in the ER have risen quite a bit since the COVID-19 crisis. So we also treat that and we see almost, you know, in the ASU at least, equal amounts of alcohol and opioid disorders.

Robin Kish: Dr. Phillips-Rowling, what are some of the MAT program's benchmarks for measuring success?

Courtney Phillips-Rowling: That's a great question too, because that's something that reflects something you've mentioned earlier about trying to develop an evidence base. We want to be part of that solution. We also want to look objectively at ourselves and improve every year. So we've instituted something called the Brief Addiction Monitor, which is something we started collecting in January of 2018. Patients get this survey, it's 17 questions that looks at their functional improvement, not just their sobriety. So did they get housing? Are they seeing family? Are they in less risky situations, et cetera? There's lots of questions, but we track those every three months on our patients and we have now for a couple of years. And so the data is building and we are now looking at year on year to see if interventions that we're making are making a difference, or if we're getting worse in some measures.

We also track the overdose, the patient self-reported number of overdoses the previous three months. We track some mental health measures, like their depression screening. We track their health measures. So hepatitis C is a big one. It's a very common issue in this population. So we track some of that. Finally, we look at quality data just to see how we're doing with it retention, are we losing patients at places, how are we losing them, and things like that.

Robin Kish: I'll ask both of you this next question. First, Dr. Phillips-Rowling, what does it mean to you when patients return and share the progress they've made?

Courtney Phillips-Rowling: I feel very privileged to have this job because, you know, I get to see the human spirit and what it's capable of every day. So although there's a lot of barriers and there's a lot of stories that don't go well, multiple times a day, I get to see that somebody who started really in a tough place almost to where even I might say, "Huh, how are they going to get out of this?" And so many months later, see what they've achieved. And it just gives me so much confidence in the human spirit for redemption, for strength, for fortitude and resilience.

Dr. Steven Keehn: So the other day, one of my patients came back and thanked me and I went out there to talk to her. And it was very rewarding. After talking to her, I called my wife to let her know how proud I was. This individual was homeless, was using drugs and lost her kids. Now, she is on Suboxone. So she's not abusing opiates anymore. She stabilized, she got a job, she got housing and she has her kids back. So it was very rewarding. I wanted to give her a hug, but with COVID, I didn't, but I wanted to.

Robin Kish: What a rewarding experience. Thanks for sharing that emotional reunion, Dr. Keene. Dr. Phillips-Rowling, as a board-certified physician in both general psychiatry and addiction medicine, what do you want people to know if they're struggling with substance use and are looking for help?

Courtney Phillips-Rowling: Well, I think a few things. Number one, whatever's happened before, whatever trouble you're in, it can always be better tomorrow. And I know that because I see it all the time. That's the first thing. So, you know, never give up and know that there's a group of people who want to support you in reaching those goals, whatever your goals are.

The second thing is we'll meet you where you're at. So if you're not sure about this, or you just want to check it out, or you want quit one drug and not the other, or you are skeptical of the whole thing, just come in. Just meet with us and let's see what we can work out together. Because sometimes I think patients think, "Well, I have to do all or nothing." And in this program in the ASU, we don't feel that way. If you're willing to do something for yourself, you're the driver of your care and we're just here to assist you and offer you the options. So that doesn't mean there aren't rules if you engage in certain programs and whatnot, but we want to partner with you with where you're at. And some people where they're at is they just want to reduce their use. And I guess the last thing is just keep trying, keep trying. So, you know, if you have an open mind and you have a few ideas of what you want, we're ready to meet with you anytime.

Robin Kish: Looking back, it's so many lives lost in the opioid epidemic, the toll it's taken on society and the local efforts that created this innovative evidence-based system of care. What strikes you the most, Dr. Phillips-Rowling?

Courtney Phillips-Rowling: I'm proud of this program. A lot of people don't know this about me, but my father really struggled with an alcohol use disorder throughout my youth and ultimately passed away from cirrhosis. And he could never quite enjoy the things he had worked on because this illness came in the way of that. And back then, there wasn't much for him. So I would say that's a huge motivator for me and probably a big reason as to why I've gone into this field.

I think of the millions of people like my father who were forgotten and sort of shoved aside and only dealt with really in the legal system. And as his daughter, I saw him also as a human. So I think what I'm most proud of in this program is that we see every single patient as a human first, who has a substance use disorder. And when you see someone as a human, I think you provide a different level of care to them.

In doing these questions, I'm speaking but I think that my voice is represented by hundreds of people who've been involved in making this happen. And I think I'm grateful for the power of communal support. Whether you're in finance and you helped fund this, or you're on the frontlines as a nurse working this, thank you. I think that we've turned something that was kind of a disaster in this small way into something that has a lot of human capital and human power behind it, which is a very powerful force. So my last comment is to be grateful to everyone involved in making this program happen and all of the patients who've taken the risk to try to get better.

Robin Kish: Thank you, Dr. Phillips-Rowling and Dr. Keehn, for all of your innovative work in the field of addiction medicine. To learn more about the Medication Addiction Treatment Program or to make an appointment, call the Health Care District CL Brumback Primary Care Clinics at (561) 642-1000 or visit www.BrumbackClinics.Org.

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Today's podcast is brought to you by the Health Care District of Palm Beach County. The healthcare district is a unique safety net healthcare system located in South Florida and provides county residents access to primary care, skilled nursing and hospital care, registered nurses in nearly all of the county's public schools and oversight of the county's trauma system, which includes operating two life-saving Trauma Hawk air ambulances. Learn more by visiting HCDPBC.org.