This feature is part of the eBook, “Evolving strategies to win the war on opioids.” Download your copy here.
While the COVID-19 pandemic has dominated the headlines over the past 18 months, another deadly public health emergency has grown out of all proportion: drug and opioid use and overdose.
The growth of the opioid epidemic has spurred an increase in public safety partnerships and task forces charged with addressing this national public health emergency. These multidisciplinary partnerships have led to the realization of the intelligence available to help understand the size and scope of the problem.
Key intelligence requirements for police and public health alike in the identification of opioid use and overdose trends is to understand the “where, when and how much.” Strategies for interdiction, intervention, prevention and treatment all arise from addressing these key questions.
The National EMS Information System (NEMSIS) has consistently reported a significant uptick in EMS responses to opioid events requiring the use of Narcan. The rate of growth has been significant, and as this is only EMS data, with the proliferation of individually issued Naloxone the number of overdoses may well be significantly higher as EMS may not be called as addicts can be effectively self-medicated. These data points on a federal level are also being identified and intelligence shared on a local level to provide understanding and intervention.
Collaboration in Massachusetts
The development of intelligence using all public sector organizations in a particular locality informs both operations and policy in response to the opioid crisis.
In Lowell, Massachusetts, which has one of the nation’s highest rates of opioid deaths, public health and safety agencies have developed programs to share information and provide appropriate interventions. Lowell’s EMS agency, Trinity EMS, has for many years provided meaningful and timely analysis of their data, sharing that information in as near to real-time as possible to help health officials, police and fire departments with the fight against opioid abuse.
Initially, Trinity started drilling down into its patient care reports (PCR) data using linkages into its FirstWatch biosurveillance system to speed up notifications of opioid overdoses into real-time data. The FirstWatch system is designed to improve situational awareness, operational performance and clinical patient outcomes by securely capturing, translating and transmitting information about 911 callers, patients and systems. The software from FirstWatch allows Trinity to gather and present data in a cross-disciplined format to aid with better understanding the situation, more specifically the opioid crisis.
Mining this information from Trinity’s PCR reports on a real-time basis has allowed fellow first responders to act proactively and assist with public awareness and life-saving measures during the widespread opioid crisis. Public health and public safety officials can have this intelligence right away and be proactive rather than reactionary.
Jon Kelley, director of operations and communications at Trinity EMS, tells the back story: “We are 6-7 miles from the opiate hub of the east coast, where we had 99 overdoses in 30 days, but we didn’t do anything with the information. We saw it occurring, but we had no process for analyzing the data.”
This led to city agencies coming together to share and collaborate, brief the public via both press releases and social media, and create public awareness campaigns. Using collective data, the combined agencies were able to put out public safety notifications to warn and inform the public.
In addition to simple data sharing and public safety alerts, the city also created an opiate outreach team that follows up after a patient has overdosed.
Deputy Superintendent Mark LeBlanc of the Operational Services Bureau for the Lowell Police Department says the team consists of a police officer, firefighter and EMT, available five days a week. The team members allow the information “owned” by each agency to be used for the benefit of the team.
“It is such a successful program,” said LeBlanc. “In the past six months, in terms of total encounters, the team made 1,209 unique encounters from January to date, that’s a lot of interactions.”
Practically the team can also vary its approach to users. LeBlanc notes, “If a police officer just happens to be knocking on the door one morning and maybe the person is averse or doesn’t want to talk to the police, the next time they go, the firefighter or EMS knocks on the door, maybe the person would be more inclined to want to have their conversation.”
The team has developed several tactics and services over the course of its development including regular patrols into local homeless encampments to talk to individuals about both substance use disorder and mental health awareness issues. LeBlanc is also excited about a new addition to the program where a master’s level social work clinician is to be hired to be embedded in the department from 12-8 p.m. every day. “They can ride in a cruiser, they can be at the station, they can be in dispatch, and they can help us with so many types of things,” said LeBlanc.
Lowell is also part of the National Institutes of Health (NIH) HEALing Communities Study. The study will test the impact of an integrated set of evidence-based practices across healthcare, behavioral health, criminal justice and other community-based settings. The goal of the study is to reduce opioid-related overdose deaths by 40% over three years. Researchers are partnering with 67 communities highly affected by the opioid crisis in four states to measure the impact of these efforts.
One of the initiatives taking place in Lowell is the ability of EMS crews to leave behind naloxone with rescued patients and provide educational resources.
“Our crews on our service area down in the Lowell area can leave Narcan behind on any 911 request for service,” said Kelly. “If we show up and there was an overdose, we can educate the family how to use the Narcan. Using a QR scan on the box brings you to a link of a training video done by the co-op team showing you how to use Narcan.”
Kelly identified a call where a 15-year-old was doing CPR on her father. He described the response and the save by the crew: “We’re able to empower that 15-year-old with Narcan and education for the next time her dad overdoses. So, it’s empowering.”
The power of a multi-agency, multi-disciplinary team has many advantages, in terms of individual knowledge, skills and intelligence. The data and results are important to law enforcement agencies as it identifies where further effort is required and where successes are being achieved. There is a firm belief that the collaboration arising from the composition of the team and the array of services and knowledge that they bring is the key to its ongoing success.
The results speak for themselves, and further information can be gained from the First Watch web page devoted to opioid data and information.
Case Study: Richmond Ambulance Authority
The Richmond Ambulance Authority (RAA), in partnership with the Richmond Police Department and Richmond Public Health District, employed its FirstWatch biosurveillance system to turn real-time activity data into actionable intelligence for all partners, within the realities of HIPAA law that surrounds the delivery of prehospital medical care.
RAA employs FirstWatch’s triggers to answer several key questions such as trend and cluster analysis, and identification of repeat or returning patients.
A key tool in the analysis armory is RAA’s Controlled Drugs Trigger. Every time a medic administers Narcan, the dose and quantity are recorded. The higher the amount of Narcan needed to revive a patient becomes a gross indicator of the complexity of the heroin mixture. As a baseline measurement, pure, uncut heroin usually takes 0.25mg of Narcan to bring a patient back to a manageable level of consciousness. If medics were using 4mg, 6mg and occasionally 10mg, it became an indicator of more volatile and potentially lethal strains of the drug on the street.
With the challenges of field testing and a backlog in state lab analysis, the trigger provides a gross indicator of drug contents and locations, as well as identifies geographic clusters or time spikes in which events occur. Retrospective analysis of both police and lab data gave credibility to the quality of information produced to validate this early warning initiative.
FirstWatch data triggers that assist with intelligence gathering include:
- Controlled Drugs Trigger – Identify usage and dosage.
- Frequent or repeat users – Identify frequent users who may benefit from the offer of rehab.
- Geo-cluster reporting – Identify locations of overdoses, particularly pertinent for strong to lethal strains of drugs.
- Heroin/overdose trigger alerts – In their HIPAA de-identified state, these could be shared among partners to alert to the frequency of 911 overdose responses.
Following on from best practices originally conducted in Albuquerque and Bernalillo County, New Mexico, RAA also scrutinized a list of opioid deaths provided by the police to backtrack against clinical records to identify how many times a person had received an intervention before their ultimate death. This understanding fed information to the opioid task force, as trends about previous usage and risk factors were revealed and informed interventions.
The success and proliferation of publicly available Narcan have slightly diluted the availability of real-time intelligence, as those close to addicts administer without necessarily alerting emergency services. One interesting self-administration came to light during an early EMS and police response to an address where a Narcan auto-injector was discovered. It transpired that the auto-injector came from a stolen batch reported elsewhere in the state and the dealer was offering their version of customer care by selling both drug and antidote as part of the same deal!
The power of collaboration and partnership in the Richmond system created a closer bond between agencies and individuals within them and led to a greater understanding of the issues to help direct strategies and procedures.
DOWNLOAD: Evolving strategies to win the war on opioids
This article, first published 11/15/2018, has been updated.
