Austin’s Buprenorphine Bridge Program Fills Gap in Opioid Support System
The Buprenorphine Bridge Program in Austin, Texas. Courtesy of Austin-Travis County EMS
By Christopher Jennings
365 days a year, Austin’s EMS Community Health Paramedic team (CHP) receives a report with all the EMS calls from the previous day that might have been an opiate overdose, or someone with opioid use disorder (OUD).
“I was regularly seeing people overdose and die while they were waiting to get into a treatment program,” Blake Hardy, CHP commander, said. “Opiate withdrawal is just too miserable for people to tolerate for a week or two waiting to get into a program.”
Hardy said that he was hearing from CHP paramedic and opiate program case manager Mike Sasser and other team members that it was taking more than a week on average for someone to get started in a program once they decided they wanted help.
“That left them ‘using’ for another week or more, each time risking death,” Hardy said. “The final straw for me was when I responded to an overdose call and found that the person wasn’t overdosing. He was in withdrawal and wanted to stop using opiates. It was a perfect time for us to help, and yet all I could offer was symptom support and a seven-day wait to enter a program.”
MITIGATING WITHDRAWAL
“We tried to start an opioid program in the city,” Sasser said. “We were working with Health and Human Services from the state of Texas to try and get some grant funding to get started with, but we couldn't get the city and the state to agree for contract stuff. But we wanted to figure out how to do it anyway.”
Sasser said that, while self-referrals do happen, every day, CHP is notified by that log of EMS calls when somebody overdoses and then interacts with the 911 system. “We get that notification and then we go find that person,” he said. "It’s a pretty simple approach of just going to the scene of an overdose after somebody's been overdosed, and just asking if they're okay and what they might need to maybe not have this problem happen again, and, by and large, the answer to that question was medication like Suboxone, or buprenorphine.”
Buprenorphine kit. Courtesy of Austin-Travis County EMS
Sasser said that, while methadone is a full dopamine receptor agonist, buprenorphine is a partial receptor agonist. “It only halfway stimulates those same receptors,” he said. “And it doesn't really cause euphoria or excitement or any of that any of the other stuff. It basically just takes away withdrawal symptoms and makes people able to function and participate in their day.”
Sasser said that, unlike methadone, where daily dosage is required, buprenorphine only requires weekly doses at first, which makes case management and harm reduction easier until treatment programs become available.
“From a harm reduction standpoint, it protects against overdose, and that's why it's such a great medication,” he said. He estimates that more than 50 percent of the people he sees want to do a Suboxone program. (Suboxone combines buprenorphine and naloxone.)
Sasser said, after their initial struggle with funding, the team started an OUD follow-up program, but they were limited in what they could do since EMS-CHP does not dispense medication. Then the team read an article about Camden, New Jersey’s introduction of buprenorphine in the EMS system.
“We started asking, ‘why can't we do that?’” Sasser said.
“The Buprenorphine Bridge Program was designed and intended to directly address a gap in the OUD care system […] to fill that time gap,” Hardy said. They named it the Bridge Program because it is intended to be a bridge-like support for someone from the time they decide they want help until they can enter a medication-assisted treatment (MAT) program.
“What we are designed to do is fill a gap and deal with a situation that's in a crisis; opioid withdrawal is becoming more and more prevalent in society,” Sasser agreed. Far from getting smaller, he said, the opioid epidemic is “getting worse, and it's going to get even worse before it gets better.”
In coordination with the Office of the Chief Medical Officer (OCMO), CHP provided a description of intent to the DEA, with medical protocols written by the OCMO and department and Hardy writing department procedures and processes.
The DEA had no objections, as both chief deputy medical director Jason Pickett, who oversees EMS in Austin, and one of CHP’s P.A.s are X-Waivered, and thus versed in the processes and legalities of providing medication-assisted treatment.
Currently, the program is almost entirely funded within the CHP budget. “The only current assistance we receive is the naloxone for the Opioid Rescue Kits that we distribute,” Hardy said. “It comes from a state grant being managed by the UT-San Antonio School of Nursing.”
Hardy stressed, however, that the bridge program, which went live in November 2020, is not itself an MAT program. “Our goals include ‘carrying’ or treating a patient for no more than seven days to relieve their withdrawal and keep them out of withdrawal,” he said. “We can go above seven days as needed, and have on many occasions, but the seven-day goal keeps us intently focused on handing them off to a treatment program and keeps our activities separate from an MAT program.”
Courtesy of Austin-Travis County EMS
SETTING PARAMETERS, LEVERAGING RESOURCES
Sasser said that conversations between CHP and MAT programs have been crucial in getting the program to where it is.
“It’s important to really get a good understanding of what resources are already available in your community,” Sasser said. “It’s knowing what's already there and working with partnerships that you can build within your own community.”
Hardy said there is a short evaluation with prospective patients before treatment can begin. “The person must understand and agree to three things – 1) they have to be in withdrawal before we can start treatment. We don’t do lab values to check for opioids currently in their system, so we need to have them in withdrawal before we start. That also allows us to establish the right dosage. 2) They have to meet with us daily and take their medication in our presence. We aren’t a MAT program and don’t write prescriptions. 3) They have to remain active in attempting to get into an MAT program. We will pave the way, but the patient must remain cooperative since we are only a short-term bridge treatment,” he said.
“After that, we can begin treatment – it takes about 15-30 minutes typically to make the withdrawal symptoms go away,” Hardy said. “We work to establish funding if needed and connect the patient to an MAT program. We will meet them daily to administer a dose until they have their intake with MAT. Often, we will dose them the day of the intake if it is scheduled later in the day to prevent them from going into withdrawal during the long intake process. In the meantime, the CHP also works to make sure they have primary medical care, any specialty medical care, or mental health care that they need. Addressing all those needs helps to ensure their success.”
Hardy said that successful OUD treatment does not occur within a prescribed timeframe and that length of treatment varies with each individual.
“It is also clouded by the fact that relapse is an accepted risk and does not provide a good metric for success or failure,” Hardy said. “We know from studies than only a small percentage of patients seen in ERs for opiate overdoses are ever connected to treatment programs through the ER. It has also been shown in studies only treatment with buprenorphine or methadone was associated with a significantly reduced risk of overdose in the three and 12 months after beginning treatment. Since buprenorphine also blocks further opioid stimulation, every day we treat a patient, we know they aren’t going to overdose. Every time we successfully connect a patient to an MAT program, we know they’ve entered the pathway that is most likely to lead to success – MAT is recognized as the most successful approach to OUD care, resulting in as much as a 90-percent reduction in opiate use.”
As for Austin CHP, Hardy said that in the first 18 months of the program, they treated 154 unique individuals. Of the program’s total caseload – including repeat cases – 166, or 92 percent, successfully started in an MAT program.
“Patients in the BBP during that first 18 months received treatment a total of 639 days – so that is 639 days that the program effectively prevented an overdose,” Hardy said.
Hardy said that success is going to depend largely on meeting the patient’s needs. “We go to their home and start with a simple, ‘Are you ok? I’m just here to check on you’ and then tell them what we can offer and provide any information or education needed,” he said. “Many people have told us, ‘No one has ever checked to see if I’m ok.’ It's the non-judgmental demonstration of concern that breaks the initial barriers.”
He said that one of the reasons he believes the program has so much more success in connecting patients to MAT and them staying in it, is that for the first several days they are essentially receiving treatment and coaching where they live.
“A CHP paramedic meets with them every day, from the date of enrollment until after they begin in their MAT program. The paramedic provides their daily dose of buprenorphine and also helps coach them to be successful. That is a fundamental part of Community Health medicine, and likely a strong contributor to the success we’ve seen with our patients,” Hardy said. “And some people aren’t ready for help yet – that’s up to them. We will be here when they are.”
More information on buprenorphine treatment programs can be found at samhsa.gov.