Despite this progress, Calvert County is
eighth in the state for opioid deaths as a
percent of the population. According to
the Calvert County Health Department,
every 11 days there is an overdose
death in our community. In 2019, the
average age of those who died was 34 and
it is believed half of those who died had
children at home.
“We quickly realized that in order to
tackle the problem in a comprehensive
way, we needed all stakeholders to be
involved,” said Dr. Stephanie Dabulis,
Chair Department of Emergency Medicine.
“We can get blinded by statistics,
but this is a human story, not just a
human health crisis,” said Dr. Drew
Fuller, former assistant director of
CalvertHealth’s Emergency Department
(ED). “We need all-hands-on-deck and we
need transformational approaches.”
After working on the CalvertHealth task
force, Dr. Fuller transitioned to the Calvert
County Health Department as medical
director for the Mobile Crisis Team, which
consists of a physician/nurse practitioner,
a nurse, a licensed counselor and a peer
counselor. Working with the hospital and
first responders, the team engages persons
with opioid crisis throughout the county.
Emerging Problem Identified
“We were seeing a dramatic increase
in overdose-related deaths and injuries
as well as narcotic-dependent behavior
in patients that were coming into the
ED and community practices,” said
Dr. Fuller.
“We didn’t know how to start the
discussion or who should be involved, but
we knew, as a community hospital, we
had to do something about the overdose
deaths,” said CalvertHealth Pharmacy
Director, Kara Harrer, PharmD.
What evolved from that first meeting
in 2015 was the Opioid Stewardship Task
Force encompassing a multidisciplinary
committee from CHMC as well as
representatives from the Calvert County
Health Department.
Setting Goals and Protocols
The task force set goals in 2016 to
formalize opioid prescribing policy and
guidelines, promote alternatives to
opioids, work to become a ‘Dilaudid®-
free ED,’ track and report prescribing
practices, and develop a referral network
for persons with opioid misuse disorder.
When used appropriately, opioids
provide pain relief by altering the way
normal healthy nerves process pain.
Unfortunately, opioids change the
chemistry of the brain and lead to drug
tolerance. If used for an extended period
of time, opioids produce dependence
such that when people stop taking them,
they have physical and psychological
symptoms of withdrawal.
“The great majority of people who
develop an opioid addiction start with
pills,” according to Dr. Fuller. “We felt
it was our duty to make sure we were
using the best evidence-based practices
for prescribing opioids and that we
had the highest level of accountability,
which is why we adopted protocols and
committed ourselves to measurement
and to transparency.”
“If we can avoid the possibility of
patients becoming dependent on opioids,
then we will see a decrease in the
misuse of opioids, fewer overdoses and
deaths,” said Dr. Harrer.
The Opioid Stewardship Task Force is a multidisciplinary committee with representatives from
CHMC, the Calvert County Health Department and the Calvert County Sheriff’s Office.
Reducing Opioids in the ED
When the task force looked at data from
the first year, they realized their plan
to address the over-use of opioids was
working -- and continues to work. By
educating doctors and nurses on pain
management alternatives, the ED has:
- Reduced intravenous Dilaudid®
orders by 94 percent
- Decreased the number of
prescriptions written for controlled
substances by 95 percent
- Decreased the number of opioid
prescribing exceeding three days by
95 percent
“When people come to the ER in severe
pain – of course our doctors and nurses
work to get their pain under control as
quickly and safely as possible and that
may be through use of opioids,” said.
Dr. Dabulis. “If a patient needs
continued access to pain relief while at
home, we try to limit doses for just the
period of time until they can get in to see
their doctor or specialist.”
Addressing Patients Who Are
Opioid Dependent
Equally important to reducing
opioids prescribed by physicians, the
Stewardship Team looked at protocols
to address patients who arrived in
the ED or other CalvertHealth System
locations with an opioid dependence.
According to Dr. Dabulis, the
Stewardship Team worked to lay
the infrastructure for trying to help substance abuse patients before they were
discharged.
“That infrastructure includes
education, empathy, NARCAN® kits, peer
counselors and getting them set up with
the health department that day or the next
day,” Dr. Dabulis said.
Unlike a patient who is treated in the
ED and told to follow up with their primary
care physician within 10 days, opioiddependent
patients don’t have 10 days to
wait for follow-up treatment. There is a near
100-percent certainty that if these patients
are not in treatment within 24 hours, they
will use again, according to Dr. Fuller.
From Emergency Response to
Treatment to Recovery
The Task Force developed protocols in
line with the Substance Abuse and Mental
Health Sciences Administration (SAMHSA)
of the National Institutes of Health.
“It has been shown that if someone in
crisis gets a dose of a medication-assisted
treatment (MAT) in the ED, meets with a
peer counselor and is linked up with a MAT
provider such as the health department,
they are twice as likely to follow up and
stay in a recovery program,” said Dr. Fuller.
“A peer counselor is not some
judgmental person coming in to fix
someone, and is not even a social worker.
He or she is someone who has been down
the same road, and has been through
multiple treatment facilities – sometimes
multiple treatment options – until they
have been successful in overcoming opioid
addiction, and now, they want to help others
understand treatment options so they can
be successful, too,” said Dr. Dabulis.
Peer counselors can usually get to the
ED in less than an hour but patients have to want to see a counselor. According to
Dr. Harrer, the percentage of patients
who accept being seen by a peer
counselor has risen, and this is great
news because it shows that patients
want help before they are discharged,
she said.
MAT is shown to decrease deaths
by 80 percent and the Calvert County
Health Department has tripled its
capacity in the last two years to take
care of MAT patients.
“There is close collaboration
between the health department and
ED. We can see people the same
day in the health department or
the following morning seven days a
week,” said Dr. Fuller.
Continued Education and
Outreach
One of the initial goals of the
Stewardship Team was to serve as
a resource -- locally, statewide and
nationally – by engaging in outreach
and education opportunities. To that
end, education initiatives started
within the Emergency Department
will continue and will expand to all
areas of the CalvertHealth System,
and to local physician and dental
practices. A sheriff’s department
representative has been added to the
task force to provide input on trends
and what law enforcement is seeing
outside of the county.
“All of these efforts are to
continue the robust collaboration we
started in Calvert County and show
how the successes we’ve had can be
possible throughout the state and the
nation,” said Dr. Harrer.