The fear was that it was futile. Emergency responders would deliver naloxone in the field, bring heroin users back from the brink of death, take them to a hospital for a quick check, and a few hours later, the patient would head back to the life that had brought them there in the first place.
As the number of naloxone doses administered each year soared, Eskenazi Health emergency room doctors felt compelled to respond. Last year they started a pilot program with a $20,000 grant from Drug Free Marion County to have trained staff approach every overdose patient to talk about recovery options.
Now, thanks to a two-year, $700,000 grant from the Richard M. Fairbanks Foundation, the program is expanding its scope. The money will allow the program to hire peer recovery coaches to provide one-on-one mentoring and will pay for rapid hepatitis C testing.
That, in turn, could open the door to another way to protect the health of intravenous drug users in Marion County: the eventual adoption of a needle exchange program that would aim to reduce the spread of HIV and hepatitis C.
More immediately, however, the program focuses on reaching drug users at a time they are most vulnerable — right after their habit has almost cost them their lives.
The past decade has seen an unprecedented epidemic of opioid abuse, from misuse of potent prescription painkillers to more recently heroin injection. With that, overdose deaths have climbed steadily. From 2004 to 2014, the number of overdose deaths nationally nearly tripled.
Indianapolis paramedics have seen the trend firsthand. In 2012, paramedics delivered 550 doses of naloxone. By 2015, that number had climbed to 1,225. In 2016, Indianapolis EMS expected to deliver more than 2,000 doses of naloxone to patients. Of those, about 700 were then transported to Eskenazi.
Paramedics or police who revive a person with naloxone must take him or her to the hospital to be observed for a few hours.
Before Project Point, “basically nothing” would happen in that time, said Dr. Krista Brucker, one of the founders of Project Point and an emergency medicine physician at Eskenazi. “They don’t need much in the way of acute medical treatment if they’re stable and awake and talking to you. … The question comes in what have we really done to intervene in the long term in the course of the disease.”
Contrast that with the experience of a heart attack patient. He or she would be sent home with medicines and a ream of information about how to prevent recurrence.
Now, those heroin patients will receive counseling, which could include a rehabilitation appointment, hepatitis C testing and a naloxone kit. Previously, emergency department staff would give them a prescription for the potentially life-saving drug, but doctors found that few people filled them.
“We’re now treating a heroin patient in the emergency department much as we would treat a heart attack or stroke patient,” said Dr. Charles Miramonti, medical director for emergency medicine at Eskenazi and Indianapolis EMS chief. “We try to route them to the best resources as soon as possible.”
The Fairbanks Foundation recently announced its intention to focus on opioid and tobacco addiction. When foundation staffers heard about Project Point, they said they would be willing to provide money to help improve the program.
The Fairbanks money will also pave the way for Project Point to take a rigorous look at how successful it has been, said Claire Fiddian-Green, Fairbanks president and chief executive officer.
“We are hopeful that this project will have even greater results than it initially had,” she said.
The program has reached about 90 patients since it began in early February 2016. Determining how many remain in treatment is difficult, Brucker said. Even if only 10 percent of those contacted remain in treatment after a year, that would count as success.
One of the broadest-reaching impacts of Project Point could be the rapid hepatitis C testing it will offer, not just to drug users but to others whom the Centers for Disease Control and Prevention considers at elevated risk for the disease, including baby boomers. Before a county can institute a needle exchange program, state law dictates it must demonstrate a public health emergency exists. A high hepatitis C rate attests to that.
In 2015, Marion County’s hepatitis C rate was not among the highest in the state, according to data compiled by Indiana University’s Rural Center for AIDS/STD Prevention. Brucker thinks the data is incomplete.
“Right now because we’re not testing our high-risk patients, I think there’s a lot more hepatitis C than we know,” said Brucker, an assistant professor of clinical emergency medicine at the Indiana University School of Medicine.
Overdose death numbers also continue to climb and paramedics and police are frustrated, saying they keep seeing the same faces over and over again. Brucker estimates that as many as 20 percent of the people who overdose are repeats.
Project Point aims to end that cycle. When a person receives a naloxone dose in the field, an alert goes out. Once the patient is awake, one of six people on the staff will talk with him or her.
“Our hypothesis was this was an intervenable moment, so that people right after an overdose who yesterday might not have been interested in treatment are interested in it,” Brucker said.
Encounters range from 10 minutes to an hour. For those who want help, the next challenge becomes finding an appointment for rehab — whether a bed at an inpatient facility or an appointment at Midtown Community Mental Health.
Often a wait exists until a patient can enter rehab and during that period many people will revert to using, Miramonti said. Project Point counselors try to ensure that the person can start in treatment as soon as possible.
“That’s where Project Point really has the potential to blow that space up and to route these folks much faster and to flag them much better than we have in the past,” he said.
A new partnership between a company called OpenBeds and the Mesh Coalition, a local public health entity, could make that an easier job. The two will create an online system that rehabilitation professionals can use to immediately find available resources.
Multiple challenges still exist. For starters, addiction treatment resources in Indiana are limited, all agree. Nor is quitting heroin simple; most people enter rehab multiple times before they stop using for good.
Once a patient agrees to enter treatment, other obstacles often arise, said Jennifer Dutton, a social worker with Project Point. Many lack insurance or don’t have transportation to get to treatment. Others lack access to food or shelter.
Many of these patients lack a working telephone or have a number that changes every few days, said Melissa Reyes, a Midtown care coordinator who has been working with Project Point.
“They are wanting and willing to change, but they have so many different hoops to jump through, at some point they may get overwhelmed and exhausted and feel that this isn’t worth it,” she said.
But if they have the slightest inclination to try to get clean, Project Point staff want to be there to help and to find a way to make a difference even in a community that has limited resources.
“Building a model that works in places that don’t have tons of suboxone clinics and addiction psychiatrists is the real value and novelty about what we’re doing,” Brucker said. “Some days I feel like I don’t know why I do this because it just feels so overwhelming, but then I can point to five or six people who are on treatment who I really think probably wouldn’t have been without us.”