In April, at the height of the coronavirus pandemic in Rhode Island, emergency physician Elizabeth Samuels was driving past Kennedy Plaza on an errand and saw a small crowd forming around a man lying in the street next to a puddle of what appeared to be vomit.
When Samuels pulled her car over to investigate, she saw that the man was blue, and barely breathing if at all. She knew one thing for sure: he had overdosed.
Samuels administered a dose of naloxone given to her by a police officer who was already on the scene, checked in on the man and tried to calm those who were watching. The dose was the man’s second; his girlfriend had already given him naloxone.
“He started to pink up, become a little less blue,” Samuels recalls, a sign that the naloxone was working, and soon an ambulance arrived to take him to the hospital.
While Samuels, a Lifespan doctor, is accustomed to using naloxone in the emergency room, she said, “I don’t normally do it on the way to Petco.”
Still, Samuels is no stranger to fighting the opioid crisis during her free time, especially since March. In addition to her long hours in the emergency room, she is the consulting assistant medical director for the state Department of Health’s Overdose Prevention Program, and as such, has been figuring out ways to sustain opioid addiction treatment during the pandemic.
The state has seen a spike in drug overdose deaths: an anticipated 22% increase in the first quarter of this year compared with the same period last year, The Journal has previously reported.
In the last few months, hiring freezes, the Rhode Island Department of Health’s all-hands-on-deck pandemic response and social distancing have stymied some of the state’s overdose-prevention efforts. In-person appointments have been swapped for telehealth measures. Even people who should see a physician have avoided emergency rooms and doctors’ offices since March.
All these factors have probably prevented some individuals with opioid use disorder from accessing care.
So to get around some of these barriers, Samuels and Rachel Wightman, another Lifespan emergency-department doctor, worked with a group of medical professionals to come up with an idea: a 24/7 hotline that could provide short-term buprenorphine prescriptions to patients living in Rhode Island with opioid use disorder.
Buprenorphine is an evidence-based treatment that can be used to stop opioid withdrawal symptoms and prevent patients from using and overdosing on other, more potent opioids, Samuels said.
Samuels and Wightman saw the opportunity to set up the hotline when the Substance Abuse and Mental Health Services Administration loosened its buprenorphine restrictions in response to the pandemic and allowed medical professionals to prescribe the drug without an in-person visit.
Samuels and Wightman had seen programs in other states, including Massachusetts, New York, Pennsylvania and California, use telehealth appointments to prescribe buprenorphine, but not all the programs were formatted clearly as hotlines. Samuels said the program here will coordinate and share data with the other states so that they can look into the programs’ effectiveness.
The hotline is a “telebridge clinic” — giving patients access over the phone to temporary help, which hopefully prevents overdose and leads to longer term treatment and recovery. As long as a patient lives in Rhode Island and doesn’t already have a prescription for buprenorphine or methadone, another medical assisted treatment, they are eligible to call the hotline and work with a medical professional to determine if a buprenorphine prescription is right for them.
The prescriptions are only for one or two weeks’ worth of medication, enough to get a patient to a follow-up appointment, Samuels said.
The hotline is supported with SAMHSA funding administered through the state departments of Health and Behavioral Health, Developmental Disabilities and Hospitals, and a phone call to the hotline is free. While the buprenorphine prescription is not covered by either department, Samuels noted that coupons and insurance can help patients pay.
The hotline has six health-care providers, including Samuels and Wightman, who take calls during their free time in 12-hour shifts as they come in through the Lifespan call center.
Samuels said they have also started to call potential patients, following up with individuals who have come into the emergency room for overdoses to see if buprenorphine might be a good fit for them. As of June 12, Samuels said they have been able to prescribe buprenorphine to 20 patients through the hotline and call-back program.
While the hotline is a circuit around the barriers created by the novel coronavirus pandemic, it is also breaking down the barriers that patients with opioid use disorder usually face within the health-care system.
On the phone with patients, Wightman has heard from some who are using the hotline because their access to care has been limited by COVID-19, while others are reaching out because they’ve always lacked the transportation to in-person appointments. The 24/7 aspect of the hotline has also helped individuals whose schedules don’t accommodate appointments during regular working hours.
Some patients have taken buprenorphine or received some sort of treatment for opioid use before, but “their care had fallen through,” Wightman said.
Wightman has also been working on the hotline when she isn’t in the emergency room. As a mother of two boys, 3 and 5 years old, some of her free time during the pandemic has consisted of making them chicken noodle soup and taking care of them, and also fielding phone calls from hotline patients.
Many of the callers have been experiencing withdrawal symptoms but who are still very happy to have access to care, she said in a May interview.
When Wightman sees patients with acute opioid use withdrawal symptoms in the emergency department, they are usually in extreme discomfort.
Profuse sweating, severe body aches and nausea are common symptoms. Patients are sometimes vomiting or experiencing diarrhea in the ER. Often, patients with these symptoms don’t want to hear about recovery treatment, Wightman said. They just want to feel better and go home.
With fewer emergency room visits overall, and fewer patients coming to the ER for opioid overdoses or withdrawal symptoms. Wightman now hears about the symptoms over the phone rather than seeing them for herself.
She tries to empathize with the patients and their pain while asking as many questions as she can to get a full picture of what’s going on.
Although body language is important in gauging a patient’s needs, Wightman said that a patient’s ability to call for treatment on their own terms has had an unintended benefit.
At times in the emergency room, Wightman finds it difficult to get patients to discuss further treatment beyond the overdose or withdrawal treatment they’ve come in for. But on the phone, Wightman said, some of the anxiety and even the stigma of addiction goes away.
She said the patients she’s spoken to have been more honest about their use and seem more trusting in the patient-provider relationship. “It really helps when patients open up, because it can help us troubleshoot going forward” in the treatment process, she said.
When a patient calls the hotline, they “get to have a one-on-one conversation without going through other people’s either perceived or real judgment,” says Laureen Berkowitz, a physician assistant who has been volunteering for the hotline.
As a PA with her own practice, Berkowitz said that the typical in-person process for prescribing buprenorphine can be harrowing for patients.
Throughout the process of getting to and arriving at an appointment, before they get into an examination room or meet their doctor, a patient has to disclose sensitive and personal information about themselves and their addiction, Berkowitz said.
“You haven’t even met the provider yet,” who will ultimately write the prescription, she said, “and you have to bare your soul.”
But that dynamic of administrative headache and uncomfortable disclosure is completely changed by the program.
“If you call the hotline,” Berkowitz said, “we know the reason why you are calling the hotline — no ifs, ands, or buts about it,” which can get a patient over the initial addiction disclosure barrier.
Although talking on the phone might be easier than speaking in person with a provider, Berkowitz acknowledged it’s still difficult. When she speaks on the phone with hotline patients, she says, the first thing she does is congratulate them for making the call.
“I congratulate them, and I thank them, validate their efforts for calling,” she said, “acknowledge the fact that for them to make this phone call took a lot of effort.”
Through her career of nearly 30 years, working through the AIDS epidemic, opioid epidemic and now novel coronavirus pandemic, Berkowitz has learned how hard it can be for patients to access care.
Berkowitz started her career in the ’90s, in Washington, D.C., diagnosing and treating patients with HIV and AIDS.
Just as Wightman and Samuels have gotten creative with their care through the coronavirus crisis, Berkowitz had to think outside the box decades ago to get her patients the treatment they needed.
In the mid-’90s, Berkowitz got the funding to buy and renovate a 36-foot RV, which she turned into a mobile health unit.
At the time, there was no rapid HIV testing, so driving through D.C.’s streets, Berkowitz would pull the van over and perform blood draws on the sidewalk, in the street, “wherever we could do it.”
When the test results started coming back positive, and Berkowitz realized there was a high prevalence of the disease, she started to wonder how they could reduce the spread among a community that often used drugs, like heroin, intravenously. So, she created an early needle-exchange program.
She still had to be creative to disprove detractors who claimed the exchange would increase the amount of used hypodermic-needle litter. Labeling each and every one she distributed (at that point in the AIDS epidemic, her program was distributing 1,000 needles every day), Berkowitz was able to prove that 90% of the needles given out were returned to the program after they were used.
With her history of ingenuitive treatment, when Berkowitz heard about Lifespan’s Buprenorphine 24/7 hotline from a colleague, she said to herself “it’s been a long time coming,” and signed up to help.
Like Samuels and Wightman, Berkowitz is volunteering her time to work the hotline and takes shifts in between working in Lifespan’s infectious disease division and running her practice, which already holds untraditional office hours on the weekends and after the workday ends.
Berkowitz has been tapped by the hotline only twice, she said, but both patients were prescribed buprenorphine.
Berkowitz, Wightman and Samuels all said that talking to the patients has been rewarding, with Samuels calling the hotline conversations some of the “most gratifying patient experiences” she’s ever had.
The SAMHSA grant will cover the administrative costs of the hotline until August 2021, but all three hope that the program can continue beyond the coronavirus crisis.
“A lot of the patients reported that if they hadn’t been able to speak with us at that time, on their schedule … they would have gone out to use,” Wightman said.
Others agree. On Wednesday, Sen. Sheldon Whitehouse, D-R.I., introduced a bipartisan bill that would make over-the-phone prescription waivers permanent, allowing programs like the hotline to continue beyond the current public health crisis.
And that outcome is something they are all willing to give up a little free time for.
If you are looking to start buprenorphine treatment for opioid use disorder, call Lifespan’s free, 24/7 Buprenorphine hotline at 401-606-5456.