The Washington PostDemocracy Dies in Darkness

ER outreach for opioid users works in many cities. In D.C., it’s off to a slow start.

Richard Davis was employed as an addiction counselor at Howard University Hospital from April through July. He and others say the District’s new program to treat people who have overdosed on opioids is not well run. (Salwan Georges/The Washington Post)
Placeholder while article actions load

Late last year, D.C. Mayor Muriel E. Bowser (D) announced a new program to combat an epidemic of fatal opioid overdoses burning through the nation’s capital.

Modeled on successful programs across the country, the initiative aimed to reach drug users where they can regularly be found: in hospital emergency rooms. Teams of outreach workers and doctors would offer a medication that diminishes opioid cravings, followed by speedy referrals to long-term treatment centers.

Bowser announced the District’s emergency room buprenorphine program in December 2018 as part of a battery of new strategies to reduce drug deaths. The number of fatal opioid overdoses in Washington more than tripled between 2014 and 2017, causing the city’s worst public-health crisis since the arrival of AIDS.

Many of those victims have been older African American men who have used heroin for decades but were dying from street drugs laced with the powerful synthetic opioid fentanyl.

The federally funded program, initially launched at three hospitals, was a cornerstone of Bowser’s plan for an invigorated response to drug deaths that had festered for years without an aggressive response from the District government. The plan was announced in the wake of a two-part series published by the Post in December that examined the city’s faltering response to the local opioid epidemic.

But the initiative is off to a slow start.

Since it began operating in late April, the city’s program — run through a contract with the D.C. Hospital Association worth nearly $2.9 million over two years — connected only a small number of patients with treatment, according to records and interviews with District officials, treatment providers and outreach workers.

During the program’s first four months, fewer than 30 patients began treatment in the emergency room with the addiction medicine buprenorphine, and just 19 of them continued treatment outside the hospital, according to city data. Over the same period, nearly 600 opioid users were taken by ambulance to hospitals participating in the program, according to D.C. Fire and EMS data.

Officials with the hospital association and the Mosaic Group, a consulting firm hired to design and help manage the program, defended the initiative, saying it would take time to yield more robust results.

Gayle Hurt, the association’s assistant vice president for patient safety and quality operations, noted that the program has also referred hundreds of patients for various kinds of substance abuse treatment outside the hospitals, although most of those referrals did not lead to follow-up appointments.

“It’s a new initiative,” Hurt said. “It’s sort of to be expected that not everything is going to be perfect.”

But community treatment providers, as well as some counselors who performed outreach to drug users through the program, said the rollout has been rocky.

“It’s been slow and hasn’t delivered much at this point in terms of having connected patients with care, that I’ve seen,” said Dr. Andrew Robie, who oversees medication-assisted treatment at Unity Health Care, one of the District’s largest providers of addiction treatment for opioid users. “I think they’re working through the issues and making an effort to improve it and soliciting feedback. But it seems a little bit like some of the plans could have been in place before the program was launched.”

Unity clinics did not see a single patient referred from the program through late August, four months after its launch, Robie said. Since then, three or four patients have been referred, he said.

The program has also had trouble tracking patient outcomes. In response to questions from The Post, the hospital association acknowledged that it had reported incorrect figures on the program’s early performance to the city, erroneously claiming that counselors had linked more patients to long-term treatment than they actually had.

Mosaic Group president Marla Oros said documentation errors by drug counselors at the hospitals had led to reporting errors.

“It is not uncommon in the first several months of reporting for Mosaic to have to circle back to our hospital partners and look deeper into the data to determine if the documentation and the reports from the electronic health records are all working as planned,” Oros wrote in an email.

Hospital association spokeswoman Jennifer Hirt said “a corrective action plan is being implemented in order to get accurate data.” D.C. Department of Behavioral Health officials also said they are working with the hospital association to improve data collection.

Department director Barbara Bazron said she when she was a Maryland public health official, Mosaic Group had successfully launched similar programs in that state. She said she was confident the District’s program would deliver better results, given more time.

Falling Out: Inside the unseen opioid epidemic killing African Americans

“This is early in the life span of this particular program,” she said. “I can tell you from the Maryland results these efforts have been extremely, extremely successful... I look forward to seeing the same thing happen here within the District of Columbia.”

She added, “As you’re breaking new ground, you’ve got to get the bugs out.”

City officials have awarded an additional $770,000 grant to the hospital association to monitor and follow up with opioid users after they leave the emergency room.

Like its counterparts elsewhere in the country, the city’s emergency room outreach and treatment initiative grew out of a 2015 study at Yale-New Haven Hospital. Researchers there found that opioid users who began treatment during visits to the emergency room with buprenorphine — an opioid medication that sates users’ cravings without creating extreme intoxication or other downsides of street drugs — often have more success in recovery.

The results inspired hospitals across the country to launch outreach programs based in their emergency departments. While the initial doses of buprenorphine are important, a reliable pipeline from the hospital to ongoing treatment is as crucial, experts said.

Without that connection, patients addicted to opioids run an immediate risk of relapse once they leave the hospital.

“It would be like starting a patient on insulin and sending them out the door hoping they can find a provider to refill it when they run out,” said Dr. Ali Raja, who oversees the buprenorphine program at Massachusetts General Hospital in Boston.

Earlier this year, following The Post’s series, the Bowser administration launched multiple anti-opioid initiatives, including a dramatic expansion in the city’s distribution of the overdose antidote naloxone.

The emergency department outreach program began at United Medical Center, MedStar Washington Hospital Center and Howard University Hospital, all of which have seen high numbers of overdose victims.

Yet key components of the initiative were not in place when it launched, according to some of the drug counselors who were hired to help emergency room patients.

Richard Davis, an addiction counselor who was employed at Howard from April through July, said the emergency department was not staffed around the clock with outreach workers, as he had been told it would be during his training. During gaps in the overnight shift, drug users who showed up would not be able to receive counseling services, he said.

D.C. responded slowly as opioid overdoses exploded in black neighborhoods

Michelle Jackson, a counselor who worked at United Medical Center through August, said she had trouble arranging follow-up appointments with community providers so that patients could continue treatment outside the hospital.

“There’s no follow through,” Jackson said. “That fast track that we were believing that we were launching — that these providers in the community were already on standby waiting for these referrals — we’ve learned that... most of them are not really quite ready.”

Jessie Gambrell, a counselor in the program who has worked at Howard University Hospital since mid-August, offered a different perspective. She said the program appears to be well run and that doctors and nurses in the emergency room had welcomed the initiative, “really seeming like they want to make it happen.”

Gambrell, herself a recovering opiate user, said the program is “meeting a need that was missing” by deploying counselors who in many cases have shared the experience of addiction. The small number of patients who have entered treatment, she said, could stem from the fact that many of those seen in the emergency room aren’t prepared to stop using, even when offered buprenorphine.

“There have been multiple ones that just aren’t ready for treatment,” she said.

Some treatment providers, for their part, said they have been puzzled that more patients have not flowed to them from the initiative.

At the end of August, The Post surveyed each of the seven treatment providers listed in the directory provided to hospital counselors. Combined, they estimated that they had seen fewer than a dozen patients.

David Sternberg, clinical services manager at the nonprofit Helping Individual Prostitutes Survive — one of the District’s oldest and most prominent providers of services to drug users — said his group’s medication-assisted treatment clinic has not seen a single patient referred from participating hospitals.

“It’s pretty well known among community providers that the program is a joke,” Sternberg said.

Mosaic and the hospital association have not tracked how many patients at the participating hospitals have screened positive for opioid use and potential treatment with buprenorphine, making it difficult to gauge the initiative’s success.

Nearly 4,000 patients were identified as having some kind of substance use disorder over the first four months of the program. But opioid users were not tracked separately, Hirt said.

Department of Behavioral Health Chief of Staff Phyllis Jones said the program will seek to report opioid patient numbers “to better measure how emergency room screenings are helping to reach those most affected by the District’s opioid epidemic.”

One measure of the number of opioid users streaming into emergency rooms comes from the Fire and Emergency Medical Services data, which show that 593 people identified as opioid users were taken by ambulance to Howard, Washington Hospital and United Medical Center during May, June, July and August.

The pool of potential patients who could benefit from the program will soon expand.

In the coming months, the program will expand to George Washington University Hospital, MedStar Georgetown University Hospital and Sibley Memorial Hospital, according to officials from the D.C. Department of Behavioral Health.

Davis, like Jackson, said he resigned from his job as a counselor out of frustration at how the program was being run. But he hopes improvements will result in more people getting help.

“This is early, you know?” Davis said. “They can turn it around.”

Months after mayor’s plan, key D.C. opioid initiatives still in planning stages

D.C. police officers to carry naloxone

Dozens criticize District’s opioid response at public hearing

Local newsletters: Local headlines (8 a.m.) | Afternoon Buzz (4 p.m.)

Like PostLocal on Facebook | Follow @postlocal on Twitter | Latest local news