By Taylor Knopf
It wasn’t enough that Gina Musa was brought back to life with naloxone again and again.
She continued to use heroin, sell her body, and live on the streets.
It wasn’t until about two years ago, when someone brought her to a detox center in Raleigh, that Musa said her “soul was broken” and she was ready to get help.
Now she’s one of two people on a newly formed rapid response team in Wake County that works with county emergency medical services to provide peer support to people who overdose and are revived with the opioid reversal drug naloxone but decline further medical treatment.
Despite the use and availability of naloxone, the number of opioid overdose deaths and emergency department visits continues to rise.
A recent, and somewhat controversial, study called “The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime” proposes that naloxone may have provided a safety net for more risky opioid use and doesn’t treat the root problem of addiction. The study authors concluded that in order for naloxone to be an effective tool in the fight against opioid addiction, it must be paired with treatment and recovery services.
Members of the Wake County Drug Overdose Prevention Coalition, which formed in the fall of 2015, also saw the imperative to connect people to services after an overdose reversal.
Link to services
“We knew we were losing people often on that second or third overdose,” said Sue Lynn Ledford, director of public health for Wake County Human Services.
At the emergency departments in Wake, there are peer support specialists helping those who recently overdosed find treatment. For those who are brought back from an overdose by EMS in the community and subsequently refuse to go to the ED, there’s no one.
Ledford said if you connect with someone and help meet their basic needs, such as food or shelter, then they might start considering recovery treatment.
“You create a vision in that person’s head that they can get better,” Ledford said. “It’s a continuum of linking. It’s not ‘one and done.’ It’s a process.”
The coalition developed a plan to hire two people who had histories of opioid use and naloxone reversals to go out with EMS personnel to meet with people 24 hours after their overdose reversal.
The county commissioners approved the funding, and Healing Transitions (a recovery facility in Raleigh) received the contract to manage the rapid response peer support program.
Musa and her colleague Rusty Kiley both graduated from Healing Transitions programs. They were hired in January, went through training, and began making connections with people in late March.
During the first month of the program, they reached out to 33 people and linked 19 to some type of service, including substance abuse treatment and harm reduction programs.
Different approach for EMS
The role emergency responders take in the opioid crisis has shifted over time. Traditionally,
EMS responds to any call involving an overdose. A few years ago, that response would always include law enforcement, said Benji Currie, Wake County EMS district chief.
EMS would treat the person and take them to the hospital. There, they would then have to deal with the law enforcement consequences of their drug use.
Colin Miller from the North Carolina Harm Reduction Coalition demonstrates how to use naloxone. Video credit: Taylor Knopf
Users frequently ended up entangled in the judicial system, Currie explained. Prior to the Good Samaritan law of 2013, these patients could, and often would, receive some sort of charge for possessing drug paraphernalia.
Currie said new evidence emerged a few years ago that a patient may not need to go to the hospital for an evaluation after an overdose reversal, so EMS workers stopped taking them.
“We would always encourage them to get treatment, but they can elect not to do that,” he said.
Then last year, EMS also began distributing naloxone after an overdose reversal, but there was always concern for those folks who chose not to seek further treatment.
Now, EMS in Wake County is taking a new approach with the rapid response peer support team.
Currie said this 24-hour later follow-up with peer support specialist is the first program of its kind in the country.
“The most vulnerable population is that which gets Narcan (a brand of naloxone) in the community but doesn’t go to the hospital,” he said. “They are not getting any type of resources at all. So that’s where we started.”
Every morning, EMS staff use software that identifies people who were treated with naloxone the day before but didn’t go to the hospital. The names and phone numbers are shared with Musa and Kiley who often reach out over text. The two also go out with EMS to the patient’s residence to make that first in-person connection.
“EMS serves as the vessel to find the population and get the folks who are trained to deal with the peer support,” Currie said.
Building relationships
Musa and Kiley often start building relationships with people through text messaging. The goal is to build trust. After that, they work with the person to meet their needs and find out what kind of services they would like.
Intervening right after an overdose can be difficult because people are not always thinking clearly, Musa said. But 24 hours later is a good call.
“Some people… that will be their breaking point,” she said. “There will be people who say, ‘I don’t want to do this again. I was almost dead.’”
Musa said her phone lights up all day and night with messages from between eight and 15 people who need her. Some days, Musa said she would like to throw her phone in the ocean because she never stops working.
The Wake coalition applied for money to expand the program through some new state-funded grants made available to fight the opioid epidemic in communities.
“We see what they’re willing to do and try to link them to those services,” she said. “Then when there’s some level of stabilization, you have to be able to hand them off. All in that time, you have to build trust. I have to let them tell me what’s going to work and hopefully they will attempt something.”
Kiley echoed that sentiment, saying he always assures people he’s not there to tell them what to do.
“That never works and puts people on guard,” he said. “I’m in recovery, and I was homeless. When people told me what to do, I shut down.”
“Some people feel so lonely. They can’t trust anybody and they’re actively using to the point where they ran their friends and family away,” Kiley said. “It’s important to have someone there who is understanding, compassionate and not judgmental.”
‘The potential of people’
Musa said she often ends up being a listening ear. She’s currently building a relationship with a couple who are living in a tent off Capital Boulevard and using heroin and meth.
When they use, Musa said most of their conversation makes no sense. But she just listens. And one day, the woman said, “Thank you for advocating for me.”
“I believe in the potential of people,” Musa said. “I know because of what I’ve been through. And it doesn’t look the same for everyone.”
These are very personal issues for Musa. “I’m really big on trying to build the core of the person up,” said Musa, adding that sex workers and drug users typically have a lot of fear and self-esteem issues.
“I remember being out there and thinking, ‘How the hell am I going to get out of this?’” she said.
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