Preventing Death and Supporting Recovery, with Ray Antonacci and Sarah Czarnecki

Organizations and resources mentioned in this episode:

• Rural Communities Opioid Response Program (RCORP)
• Lincoln County Ambulance District
• Lincoln County Sheriff’s Office Jail
• Clinical Opioid Withdrawal Scale (COWS)
• PreventEd
• Community Paramedicine
• Missouri Opioid Settlements

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved.

Today we're going to be talking about an initiative providing buprenorphine to individuals experiencing opioid withdrawal symptoms at the Lincoln County Sheriff's Office Jail in Troy, Missouri. It began specifically as an overdose prevention effort and has developed into a medication-assisted treatment [MAT] program helping folks on the path to recovery.

Joining me is Lincoln County Ambulance District Chief Ray Antonacci and Battalion Chief Sarah Czarnecki. Thank you both for joining us today.

Ray Antonacci: Thanks for having us.

Sarah Czarnecki: Yeah, thank you for having us.

Andrew Nelson: To provide a little context here, can you walk us through how the idea of bringing buprenorphine treatment into the Lincoln County Jail first emerged?

Ray Antonacci: Yeah, I can kick that off. So, we were grant-funded by the HRSA RCORP grant to give buprenorphine in the field, and we did Narcan wake-ups. And we just were not seeing the calls of Narcan wake-ups that we had seen in years past. So, in a one-year grant, we really knew that we needed to gather up more data than we were getting. One day I was having a conversation with the sheriff and it was just a casual conversation, and he was mentioning that he wanted to have zero deaths from overdose in his jail. And he started telling me about the problems with fentanyl being smuggled into the jail. So, I proposed us coming in, and using buprenorphine to help inmates that were going through withdrawal.

Sarah Czarnecki: We spent years responding to overdose after overdose after overdose, administering Narcan every single time. And that was our original plan. But we had to pivot, and we found the population we were looking to work with in the jail setting.

Buprenorphine has a higher affinity to that opioid receptor than fentanyl or any other opioids. So, I know that if I've administered someone that medication in the jail, at least for the next 6, 8, 12 hours, even if they do try to use, it's not going to work. If they try to use some random opioid from someone, it's a good safety net. It doesn't work as a blocker, but it works like ice in a cup as opposed to water in a cup. It fills that cup up just like water would, but it leaves holes. So, it has that ceiling, that partial agonist, and it has that higher affinity. So, what a great medication to be able to utilize in that overdose prevention space.

Andrew Nelson: You said that the sheriff reached out to you, correct?

Ray Antonacci: It was more like a casual conversation, really. We're friendly. We see each other at Rotary meetings and community meetings like that. So, this grew from a friendly conversation of, "What's going on in your world?" And we knew that there was a recent death in the jail from an overdose. And when that subject came up, he had mentioned that he wants to have zero deaths in his jail; that's his goal. And I just quickly jumped on that opportunity to tell him about our buprenorphine program. And he accepted it right away. Now, when I say that he accepted it, that doesn't mean that everybody accepted it. So, between the two administrators, we now had a program. Of course, it wasn't in writing, but we had an idea for a program, and then, it took time for us to sit down and write out protocols, and get a written document in place, a partnership, spell out everything that each one of us is going to do. That took a little bit of time.

And it's kind of funny — finally, one day, as we were going back and forth, trying to make it perfect, I was tired of waiting. I just handed my cell phone number over to the community behavioral health liaison. And I said, "Tell the COs [corrections officers] to call me if they have a person who's going through withdrawal from opioids." A few days passed, and then one day I got a phone call, and it was my time to shine, right? I got the phone call, I got my box of meds, I go in there, and this is the first time I've administered this medicine.

So, I go in and utilize the medication, and I was astounded at how quickly the patient started to turn around. She went from being cold, sweaty, climbing all over the bench, just couldn't sit still. She had a very high COWS score, which is an opioid withdrawal score. She just started to calm down, and I came back to the ambulance district and told Sarah and anybody else that would listen to my story, how well this worked. I was ready to treat the world. It was very cool.

We have not had a death in two and a half years, and we've had only a couple of overdoses, which were not opioid-related. So, we really encouraged the inmates to use our medication rather than using smuggled-in medication.

When I first started the program, I administered the medication every 12 hours. And so, I would go in, in the morning and in the evening. And as you can imagine, there are a lot of moving parts to moving inmates around the jail and getting them to me or to Sarah to have medication administered to them, and our own schedule of running an ambulance district. It became very tedious; a lot of documentation, a lot of time. So in the end, as the chief of an ambulance district, I ended up having to hand it over to Sarah. I told Sarah I was drowning. I just had too much work, and I wasn't keeping up with everything. And Sarah, to her credit, she stepped right in. And about a year and a half ago or so, she took over.

Andrew Nelson: Sarah, do you want to tell me a little bit about what it was like to take over from Ray?

Sarah Czarnecki: Absolutely. It was a job. I don't know how he stayed afloat as long as he did. [With] the amount of patients that we have at the jail, time is about three hours every time we would go and dose. And if we were there in the morning and we would dose 10 or 15 people, and then we were in there in the evening and dosing 10 or 15 people, and then you have to do all the documentation that comes with that… it was about six hours a day that we had to contribute. We did some revamping of the program as we figured out, "This is a lot. We need to make this more sustainable." And we now go once a day. I had to go find the evidence to make sure that it was best practice to be administering this medication once a day, and that it was still okay to do so. So that was what our program has ultimately transformed into. I go once a day to administer medication every morning, which definitely cuts down on the amount of time that we are there.

Andrew Nelson: You said you've been doing this for about two and a half years. Right now, you're midway through an RCORP Overdose Response grant. How were you funded previously?

Sarah Czarnecki: Well, this is our second grant funding with the same grant. That's what has allowed us to continue.

Ray Antonacci: And what's interesting about that is that it took about half of the first grant period for us to just figure out what we were doing. Like I explained before, it was a lot of document-writing and a lot of back-and-forth until finally, we just started working. So, we only had less than half a year of patients the first time. But it worked so well, that in between the end of our first grant period with the RCORP grant and the beginning of the next RCORP grant, there was about six months. The Sheriff's Department paid for the buprenorphine. We supplied the manpower, and the sheriff's department came up with some money to continue the program. I just explained to them that we were out of grant funds, and they found the money somewhere in their budget and were able to continue it. They believed in it that much.

Andrew Nelson: You understood the value of buprenorphine, especially when it comes to managing those withdrawals of incarcerated individuals. Can you tell me about some of the obstacles that you encountered getting going, and how you were able to move past those?

Ray Antonacci: The difficulty that I encountered right at the beginning of the program was stigma. Trying to get the corrections officers to understand the medication and understand that we were not trading one drug for another, and that we were trading one illicit drug for a medication, a treatment drug, and get them to understand that this was not a form of punishment, and this was not a form of privilege. This was just medicine. So that was one of the biggest things that I had to get over. And I think that as I handed it off to Sarah, she still met that same resistance from not only people in the jail, but our own paramedics.

Sarah Czarnecki: Absolutely. It's really difficult, and I had to shift my lens as well, when it comes to substance use. Many people continue to see substance use as a moral failing, and not a diagnosable disorder. And when we are able to see it as a diagnosable disorder, just like hypertension or just like COPD, we can then understand, if we have diagnostic criteria, we could also have interventions to treat that, including medication. And that's still something I stress and educate on within the jail, as well as with my own coworkers.

Andrew Nelson: Yeah. I think a lot of people, when they're being introduced to a concept like that, feel like, "Well, you're enabling these people," but reframing it as just providing medication for a condition that they have, that can make a lot more sense to people.

Sarah Czarnecki: Absolutely. I like to compare it to high blood pressure. So many patients that paramedics come in contact with have high blood pressure. And a lot of times we ask people, "Do you have high blood pressure?" And they say "No." And then we find on their medication list, "You take a medicine, your blood pressure is not high because you take the medicine." And the same concept can be utilized with substance use disorder. Your substance use disorder is not negatively affecting your life, because you're using medication to treat the disorder. People can come off of blood pressure medication, no problem. Right? There's other things that have to happen, though. They have to have lifestyle changes, exercise, eat healthy, lower your cholesterol, and then maybe we can talk about no more high blood pressure medication. The same concept can be utilized with buprenorphine and substance use or opioid use disorder. It's a hard, hard lens, and it's a hard sell for many people. But when I was able to shift my lens to that, it helped me look at it in a whole different way.

Andrew Nelson: Initially, you were just responding to somebody from the jail calling you to treat somebody who was experiencing withdrawal. Who qualifies for this program, and how do you determine which individuals are appropriate candidates for medication-assisted treatment versus other treatment pathways?

Sarah Czarnecki: We utilize a protocol in the state of Missouri. There are standing orders; protocols that are predetermined. Every entity has their own medical director. So, within that protocol, we find someone that could be a candidate who's experiencing opioid withdrawal. And we go through what's called a COWS scale, a Clinical Opioid Withdrawal Scale. We use the number 7. So anybody who has a COWS score of seven or higher qualifies for buprenorphine. Most everyone self-discloses, "Yes, I use opioids or fentanyl." The higher the number, the worse the withdrawal symptoms are. We evaluate the patient, make sure that there's no contraindications, because there are a few contraindications. And if they are willing to take medication, we administer medication.

Andrew Nelson: Can you tell me about how the paramedicine model differs from traditional emergency responses to the same issue, and how this approach can be particularly well-suited for addressing opioid withdrawal in the incarcerated population?

Ray Antonacci: I'm going to give kind of a short answer to that, and then you can expand on it with community paramedicine. How this differs is really night and day. The old response is, "Let's wait for them to almost die, or die." Then we respond to them. We either A), wake them up, or B), pronounce them dead. And then we either take them to the hospital or wait for the funeral home to come get them, or the coroner to come get them. What we're doing is, we're catching them when they are in withdrawal. But we can keep them on our medication, keep them stable, and keep them from utilizing fentanyl or any other opioid that's been smuggled into the jail.

Buprenorphine has a therapeutic ceiling, and they won't die from an overdose. Even if it gets diverted to someone else, it's not going to hurt them. So, where our medicine works is that it cuts the cravings and it cuts down on their usage or desire or craving for that illicit drug. So, we don't have to respond to the jail 911 at 2:00 in the morning for an overdose. And I get kind of sentimental about this sometimes, and I'm like, "You know what? No matter what they've done in their life, they're in jail obviously for a reason… they did something, but they're somebody's kid. They're somebody's father. There's somebody's husband, wife, girlfriend, boyfriend, and we owe them the best medicine that we can give them in our community." So that's what we're doing. We're working towards the prevention of death. And as long as we can prevent death, they can go to recovery. They don't get recovery after death.

Andrew Nelson: Do you have a sense of how individuals have stayed connected to recovery services after they've been released? Or is that beyond the scope of your involvement?

Ray Antonacci: We do have some wraparound services, and some of these folks have been difficult to keep track of. So that's one of our data points that we've been working on.

Sarah Czarnecki: We have in our protocol that we don't want to leave people high and dry without access to the medication. So, we have a referral that we send to virtual care. And once they engage with that virtual care, we do lose track of a lot of people. However, sometimes within those first 24 to 48 hours, we have connection with those people that they get out; we're able to connect them with what are called "bridge medications" to get them to that virtual provider. So those first few days, we may have connection with them after they get out. After that, connecting with them is a little more difficult.

Andrew Nelson: What does the internet connectivity situation look like around Troy? Is that something that's available so it's easy for folks to access the virtual care?

Ray Antonacci: We have some larger towns that have pretty good internet. But a lot of the folks that leave the jail, they end up living pretty far out of town or in a trailer out on somebody's farm. And we have difficulties with that. We were just on a meeting earlier today, and one of Sarah's barriers is that people don't have phones, and she's bought multiple phones with phone cards for people to use. So, that's a way that we're trying to get over that barrier. But again, that takes money.

Andrew Nelson: You already talked about stigma. Would you say that there were other challenges that you've you had to overcome that you haven't already talked about?

Ray Antonacci: Provider shortages have been an issue. We're currently putting many of our paramedics through community paramedic school to get the additional education to go out into the community and do more prevention work on chronic disease management and behavioral health and, in our case, with this grant, the substance use programs. But there is a shortage of paramedics in Missouri. So, the more people I take off an ambulance and put on the street to do prevention work, I have to replace those people with people to run the 911 calls. And that becomes difficult. So, I've got a balancing act as a chief to keep trucks rolling out the door for our main mission of running 911 calls and responding to people's emergency and starting this new service line.

Sarah Czarnecki: I think the stigma has been the biggest one, not only for myself, but for everyone that we come in contact with. I very rarely have to defend what we do with buprenorphine. And it's a difficult population. It's a difficult, and new, concept.

Andrew Nelson: We've mostly been talking about the interactions that you've had with the sheriff's department and then of course patients that are incarcerated. Have you had any communications with other people in your community about the importance of this service?

Sarah Czarnecki: We have. We've had a lot of great partnerships that have been built with this. PreventEd is a big one that has been amazing and supportive. I many times don't understand what someone is going through, what they're going through in the world of substance use and opioid use, and I'm able to refer them to a peer support specialist, someone who is in long-term recovery, who has actual real life experience struggling not only with substances in their past, but with the court system as well. And they have been a wealth of information, not only for me, but for my patients, and they're very supportive in what we do.

Andrew Nelson: I would imagine that there are people in your community that haven't experienced substance use issues themselves, but they have family members and loved ones that are still in their lives that that wouldn't have been, if this treatment was not available. Have you heard any stories from those folks?

Ray Antonacci: I have. On two separate occasions, while I was in the jail, family has come to visit the individual that I was treating. In one case it was a wife, and another case, it was a mother. They were in tears thanking me for doing what we're doing. The alternative is that their loved one would've been in jail, and they would've been lying on a cold, wet floor in a jail next to those open stainless steel toilets. And they'd have been vomiting. They'd have been sweating, they'd had chills, they'd had diarrhea. They would've been a horrible week, maybe two weeks of just agony. And they're sharing that cell, and there's people stepping over them to use the toilet.

This is nothing against our jail system. They do the best that they can with the resources that they have, but this is one reason why the sheriff is so welcoming of us, is that we get to do the things that he's unable to do. He provides the food and he provides the place where these people are incarcerated. But I think that in the case of opioid withdrawal, this medication provides the humanity, and lets them withdraw with dignity.

Andrew Nelson: So, if there was another rural ambulance district that wanted to replicate this program or set up a program like it, are there any pieces of advice you'd have based on what you've learned during these first couple years of operation?

Ray Antonacci: We could talk about this for like a whole other hour. The first thing that I would say is that, if you would like to start this, you need to approach your sheriff or whomever is in charge of the jail, whoever that sheriff directs you to, and begin developing a relationship, begin developing trust, and talk about the program in the terms of medicine, because their terms are more "incarceration" and "punishment." And our terms are "medical" and "treatment" and "reducing death." So, I would say that is the biggest thing that I did for this program, was just start the conversation and then just got into the jail. Once I got my foot in the jail and I handed it over to Sarah, Sarah built out the rest of the program.

Sarah Czarnecki: I would say that the ambulance district has to find their champion. Every ambulance district has that champion who wants to work in this space, who wants to take on a challenge, who wants to do something different, and they have to be driven to stay in it even when it gets hard. So, if they can find that champion in their ambulance district to say, "Okay, let's do something different. And I might find obstacles in the way, but I'm going to figure out how to get around them and keep going," because it can work and it does work, and it does save lives.

Andrew Nelson: In your case, who would you say was the champion that helped you get this program going?

Sarah Czarneck: I would have to say Ray. This guy right there.

Ray Antonacci: And I would throw it back at Sarah because I would say that, yeah, I championed it. I thought this program would work. I believed in it and I believed in the medication, and I just went out there and I just did it. And if it failed, everybody was going to laugh at me, but it didn't fail. So, when it didn't fail and I found out that it was growing and it was growing beyond my capacity, I had to find another champion. And I found that champion in Sarah, and that's how we were able to keep it going. If it wasn't for Sarah, I'd have probably stopped the program after the first year. And the second year of programming would've never happened.

Andrew Nelson: Speaking to that, in terms of maintaining sustainability, what are your hopes for being able to continue to provide this service after the end of the grant period coming up in August?

Ray Antonacci: We've approached the county commissioners and explained to them that grant funding may not always be here, and that we would continue to try to find grant funding, but in the event that it's not, we would like to access some of the county's opioid settlement money and to purchase the medication. And along with the sheriff by our side, the county commission verbally agreed to do that. And at the same time, the other point of that is that we're going to burn Sarah out, just like I got burned out. Sarah is the battalion chief over an MIH [mobile integrated healthcare] division. So, under her are some part-time community paramedics. And we're growing new community paramedics to work in this space. And hopefully this becomes an entire division that has Sarah running it completely, with multiple people under her. That's our hopes someday.

Andrew Nelson: So, you have a plan going forward to maintain this program. Are there any ways in which you'd like to be able to expand it?

Sarah Czarnecki: Yes, I would love to see this in other jails. I would love to see my neighboring counties copy and paste into their county. I find that when I have patients in the jail that are transferred to other jails, we worry, "Do they provide MAT?" I would love to be able to just call my counterpart north of me and say, "Hey, I have somebody coming to you. They're doing great. Continue them in their recovery." I would also like to offer the injectable form of the medication. That is my newest endeavor. That's what my push is for the last few months of our grant funding, is to access and offer long-acting injectable buprenorphine to the people that we're seeing in the jail.

Andrew Nelson: The current treatment you're offering is administered once a day. How much does the long-acting buprenorphine increase that interval?

Sarah Czarnecki: There are two brands that are available, and they come in a weekly dose or a monthly dose. And I would love the opportunity to offer a monthly dose for those people that I'm seeing, especially those people that I'm seeing on a daily basis for many weeks that have stabilized on medication orally. "Let's transition you over to something that's injectable, that's long-acting." And we can continue that hopefully the entire time. And then it can follow them when it goes with them. There's a little less of that, "Oh, are they going to be able to provide me with medication at the next place?" It gives them coverage with medication when they get out, as well, if it's in that time period. It's expensive medication though, so that's another barrier that we're going to work through.

Andrew Nelson: What would you need to do to be able to provide that medication, as opposed to the shorter-term treatment you're currently providing?

Sarah Czarnecki: My doctor has to agree to allow me to give it. That's the first part of it. So, I need a medical control standing order to do it. We're working through that process now, and then I have to be able to buy it. I have the certifications and to be able to store it, and I have the skills to administer it. So being able to be guided by a physician who can write down on a protocol, "This is who's a good candidate, these are the vital signs you need, this is the history you need to take," just like we would do with anything else in paramedicine, to be able to then utilize that in that population.

Ray Antonacci: One of the success stories that we had was a young woman who I was treating in the jail, and this is early on, this is right when we first started. And I was treating her, and she went to court and in court she said, "I'm on Ray's program." And nobody knew who Ray was. So, they looked at the court liaison, and the court liaison knows me, but wasn't sure where I worked exactly; wasn't sure exactly what I did. And this story then comes back to me. I went back and told Sarah about this, and Sarah did a PowerPoint for the court system. So, we did all the judges, prosecuting attorneys, defense attorneys, anybody that would come into this room and listen from the court system. And that, that was early on. And it really opened our eyes to the fact that we needed more partners. We needed more people to know who we are and what we were doing. So, from that point on, Sarah has spoken at every community room that would have her. She's been all over town, speaking everywhere.

If you're going to do this, you need lots of partners and lots of open communication in your community as to what you're doing.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with Lincoln County Ambulance District Chief Ray Antonacci and Battalion Chief Sarah Czarnecki. Look in our show notes for more information about their work and visit ruralhealthinfo.org for all things pertaining to rural health.