A Colorado doctor and a pharmacist set off on a mission about a year ago to change hospital policy statewide, a monumental effort to save people from dying in the escalating opioid crisis that took 1,258 lives in 2021.
It took some educating, and a few changes in state law, but every single hospital emergency department in Colorado — all 108 of them — agreed to offer take-home doses of naloxone to any patient treated for an overdose.
Now, in its second year, the Colorado Naloxone Project is focusing its efforts on distributing the life-saving opioid antidote to another part of the hospital: labor and delivery units. While that might not seem like an obvious next step, consider that the top causes of maternal death in Colorado are overdose and suicide.
Already, 14 of the state’s 48 labor and delivery units have signed on and project leaders are again pushing for 100% participation within a year.
The project is novel because hospitals almost never give take-home medicine. Patients normally leave with prescriptions, then must take the extra few steps to get them filled at a pharmacy. Multiple studies have shown, though, that when patients receive a prescription for naloxone, a nasal spray or an injection that can reverse the deadly effects of an overdose, they rarely go to a pharmacy to fill it.
The rate of filling hospital prescriptions of naloxone is about 1-2%.
Under phase two of the hospital naloxone project, called Maternal Overdose Matters, or the MOMS initiative, hospital staff will screen new mothers through conversation or a written form, then offer two-dose packages of naloxone to take home when they are released. The protocol is intended to flag new moms who are currently using drugs or have any history of addiction, but also moms who say that someone else in their family or a close friend has used drugs. Or moms who were prescribed opioids, often Percocet, because they just had a C-section or suffered a tear.
The naloxone itself is only part of the effort to reduce overdose deaths.
“It’s building a bridge,” said Dr. Kaylin Klie, who runs two addiction medicine clinics for parents and is co-chair of the naloxone project. “You have told me you’re not ready for substance treatment today, but I want you to live. That’s it. That’s the whole message: You matter. I don’t want this disease to kill you.”
Klie works with pregnant women in her addiction clinic in the hopes of getting them help before they become mothers. She also just finished a term as chair of Colorado’s maternal mortality review committee, which investigates deaths of pregnant women and new moms.
The committee’s latest report, which looks at deaths of mothers from pregnancy through a year after giving birth, found the leading cause of death was suicide, followed by accidental overdose. The report included 94 deaths from 2014 through 2016, and the committee is now reviewing another three years of data.
Overdose deaths in the next report are expected to climb even higher because the third wave of the opioid epidemic — fueled by illicit fentanyl pressed into pills or added to heroin and meth — has gripped Colorado in the past two years. A national study published this week in JAMA found that overdose deaths of pregnant women and new moms hit a new record in 2020.
Besides the bleak statistics on maternal overdose, project organizers said it made sense to focus on maternity wards because, second to the emergency department, that’s how many at-risk patients first enter a hospital. Also, the first time women are exposed to an opioid is often after giving birth.
One national study found that among women who had never taken opioids before and were prescribed them following a C-section, one in 300 were still taking opioids a year later. “That doesn’t sound like that big of a number, but when you consider that over a million C-sections are done in our country every year, that’s a lot of women,” Klie said.
Racquel Garcia, who is in recovery from opioid addiction and serves on the Moms initiative steering committee, said the first time she was exposed to fentanyl was during childbirth. She didn’t want an epidural so hospital staff gave her fentanyl instead. Though her opioid use disorder began after a surgery, Garcia is focused in her HardBeauty coaching service on making sure other moms have access to naloxone and treatment, starting from the moment they become mothers. She lost her best friend, also a mother, to an opioid overdose in 2009.
“When you talk about the collateral damage of the loss of a mother,” she said, crying. “My best friend, her kids, it’s been a long time, but they are not well. It’s the ripple effect.”
Normalizing the overdose antidote
Hospital patients don’t fill prescriptions for naloxone mainly for one reason: stigma.
“That is adding another person or group into your substance abuse disorder,” said Rachael Duncan, a clinical pharmacist at Swedish Medical Center who helped start the naloxone project with Swedish emergency physician Dr. Don Stader.
Colorado has gone to great efforts to make obtaining naloxone easy. There’s a standing order from the state’s chief medical officer, meaning people can basically buy it over the counter in pharmacies across the state. It’s also covered by Medicaid, so low-income people on the government health insurance plan don’t have to pay the $40 or so for a two-dose box.
Handing it out at hospitals, along with the right message from the nurse or doctor, will help diminish the stigma, Duncan said.
“I want us to get from a place of, ‘Oh, we don’t talk about that,’ to a message that strong moms carry naloxone,” she said. “You have kids? Of course you should have naloxone. I like to normalize it with my patients. I say, ‘Hey, I carry naloxone. I think that’s a responsible thing to do.’”
The education process begins with the hospitals, said Duncan, who is in the process of talking about the Moms initiative to hospital executives all over Colorado and “Zooming into” labor and delivery department meetings. In rural areas, hospital staff will often tell her that they don’t have an opioid problem — they have a meth problem. But, Duncan tells them, an increasing amount of methamphetamine infiltrating Colorado is made with fentanyl, a synthetic opioid 50 times more potent than heroin.
Swedish was the first hospital to begin handing out naloxone to new moms, kicking off a pilot project in September 2021. Little more than a year later, the entire HealthONE system, which includes six hospitals with labor and delivery units, has signed onto the Moms initiative.
Recruiting other maternity departments began in full force in August. Others that have committed so far include Denver Health, East Morgan County Hospital in Brush, Valley View Hospital in Glenwood Springs, Southwest Health System in Cortez, and Gunnison Valley Hospital.
Hospitals questioned liability, expense, child abuse reporting laws
At the start of the naloxone project, in the emergency department phase, hospitals were concerned about the liability and expense of dispensing take-home medication instead of a prescription. Stader, whose ultimate goal is to expand the project across almost all hospital departments, spearheaded an effort at the state Capitol to change laws surrounding insurance reimbursement and regulation.
Legislation passed in 2020, House Bill 1065, created a way for hospitals to recoup the costs of giving out naloxone from private insurance companies. And last year’s controversial fentanyl bill, House Bill 1326, included a provision that mandated Medicaid reimbursement of naloxone. It also stripped labeling requirements and the threat of a fine for not including proper labels or instructions.
“This was a concern when we were recruiting hospitals,” especially in rural areas, Stader said. “We’re small. We would like to, but all these regulations about labeling and storage.”
And as the project moved to maternity wards, hospitals have questioned how the new protocol fits in with legal requirements that hospital staff report suspected child abuse and neglect, including when babies are born addicted to opioids. A new mom should not have to worry that agreeing to take home naloxone will automatically make her the subject of an abuse-and-neglect hotline report, Stader said.
“This is an area of tremendous ongoing discussion and debate,” he said. “We do know that drug use is vastly underreported by women who are using substances. The last thing they want is for their child to be taken from them so it encourages women to hide substance use.”
Or, as Dr. Klie, the addiction counselor, puts it, “a drug test is not a parenting test.”
HeathONE officials said that its hospitals still will make required reports to child welfare authorities when a newborn is unsafe. But there are many situations in which a new mom would want to take home naloxone that would not include a baby at risk of abuse or neglect.
New moms who are prescribed Percocet are also offered naloxone. Moms who are in recovery and aren’t using will get naloxone. Moms who have used drugs in the past or know someone who has can take home naloxone. Some new moms are in recovery and have been taking suboxone or buprenorphine, opioid use disorder drugs, throughout their pregnancy, which is considered safe under a doctor’s care.
HealthONE, the first hospital system in Colorado to take the MOMS initiative to all of its hospitals, wanted to expand the program because it not only helps protect patients once they are discharged, but it has allowed nurses and other staff to have more open conversations with patients, said Holly Monatt, vice president of pharmacy services.
Still, it’s not often so far that a new mother takes home naloxone. Swedish, in Englewood, gives out an average of three naloxone kits per month, for example.
“People think it’s rare and it’s so small that it’s not important,” Monatt said. “It’s all about keeping people alive until they can reach recovery.”
“It’s about the connection”
The naloxone project is unique across the country, and has piqued the interest of hospitals in other states. In the next year, the project will expand to 10 other states, Stader said, and project leaders will then begin the work of convincing hospitals there to adopt Colorado’s protocol.
Also on Stader’s agenda is revamping regulation so that federal insurance payers, namely Medicare and the health care system for veterans, must reimburse hospitals when their clients are given doses of naloxone. The project is funded with state grants, donations and federal pandemic aid.
Stader also wants obstetrics clinics, addiction clinics and family physicians to begin handing out naloxone, all part of his effort to make talking about drug use and solutions to the opioid crisis more out in the open.
“Colorado is a national leader on this because we have designed a system that is just part of normal medicine,” he said. “People think it’s about the naloxone — the compound and the ability to save a life. It’s not. It’s about the connection.”
Garcia, who said that many of the mothers she works with — especially women of color — are afraid to talk openly with their doctors about addiction, hopes the initiative will change that. “For the first time in a long time, I’m so inspired,” she said.