Change in EMS isn’t usually easy, or painless. The first research suggesting that pneumatic anti-shock garments (PASGs or MASTs) might do more harm than good appeared in the mid-1980s, when I was just starting elementary school. In 2002, my first EMT class was still teaching their use. I never saw them in practice, and months later they were removed from the ambulances.
Rapid rise of naloxone
The past few years have seen the rapid rise of laws that allow naloxone (also known by the brand-name Narcan) administration by BLS providers, first responders, and even non-medical personnel, including police officers and civilian bystanders. In 2013, at least five states or territories expanded the scope of practice for BLS providers to include the use of naloxone for opioid overdoses, and others were implementing pilot programs.[1]
Public health authorities have identified wider access to naloxone as a priority for curbing the rising number of deaths from opiate overdoses.[2] Law enforcement agencies have started carrying naloxone in much greater numbers. According to the North Carolina Harm Reduction Coalition, hundreds of police and sheriffs departments across the U.S. now authorize officers to carry and administer the drug.[3]
Generally speaking, it is difficult to argue against empowering law enforcement to provide time-sensitive medical interventions. I have always supported utilizing police officers as medical first responders in the rare cases where a few seconds can make a difference. Training them in CPR and even equipping law enforcement with AEDs in some communities may be useful in cases of sudden cardiac arrest, where a few seconds definitely can save a life. Giving officers tourniquets is also no-brainer—they can use them on themselves and each other, and they are often able to gain access to injured civilians long before EMS can.
Naloxone concerns and doubts
With naloxone specifically, however, I have some concerns.
For one, as we continue to increase the medical capabilities of non-medical responders, we also necessarily increase their training requirements. As someone who was once told by leaders of a local police agency that they did not have time to teach hands-only CPR to officers (each of whom had received CPR training in the academy but rarely, if ever, re-certified), I question the amount of time and money that law enforcement agencies are willing to spend on continuing medical education.
There’s also the question of cost. The recent spike in the cost of naloxone is likely tied to the increased demand for the drug.[4] Conducting a cost-benefit analysis in these situations is always difficult, given the variables involved, but I can’t help but think that providing police officers with a bag-valve mask (which officers can use to provide rescue breaths to overdose patients who have stopped breathing) might be more cost-effective, and safer.
After all, the primary danger with naloxone is that law enforcement officers, civilians, BLS providers, and even paramedics sometimes jump to use naloxone without fully evaluating their unresponsive subject. In a course I’ve taught on anchoring (the phenomenon where medical providers become so focused on one piece of information that they fail to see the whole picture), I discuss several examples where paramedics assume that a patient has overdosed on narcotics and administer naloxone, but fail to consider other signs or symptoms (such as hypotension, hyperglycemia, and trauma) that may be a more likely cause of their patient’s presentation. Ventilating a patient with a BVM (with or without supplemental oxygen) is an effective treatment for respiratory depression in all patients, regardless of the underlying cause.
For this reason, I have often discouraged my students from reflexively using naloxone in all potential overdose patients. If a patient is breathing adequately (whether conscious or not), there is simply no need to wake them up quickly. Naloxone does have side effects (such as nausea and vomiting). More significant is the potential danger to responders from quickly waking an overdose patient—who is likely to become hostile and combative as a result of acute withdrawal.
Skeptically evaluate ‘seconds count’ argument
Lastly, I have to admit that I’m sometimes skeptical as to how many lives can truly be saved with law enforcement use of naloxone. I have been in EMS for more than a decade, albeit not in areas with extremely high use of narcotics. During that time, I have rarely arrived at the scene of an overdose where immediate naloxone use would’ve made a difference. Sometimes, the patient has already stopped breathing for several minutes and needs ventilator support or CPR. In most cases, however, they are still breathing adequately and do not require naloxone at all.
In many articles and even some medical literature, the evidence seems circumstantial at best. Police departments across the country have received media publicity for “saving lives” with naloxone.[5] But in some examples, it’s unclear if that’s what actually occurred. In most of the stories, the victim is described as unconscious, but not necessarily in respiratory depression or arrest (and thus not an appropriate candidate for naloxone administration). And there’s no evidence that had police waited for EMS to arrive and treat the overdose, the outcome would have been any different.
Circumstances when naloxone makes sense
For naloxone use by law enforcement to be effective and necessary, police officers have to be in an area where they frequently arrive on scene long before any EMS providers. As such, it is imperative that agencies look at both law enforcement, medical first responder, and ALS response times before making final decisions on who should carry naloxone.
I have always been an advocate for making change when appropriate and not waiting for the “perfect” study, but I am also skeptical of any change in EMS that involves providing a new tool to anyone. Not because I don’t want to expand my capabilities, but because in EMS we are always much more likely to quickly adopt a new skill or toy (impedance threshold devices, mechanical CPR devices, simulators) than we are to give one up (PASG, intubation in cardiac arrest, lights and sirens for every response).
The quick adoption of naloxone by law enforcement agencies may ultimately save lives, but so far that’s still unclear. The same goes for other new practices, from mobile integrated healthcare to the rescue task force. Let’s keep innovating, but let’s make sure we are innovating based on evidence and what’s best for the patient, not just based on anecdotal experience or what’s fun for us.
References
1. Davis, Corey S., et al. “Emergency medical services naloxone access: a national systematic legal review.” Academic Emergency Medicine 21.10 (2014): 1173-1177.
2. Mello, Michelle M., et al. “Critical opportunities for public health law: a call for action.” American journal of public health 103.11 (2013): 1979-1988.
3. http://www.nchrc.org/law-enforcement/us-law-enforcement-who-carry-naloxone/
4. Goodman, J. David, “Naloxone, a Drug to Stop Heroin Deaths, is More Costly, the Police Say.” The New York Times, Nov. 30, 2014. http://www.nytimes.com/2014/12/01/nyregion/prices-increase-for-antidote-to-heroin-overdoses-used-by-police.html?_r=0
5. Milo, Paul, “Newark police use Naloxone for first time, save woman’s life.” NJ.com, Jan. 14, 2015. http://www.nj.com/essex/index.ssf/2015/01/newark_police_use_naloxone_for_first_time_save_woman.html
