This feature is part of our Paramedic Chief Digital Edition, a regular supplement to EMS1.com that brings a sharpened focus to some of the most challenging topics facing paramedic chiefs and EMS leaders everywhere. To read all of the articles included in the Winter 2018 issue, click here.
By Matt Zavadsky, MS-HSA, EMT
Epidemic. Saying the word out loud is enough to send chills down the spine of any healthcare provider. It’s a term that has been used often to describe the opioid crisis in our country.
One of the many responses to the opioid epidemic has been to equip what seems like virtually every member of society with naloxone to counter the life-threatening consequences of opioid overdose.
Naloxone is now available over the counter without a prescription in 45 out of 50 states in America [1]. Many law enforcement agencies have added naloxone to their repertoire for treatment of opioid overdose victims. And – as I recently found out during a ride-along in a large, mid-Atlantic city – many drug dealers are even providing naloxone auto-injectors to some of their best customers.
As healthcare providers, we first seek to do no harm. In headlines, grant applications and public meetings, arming as many community members as possible with naloxone sounds like the right thing to do. It makes sense, since it’s true the early administration of naloxone for an overdose victim who is apneic could save a life, in the short term.
But, should there be a much larger discussion about the adverse outcomes from naloxone administration by non-medically trained responders?
Two scenarios illustrate potential ramifications of non-EMS opioid treatment
In the quiet hallways of health policy agencies and substance abuse treatment centers, there is another question being asked: Are we doing more harm than good with the proliferation of naloxone in the community?
Consider these scenarios:
Scenario 1:
It’s 2 a.m. and you are responding to a 9-1-1 call for a possible overdose. You arrive on scene, where you find a male in his 30s whose very concerned family members inform you possibly overdosed on fentanyl.
Your patient is apneic, with a stable heart rate and blood pressure. While you are effectively managing his airway with a BVM, your quick secondary survey confirms your index of suspicion that your patient may be experiencing potential opioid overdose.
You begin packaging the patient for transport, still effectively managing his airway. Following protocol, you titrate the administration of Narcan to the desired effect. During your non-lights and siren transport, the patient begins having spontaneous respirations, no longer requiring BVM assistance.
On arrival at the ED, the patient is slowly aroused to consciousness, where he is greeted by concerned and loving family members, and a well-trained substance abuse counselor. After listening to how close he came to death, and with the motivational interviewing skills of the substance abuse counselor, the patient consents to in-patient substance abuse treatment.
Scenario 2:
It’s 2 a.m. and you are responding to a 9-1-1 call for a possible overdose. You arrive on scene, where you find a male in his 30s who is yelling, agitated, doubled over in pain and shaking. The patient is oriented to person, place, time and events.
The family tells you the patient has been addicted to carfentanil and they have been trying to get him into rehab for months, to no avail. Out of fear of a fatal overdose, they purchased OTC intra-nasal Narcan from their neighborhood pharmacy and have kept it handy for just such an emergency. The family administered the Narcan while you were responding and the patient woke up in this current state.
Despite the best efforts of you, the family and law enforcement on scene, the patient refuses all care, and signs an AMA. He tells his family to leave him alone, goes to his bedroom and locks the door. The following morning, the patient is unresponsive, and his family breaks open the door to find him obviously dead.
Are these scenarios too cut and dry? Perhaps, but the clarity of the scenarios helps pose the following difficult questions for EMS providers:
1. Is the use of naloxone by non-medically trained personnel helping or hurting victims of an opioid overdose?
Consider these realities:
- The average half-life of fentanyl is 219 minutes, while the average half-life of naloxone is 60-90 minutes [2]. This means that without follow-up care, although the risk is low, it is possible that the overdose victim will suffer another apnea event when the naloxone wears off [3].
- The sudden reversal of the overdose effects caused by naloxone results in the patient experiencing severe withdrawal symptoms, vomiting, irritability, severe body aches and greatly disturbed mood [4]. At best, this reaction triggers the patient to refuse transport to the hospital against medical advice, leading to a missed opportunity for further management and observation.
- The above manifestations could also create scene safety risks for the patient, other responders and even bystanders.
During a recent night-shift ride along with the EMS battalion chief in a large East Coast city, we responded to five EMS calls in four hours. Three of them were reported overdose victims who were apneic. When we arrived, all three patients were conscious and alert, having been revived by a bystander with a Narcan auto injector. Not one of them agreed to allow EMS to transport them to an ED of their choice.
2. What is EMS’s role in helping communities navigate the myriad issues relating to the opioid crisis?
EMS agencies enjoy some of the highest community trust of any profession. People will listen to us. We are the experts. We often respond to calls related to the untoward effects of opioid addition. And, we are supposed to be patient advocates. This places us squarely in the community influencer role in the opioid crisis.
Think back to the second scenario. Does the outcome of that patient interaction seem to be in the best interest of the patient? Is there a difference between saving a life and preserving a life? Yes, the former is important and consistent with our core mission, but so is the latter.
The desired goal for overdose patients should be providing them an opportunity to engage with mental health and substance abuse professionals, generally in a hospital setting, who may be able to use motivational interviewing techniques to help the patient agree to a drug treatment program.
It’s possible patients fully revived by naloxone prior to EMS arrival may refuse transport against medical advice, making the connection to definitive substance abuse care more difficult.
Mobile integrated healthcare options for the opioid crisis
There are some EMS agencies taking very unique, if not controversial leadership roles in the opioid crisis.
In Pittsburgh, the Community Connect program, led by Dan Swayze, the vice president and COO of the Center for Emergency Medicine of Western Pennsylvania, has received grant funding to create a post-overdose response team.
The program will send a community paramedic and a peer specialist out after 9-1-1 interactions (for police or EMS) related to overdoses. They will navigate people into rehab if they are ready to quit. If they are not willing to enter rehab, they will discuss harm-reduction strategies, and help the patient manage any comorbidities.
In Florida, Palm Beach County Fire Rescue (PBCFR), under the direction of Captain Houston Park and Division Chief of Medical Services Richard Ellis, pilot tested an opioid medication assisted treatment (MAT) program for 31 patients.
In this program, overdose patients were given an initial dose of Suboxone in the ED. After about an 8-12 hour ED stay, the patients were discharged. PBCFR MIH paramedics, along with a peer counselor from a local behavioral health network, provided follow-up care for the patients in their own homes for the next eight days, delivering a daily dose of Suboxone, as well as providing peer counseling.
After the eight days of follow-up, the patients were transitioned to the local healthcare district for further evaluation, administration of Suboxone and continued peer counseling, with the goal of eventually weaning off Suboxone.
Due to the expense and the limited number of patients the team was able to impact, the study was not renewed after the initial 31 patients. However, many people in the community have seen the benefits of MAT and there are several groups working on different ways to replicate the program with lower costs and a wider reach. Chief Ellis is confident a new program will start up within the next six months.
Transitioning to an integrated opioid response model
It would seem that if non-medical personnel are going to be equipped with naloxone, they should have the training and ability to be able to potentially titrate the medication to the desired effect of spontaneous respiration.
Or, more radically, perhaps non-medical first responders should be provided training and equipment to effectively manage an airway through the use of a bag-valve-mask. That may be an intervention that is more patient centric, and – given that the price for OTC naloxone auto-injectors has increased by nearly 500 percent, it may be a more cost-effective solution [5].
Yes, the opioid crisis creates a significant conundrum for EMS agencies, balancing the lifesaving role with the responsibility to ensure a safe transition to definitive care (in this scenario, connection to a substance abuse treatment program).
Fully reviving patients who may not consent to transport becomes the pivot point that EMS should be actively involved in helping local communities navigate.
New EMS service models specifically designed to fill a targeted gap in substance abuse treatment resources may be a valuable role for EMS agencies that are able to make the transition from traditional EMS models, to a more integrated, community-based model.
References:
- Gorman A. Pharmacists can dispense life-saving overdose drugs, but do they? Available at: www.governing.com/topics/health-human-services/khn-naloxone-pharmacists.html
- DailyMed. fentanyl citrate (Fentanyl Citrate) injection, solution. Available at: https://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=4059
- Levine M, Sanko S, Eckstein M. Assessing the risk of prehospital administration of naloxone with subsequent refusal of care. “Prehosp Emerg Care,” March 2016:1-4.
- Clarke SFJ, Dargan PI, Jones AL. Naloxone in opioid poisoning: walking the tightrope. “Emergency Medicine Journal,” 2005:22;612-616.
- Gupta R, Shah ND, Ross JS. The rising price of naloxone – Risks to efforts to stem overdose deaths. “N Engl J Med,” 2016, 375;2213-2215
About the author
Matt Zavadsky is the public affairs director at MedStar Mobile Healthcare, the exclusive emergency and non-emergency EMS/MIH provider for Fort Worth and 14 other cities in North Texas. He has 37 years of experience in EMS and holds a master’s degree in Health Service Administration with a graduate certificate in Healthcare Data Management.
