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 Dan Swayze, DrPH, MBA, MEMS
Drug overdoses are the leading cause of accidental death in the United States, killing an estimated 60,000 people in 2016 [1]. The CDC now attributes most of the deaths from opioids to illicit synthetic opioids, such as fentanyl and its analogs, rather than traditional forms of heroin [2].
Not surprisingly, many EMS agencies are reporting record numbers of overdose-related 911 responses and unprecedented amounts of naloxone being administered during resuscitative efforts. Many systems are turning to new mobile integrated healthcare and community paramedicine approaches to help.
Here are five things community paramedics need to know about the opioid crisis to be effective:
1. The brain changes on opioids
Many people perceive drug use as nothing more than the result of poor life decisions. The inability to quit using the drug is often viewed as nothing more than a lack of willpower. However, the neurobiological changes that occur in the brain tell a very different story.
The part of the brain affected by drug use is called the nucleus accumbens, otherwise known as the brain’s pleasure center. Normally, that area is stimulated by either thinking about or engaging in important activities such as eating and sex.
Such thoughts and actions result in dopamine release in the area, which generates a slight feeling of euphoria. Once the person is fulfilled, the system normally responds by decreasing the dopamine, thereby decreasing the pleasure associated with the activity.
Compare this response to how most people feel before, during and after Thanksgiving dinner or when a holiday cookie tray is nearby. We tend to look forward to both (so long as we have enjoyed previous experiences). We feel happy while we eat, but soon reach a point where we simply cannot entertain the thought of eating another bite.
Heroin, fentanyl and other opioid derivatives cause a massive release of dopamine that is somewhere between two and 10 times the amount released during more natural activities [3]. As the amount of dopamine released is so much greater than the amount normally produced, the person is quickly overcome with an euphoria that is several times stronger and lasts much longer than even the most earth-shattering orgasmic experience.
Not surprisingly, people are often motivated to experience those feelings again. The physiologic rewards of drugs are so significant, that the system that normally encourages an individual to engage in essential behaviors suddenly creates an all-consuming compulsion that overrides any other priority. Eating, bathing and adhering to moral standards all take a back seat to the urge to use.
2. Addicts use to feel normal
Once highjacked by a maladaptive reward system, the body begins to crave the dopamine storm on a more frequent basis. The body adapts (or maladapts) to the new levels of dopamine in the circulation by increasing its tolerance to the drug. Higher tolerance means doses that were previously enough to elicit the euphoria are no longer sufficient. Increasingly higher quantities are needed to achieve the same effect.
As dopamine also works as a neurotransmitter in other anatomical systems, those other systems also adjust and become dependent on the higher levels of dopamine to function. When levels return to normal, the addict begins to experience debilitating withdrawal symptoms as quickly as six hours after their last use. Individuals who become “dope sick,” or dependent on the drug will tell you that they primarily use simply to avoid being sick.
3. Opioid use frequently starts with a prescription or with pain
Once an opioid is ingested, the pathophysiology of the body can wreak havoc on the person’s ability to control their drug use. Skeptics will argue that those symptoms are consequences of a poor choice to start using in the first place.
While partying is undeniably a potential starting point for addiction, coping is much more likely to be the original motivation. An estimated 75 percent of heroin addicts report that their first opioid use was prescription based [4]).
Many believe that a combination of an overemphasis on pain as a vital sign, coupled with the fraudulent claim that Oxycontin was not as addictive as traditional opioids is largely responsible for the exponential increase in opioid abuse today.
Another significant predictor of opioid use is exposure to adverse childhood experiences. Exposure to each of the adverse childhood experiences listed in Table 1 results in a 27 percent increase in the likelihood that the individual will use illicit drugs [5]. Those exposed to five adverse experiences as a child are seven- to 10-times more likely to use in later life than those who were not exposed [6].
Using illicit drugs to self-medicate, be it for relief from physical or emotional pain, is likely to be the most common reason community paramedic patients become addicts.
4. Redefining ROSC
Despite efforts to make naloxone administration more timely and available through a wider distribution of the drug, the death rate from the crisis continues to rise. Some of our colleagues, fed-up with the growing number of overdose calls, are showing signs of burnout.
Whether out of frustration or concern, they display “tough-love” to their patients by belittling the patients’ drug use or the patient themselves, or emphasizing the consequences of the patients’ continued drug use in an attempt to get them to see the light and enroll in a rehabilitation program. What our brethren fail to realize is that what they view as tough-love is more likely to be a trigger for the patient to seek out more drugs.
Naloxone is a resuscitation medication, and countering the opioids to help our overdose patients to breathe is a critical step. However, naloxone administration is just the first step in helping our patients to quit. We need to bridge our resuscitation efforts with systems that are better designed to help our patients. Community paramedics offer an opportunity to evolve our limited EMS response from a system focused only on resuscitation to a recovery-oriented system of care (ROSC).
By partnering with those historically involved in rehabilitation services, like detox centers, treatment programs, government entities, payors and police, CP programs can develop a more effective option than simply transporting the patient to the local emergency department.
Mobile integrated healthcare designs may involve:
- resuscitating overdose patients and leaving naloxone behind for those who refuse transportation;
- simultaneously dispatching a specialty care team on overdoses that begin recovery efforts immediately after resuscitation; or
- post-overdose response teams that enroll patients after discharge from the emergency department, in-patient treatment facility or upon release from jail.
5. Post-overdose response teams
Stroke, STEMI and trauma patients benefit from designated facilities and specialized treatment teams, yet our only option for overdose treatment in traditional EMS models is to transport the patient to an emergency department that is unlikely to offer the type of recovery services the patient needs.
Community paramedic programs offer an opportunity to bridge traditional 9-1-1 care to more appropriate recovery-oriented services. Communities in Florida, Missouri, Ohio and Pennsylvania are using community paramedics teamed with recovery services to provide follow-up care for patients who have overdosed.
Pittsburgh’s program will partner a peer recovery specialist with a community paramedic to provide recovery oriented services following a 9-1-1 call for an overdose. If the patient is ready to quit, the team will provide navigation to the most appropriate treatment and support programs. If the patient is unwilling or unable to abstain from drug use, the team will focus on practical strategies to decrease the likelihood of a fatal overdose using a somewhat controversial and politically polarized style known as harm reduction.
Paramedics in Palm Beach, Florida, added recovery services with a clinical intervention by offering a mobile medication-assisted treatment program. Rather than waiting for placement in detox or rehab programs, buprenorphine was initiated in the emergency department and administered in the patient’s home for up to eight days after their emergency department visit to help the patient manage their withdrawal symptoms. The in-home program ended once the patient was enrolled in a more suitable rehabilitation service.
The opioid crisis represents a new challenge and a new opportunity for CP programs nationwide. Reframing the nature of addiction as a brain disorder rather than a behavioral or criminal problem may help the CP better respond to the challenges these patients face. While traditional response models continue to provide a lifesaving resuscitative role in the crisis, innovative CP programs may represent a more effective strategy to managing this public health crisis in the long run.
References:
- CDC. Opioid overdose. Available at: www.cdc.gov/drugoverdose/data/index.html
- CDC. Provisional counts of drug overdose deaths, as of 8/6/2017. Available at: www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdf
- Di Chiara G, Imperato A. Drugs abused by humans preferentially increase synaptic dopamine concentrations in the mesolimbic system of freely moving rats. “Proc Natl Acad Sci,” 1988, 85;5274-5278
- NIDA. Prescription Opioids and Heroin. Available at: www.drugabuse.gov/publications/research-reports/prescription-opioids-heroin
- Choi N, DiNitto D, Marti C, Choi B. (2017). Association of adverse childhood experiences with lifetime mental and substance use disorders among men and women aged 50 years. “International Psychogeriatrics,” 29(3);359-372. doi:10.1017/S1041610216001800
- Dube SR, Felitti VJ, Dong M, et al. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. “Pediatrics,” Mar 2003, 111(3);564-572; DOI: 10.1542/peds.111.3.564
About the author
Dan Swayze is the vice president and chief operating officer of the Center for Emergency Medicine of Western Pennsylvania, Inc., and an adjunct instructor at the University of Pittsburgh. He has been involved in EMS since 1984, and is widely considered an early pioneer in the field of community paramedicine. Dr. Swayze offers consulting services for MIH and CP program development and runs a popular community paramedic training academy in Pittsburgh and other locations throughout the country. He can be reached at dswayze@statmedevac.com.
