Mitigating the risks of the opioid epidemic with harm reduction strategies

You administer 0.4 mg naloxone IV to an unresponsive, apneic male found in an alley. After he comes around, he tells you, “I didn’t do drugs, I just fell out. I’m tired.” There are fresh track marks in the man’s AC vein, and you have already disposed of his used needle in the sharps box.

What do you say to him?

“Don’t lie. You used drugs. You weren’t breathing. I gave you naloxone. I saved your life. Stop doing drugs or you are going to end up dead or in jail.”

That’s what I used to say when I started as a paramedic in Hartford, Connecticut, over 25 years ago. I felt I was giving drug users tough love. At the end of this article, download your copy of a harm reduction conversation to have with your patients.

I believed then drug addiction was a character flaw. I thought drug users were a plague on the healthcare system, views that I saw reiterated as I watched healthcare professionals and drug users shout insults at each other in ED scenes that resulted in patients storming out of the hospital or security guards tying them to gurneys.

That all changed when I started asking my patients who had overdosed (whose numbers were increasing each year), how they got started using opioids.

“I got hurt in a skateboard accident.”

“I broke my back in a car accident.”

“I was shot in Iraq.”

“I had a tumor.”

“I got hurt on a construction job.”

More than one person used the words, “I used to be a normal person once.”

Their tales were similar. They were prescribed pain medicine. As their tolerance grew, their doctors gave them more and stronger pills, until one day they were cut off. To fight off sickness, they bought pain pills on the black market, but the pills were expensive. The same dealer that sold them pills could sell them heroin, which was chemically similar, but much cheaper. They started sniffing the powder, and when their tolerance grew, they switched to IV use. Along the way many lost their jobs, families and some would lose their lives.

A harm reduction script

It was not uncommon for us to stand over bodies in rigor mortis with needles still in their arms. In Connecticut in 2012, 357 people died of drug overdoses. By 2020, the annual body count was 1,374.

They didn’t teach us about addiction in my paramedic class in 1992. I started learning on my own. Today, I understand addiction is a chronic relapsing brain disease that many users never recover from. Expecting someone with the disease of addiction to just say no may be tantamount to expecting someone with a broken leg to run a 100 yard dash or someone with COPD to climb Mount Everest.

We in EMS like to respond to calls where a crisis is occurring and we can fix it, and the person is better and can return to their normal life. Unfortunately, EMS calls are rarely that simple.

We revive someone with naloxone and then we find the same person overdosed several weeks later. Does that mean, we stop trying to save them? Or does it mean we have to find other ways to get through to them?

If we can’t stop someone from using drugs that could kill them, we can at least try to help them mitigate the risks. This is called harm reduction. According to the National Harm Reduction Coalition, harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm reduction “accepts, for better and or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.”

In EMS, we often have the opportunity to educate our patients and to intervene at critical moments. Patients who have suffered one overdose are at the highest risk for suffering a fatal overdose. We may revive a patient who does not wish to be transported to the hospital, or even in the cases of patients who do, we can employ the concepts of harm reduction, to help gain a foothold toward eventually making a difference.

Here is a harm reduction conversation you can have with your patient:

• Do you know where to get clean needles? Never share a needle with someone else.
• Do you have naloxone? If not, do you know how and where to get it?
• Don’t do heroin alone. Have naloxone readily available for your friend to use on you or you to use on your friend.
• If you haven’t used for a while (after a period of abstinence, rehab or prison time), use a smaller amount because you no longer have the tolerance you once did and you may overdose.
• If you are going to use an unfamiliar batch, use a small amount.
• Be careful mixing heroin with benzos or alcohol.
• If someone overdoses, call 911.
• If you are ready for help, here’s a toll-free number you can call: 1-800-563-4086.
• Your life has value. You can’t recover if you are dead.

Not everyone will hear the message, but some will. The message we give to one patient, they may pass on, and someone might be saved.

Just as we don’t save all of our cardiac arrest patients, we will lose many of our drug abusing patients, but every life we save should be celebrated. We should never stop trying.

It may not be as dramatic as defibrillating a 50-year old who has just collapsed in v-fib cardiac arrest, or applying CPAP to a patient in flash pulmonary edema, but never underestimate the power of words and of fundamental kindness to save another human being.

Imagine the possibilities. A man walks up to your ambulance, and says “EMS saved my life. You gave me Narcan. You treated me decently. I wasn’t ready yet, but eventually I made it. Here’s a picture of my son.” He hands you a photo of a smiling child. “Thank you.”