Who Narcan Saves

I was at a recent meeting of a statewide opiate overdose working group, composed of a wide variety of community stakeholders all committed to helping curb the crisis, when I heard one woman say our goal should be Narcan in every medicine cabinet. Certainly Narcan should be in the homes of any person with a history of opiate use.

Narcan saves lives.

But it is important for those who view Narcan as a magic bullet to understand Narcan does not save a life every time it is used.  It is irresponsible for those who know better to issue press releases equating the number of Narcan uses by their organizations with the same number of lives saved.

Narcan does not save patients in true cardiac arrest.

Narcan does not save patients with coma not of opiate etiology.

Narcan does not instantly restore adequate ventilations in those patients who may still be breathing, but who are hypoventilating.  If not given in time, Narcan may not save these people unless someone is there to ventilate them.

Narcan does not save patients who are merely dosed on opiates, unresponsive or semi-responsive patients who are breathing/ventilating adequately on their own (These patients don’t need saving).

Here’s what Narcan does do:

Narcan saves the patient whose respirations have become so inadequate that hypoxia is building up, and if not corrected, will ultimately lead to cardiac arrest or anoxic injury prior to the arrival of competent responders equipped with the means to properly ventilate the patient.

This includes patients for who responders have not been summoned and for patients whose responders have arrived but who are not competent with their tools of ventilation.

In addition to saving lives, Narcan spares the need to intubate many patients whose airways would otherwise have to be protected until their opiate wears off.

The number of patients who Narcan saves will be but a portion of those patients who actually receive Narcan, but the lives Narcan is saving is no small accomplishment.

Narcan is saving sons, daughters, spouses, parents, family, friends, and strangers with families and friends of their own.*

We must make timely Narcan available to all patients who fit these categories.

That means Narcan for all responders, Narcan for lay people and indeed Narcan in a medicine cabinet in every home where opiate users reside.

If we want to save more lives we have to expand Narcan provision to include face masks and training in mouth to mouth or perhaps simple cardiac compressions in those without any respirations to provide passive ventilation until the Narcan kicks in or trained responders arrive.

We should also consider upping the initial layperson/single first responder dose (in those areas that haven't already) of 2 mgs IN to 4 mgs IN to bring effective breathing/ventilation back sooner.

 

* Narcan is saving some of these patients more than once. Just as we in EMS save many of our patients with other diseases (heart, diabetes, lung, psychiatric, trauma) more than once. 

Oxycontin Worldwide

 As the opiate epidemic fueled by the overprescription of Oxycontin and the false claims of its safety is devastating our country, the Los Angeles Times is reporting the drug companies are now aggressively marketing the controversial painkiller overseas, using the same tactics they employed in this country.

OxyContin goes global — “We’re only just getting started”

Read the entire investigative series:

‘YOU WANT A DESCRIPTION OF HELL?’ OXYCONTIN’S 12-HOUR PROBLEM

More than 1 million OxyContin pills ended up in the hands of criminals and addicts. What the drugmaker knew

How black-market OxyContin spurred a town's descent into crime, addiction and heartbreak

His next pill: An OxyContin user’s journey from pain relief to obsession and addiction

Bravo LA Times for bringing attention to this issue.

For their next investigation, I would like to see them investigate the campaign contributions OxyContin makers have made to current lawmakers.  My guess is they have donated widely and greatly and few have rejected their money.

Hartford Police To Carry Narcan

 When I started as a paramedic in Hartford in 1995, only paramedics carried Naloxone.  Today, BLS ambulances carry it as well as our first responding Hartford Fire Department.  A month from now, our Hartford Police Department officers will also carry it.  This is a good thing.

Hartford Police Begin Carrying Naloxone As Drug Overdose Deaths Continue To Rise

Many times I have shown up at a car accident scene or a report of a man down where the first arriving police officer has shouted to me, "You're going to need your Narcan!"

Hartford is a drug mecca for our surrounding suburbs, as well as states in northern New England.  Substance users drive in to buy the drug going now on our streets for just $4 a bag or $35 for a bundle of ten bags.  Unable to wait till they get home, they shoot up in their cars and crash or pass out at the wheel in the middle of intersections.  Some who come in on public transit OD at the bus stop or in public restrooms.

The white powder is potent too.  Increasingly, the dealers are selling Fentanyl mixed with, or in place of, heroin.  Its not just one or two bad batches that are killing people.  Many experienced users refuse to buy any bag that carries "white heroin" because they fear the Fentanyl.  Others, of course, flock to it for the chance of a stronger high.  The novice user or the person whose tolerance is not what it used to be thanks to rehab or a prison stretch are extremely vulnerable.  The police carrying Narcan will no doubt save some lives.  They may save some of the same lives repeatedly, but substance use is what it is.  People are subjugated by one of the most addictive drugs in the world, a drug that damages and permanently rewires their brain.  The job of the strong is to help the weak.  A man's life is worth saving the second and third times as much as it is the first.

Those against giving first responders Narcan can say it doesn't matter that as long as a responder who is capable of bagging gets there, the Naloxone will eventually arrive, but not all first responders are great at bagging.  Bagging is hard for a single cop, much less two EMTs or two paramedics.  I was at a heroin cardiac arrest when after 2 minutes of CPR we converted a brady PEA rhythm into vfib, which we then blasted with 200 joules and 1 mg of epi into a perfusing rhythm.  The man still wasn't breathing and my partner and the firefighter were bagging and having difficulty getting good chest rise.  I helped  them reposition the head.  I oversaw what I thought was excellent bagging.  Good seal, good chest rise, good compliance.  When our patient still wasn't breathing on his own  despite Narcan, I finally decided to put a tube in.  The ETCO2 was 70, but came down to 40 within a minute.  In other words, despite excellent bagging the patient wasn't ventilated nearly as well as he was with the tube in place.  I have seen that on other occasions.  A typical heroin overdose I put ETCO2 nasal capnograpgy on, and often find initial readings of 90 or 100.  I can bag it down sometimes to the 50s or 60's, but when they start breathing on their own, their ETCO2 plummets to the normal range of 30-40.  If the cops get their first, let them get the Narcan in and get these people breathing/ventilating on their own sooner.

So welcome to the battle, Hartford Police!

The fact of the matter is we have all been late to the forefront in fighting this epidemic.  EMS, Fire, police, and citizen -- we are all uniting now to take on this terrible disease that is costing us so many lives -- family, friends and strangers.  Let no one die for lack of giving our best efforts or lack of having the best tools to fight with.

A Life Saved

 A 24 year old man from one of Hartford's suburbs had his life saved by a newspaper.

He got into heroin five years ago through, in his own words "stupidity."   While many get into it through injury, a doctor's prescription exposing them to opiates, taking too many, becoming addicted, getting cut off or needing more than the doctor will give, having to buy pills on the street, then transitioning to the cheaper heroin, he got into the deadly opiate through partying.  Hell, try Heroin, why not? Rock on, Dude!

He comes down to Hartford and buys on the street.  A two bundle (20 bags) a day habit.  He doesn't inject, he sniffs.  He just walks down Park Street and the dealers know what he's looking for.  Pale white guy with tattoos, wearing a hoodie.  We know you're not here to sample the empanadas at Aqui Me Quedo.  KD? KO? Fasttrack? Night Owl?  High Power?  We got what you're looking for.

He got caught up in a drug sweep once, but hadn't bought his drugs yet, so after being frisked, they let him go.  He nearly Oded one time.  On the nod on a park bench.  The ambulance came, but he woke up, and refused transport.  He's been to rehab once, and was on suboxone once too.  He didn't like it.  A couple weeks ago, he came into the city,  bought his heroin and drove home.  His parents don't know he is still using.  His friends don't know either.  There is no Narcan in his house.  He sniffs alone.  He prefers to be by himself.

Before he goes into his room to use, he picks up the newspaper his father had left in the bathroom.  There is the story about the triple overdose on Green Street, including a fatal.  He sees the pictures of the bags found at the scene. Skull and Bones  and some fancy black design on the other bag.  He doesn't even know the design is RR Rocafella, an upscale Australian apparel company.  But the stamp catches his attention.  It is the exact same design as on one of the bundles (10 bags sold for $35) he just bought in Hartford.  Whoaa!

You or I might immediately find Jesus, take it as a sign from above and flush the white powder down the toilet, but he is a heroin user and he needs his fix to fight off the sickness.  He does what he does if ever he hears of a dangerous batch.  He just does a little sample.  He doesn't do the whole bundle.  He just sniffs half a bag at first.  Shit is STRONG!  Finish two bags and he is down.

No knock on the door in the morning.  Son, are you okay?  You're late for work!  No knocking the door down when his Dad finds it locked, and hears no answer after shouting.  No hand on his cold neck.  No call to 911, saying my son is dead.

When he comes around in the morning, he is still in his room.  No pearly gates, no fires of hell.  Just his life.  And hey, he's still got some heroin to get his day started.

That was a couple weeks ago.  Today, he's sick.  He hasn't used in three days, and he wants help detoxing.  He knows if he doesn't get help, he will use heroin again, and one of these days, he's going to meet the batch that will kill him.  We put him in the ambulance and take him from the health clinic to the hospital, and it is on the ride he tells me his story.  "I'm looking at the paper and I recognize the bag.  I just bought that brand.  I think, I got to be careful. I don't want to OD.  If I didn't moderate I would have died. 

Kudos to the Hartford Police for getting the word out and the Hartford Courant for putting it on the front page.

Hartford Cops: Rash of Heroin Overdoses Part of Upward Trend

Bad Batch?

THE NEUROBIOLOGY OF SUBSTANCE USE, MISUSE, AND ADDICTION

 

I used to believe that addiction was a character flaw, and that the drug fiends I treated on the streets of Hartford were there due to their own poor choices.  That doesn't mean I treated them badly. I have always tried to treat all my patients as if I were treating members of my own family.  That said, like anyone I have good days and bad days, and don't always live up to my expectations.

The older I get the less judgmental I am.  I guess I have seen people go through hard times over the years, and am more sympathetic.  I view the drug fiends, as I called them, differently now for two reasons.

One, I know people can stumble, they can make mistakes and they can have bad luck.  Not all roads traveled lead to good ends.

Two, science now makes a compelling case that addiction is a brain disease. Hard core addicts are crippled in their thinking in much the same way that people with heart disease have diminished cardiac capacity or diabetics have problems regulating their sugar.

I advise all to read the chapter on THE NEUROBIOLOGY OF SUBSTANCE USE, MISUSE, AND ADDICTION  from the just published Surgeon General's report Facing Addiction in America.

Here's the jist:

Use of opiates causes neuroadaptations in the brain's structure and function that impair logical thought and breed abnormal behaviors.  These neuroadaptations can persist long after a patient has gotten clean and cause them to relapse.  People with substance addiction are damaged in the same was as people with heart disease, COPD or diabetes have damaged hearts, lungs, and endocrine functions.  People with opiate addiction have damaged brains.  This can be seen on MRIs.  We can't expect them all to sudden act rationally in the same way we can't expect someone with a heart transplant to run a marathon, a COPDer to climb Mount Everest or a diabetic to live without insulin.

This from the Surgeon General's report:

• Well-supported scientific evidence shows that addiction to alcohol or drugs is a chronic brain disease that has potential for recurrence and recovery.
• Well-supported evidence suggests that the addiction process involves a three-stage cycle: binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation. This cycle becomes more severe as a person continues substance use and as it produces dramatic changes in brain function that reduce a person's ability to control his or her substance use.

• Well-supported scientific evidence shows that disruptions in three areas of the brain are particularly important in the onset, development, and maintenance of substance use disorders: the basal ganglia, the extended amygdala, and the prefrontal cortex. These disruptions: (1) enable substance-associated cues to trigger substance seeking (i.e., they increase incentive salience); (2) reduce sensitivity of brain systems involved in the experience of pleasure or reward, and heighten activation of brain stress systems; and (3) reduce functioning of brain executive control systems, which are involved in the ability to make decisions and regulate one's actions, emotions, and impulses.

• Supported scientific evidence shows that these changes in the brain persist long after substance use stops. It is not yet known how much these changes may be reversed or how long that process may take.

• Well-supported scientific evidence shows that adolescence is a critical -risk period for substance use and addiction. All addictive drugs, including alcohol and marijuana, have especially harmful effects on the adolescent brain, which is still undergoing significant development.

* Well-supported: when evidence is derived from multiple rigorous human and nonhuman studies; Supported: when evidence is derived from rigorous but fewer human and nonhuman studies.

Our job in EMS it to keep these people alive and help steer them toward recovery. We can do it by reversing their overdoses, by guiding them to treatment and treating them like fellow human beings.  We are all in this human journey together. Let's help each other out.

Peace to all.

Graphic from Facing Addiction in America.