One of my EMS coworkers and a budding journalist Sean Freiman interviewed me recently about Hartford's Opioid Crisis with a focus on the heroin bags.
Click on the picture to view the interview.
Thursday, April 26, 2018
Naloxone's Effect on Opioid Use
Does access to naloxone influence an opioid user’s decision to use?
That is the crux of a recently published (on-line) economics paper, The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime, which argues that increasing access to Naloxone sanctions risky behavior, unintentionally increases opioid abuse, leads to greater crime, and may increase the death rate.
The paper has generated a great deal of controversy. (The authors have rewritten some of their paper to accommodate some of these expressed concerns.)
The moral hazard of life-saving innovations: Naloxone access, opioid abuse, and crime (Blog Post)
The ‘moral hazard’ of naloxone in the opioid crisis
Why a Study on Opioids Ignited a Twitter Firestorm
Research Analysis: Conclusions about 'moral hazard' of naloxone not supported by methodology
Their underlying assumption seems to be that naloxone creates a safety net whereby opioid usage will increase because users have less risk knowing if they overdose they can be revived. The authors cite a legislator who told a Congressional hearing “Kids are having opioid parties with no fear of overdose,” news reports of police finding naloxone at overdose scenes, and an Ohio police officer who is quoted as saying “We’ve Narcan’d the same guy 20 times.” The researchers say their data proves these anecdotes represent valid concerns, even if the “Narcan Parties” anecdote seems to have little substance in truth.
I am not well enough versed in economic theory and concepts to discuss the quality of the paper or the methods they have used to build their findings. I can say other papers have found the opposite.
The authors use the concept of moral hazard, which is an economic term, that suggests that people may not do what is right for them if the consequences of their action are covered by someone else. It is a term used often in insurance, where if you have car insurance, you may drive with less care than someone driving without insurance who would have to bear the full cost of an accident.
Translated to the opioid crisis, a user doesn’t have to worry about overdosing because a system is in place to revive him. He will consequently use when otherwise he might not have and/or will use with less concern than he might otherwise have had. I have doubts that this risk/reward thought process applies well to addicted individuals who no longer have a good concept of risk due to the damaged circuitry in their brains that opioids have inflicted on them.
As as a paramedic with experience dealing with opioid users, and as member of an overdose working group that seeks to increase access to naloxone, I can say the following:
1. Users are going to use. I don’t think they are going to put off their next hit because they are out of narcan or there is no person available to call 911 if they keel over.
2. Users hate Naloxone. They will have it around to save their lives if they have to, but no one is deliberately dosing with the intention to let themselves get “Narcan’d.”
3. Yes, by keeping people alive, Naloxone will allow a user to use again. The user instead of dying, may commit more crimes (if that is how the user supports his habit). That is a trade-off I am sure we all are willing to make as human beings.
4. No one has ever said that Naloxone alone is the key to ending the epidemic. Naloxone is about keeping people alive until they are ready to recover. I agree with the mantra of the Harm Reduction Community: Dead people can’t recover.
Here is the CDC's three pronged response to the Heroin Epidemic:
Friday, April 20, 2018
Rescue Breaths or Compressions in Overdose?
Should unresponsive overdose victims receive rescue breaths or chest compressions from lay bystanders?
If a person is apneic but not in cardiac arrest, failing to give rescue breaths may lead this person to fall into cardiac arrest.
But, if the person is apneic and in cardiac arrest, failure to do quality chest compressions, will lead to their death.
This is a difficult question that we debated in our opioid overdose working group last year. We chose to follow the American Heart Association standards and tell lay rescuers to do chest compressions in apneic patients rather than attempting rescue breathing.
Chest compressions-only are simple, easy to learn, and backed by science.
I like the chest compression for the lay public because:
Chest compressions while providing some circulatory support also provide passive ventilation. *
Chest compressions are also a great stimulus to revive someone from an apneic state.
Most people don’t do rescue breathing very well.
The Ontario Canada Ministry of Health debated the same question and has decided to abandon the AHA standard and instead teach rescue breaths. Lay people are now taught rescue breaths, but are given the choice to perform rescue breaths and/or cardiac compressions.
An article on the Canadian CBC News website, Ontario makes controversial change on how to help overdose victims, does a nice job detailing the debate up there.
Here is some other info on the debate:
Should the public be trained to do CPR on overdose victims?
Evidence Brief: Evidence on rescue breathing or chest compressions in local naloxone programs
***
Having voted on the compression only side, the truth is most of the unresponsive overdose patients I respond to are unresponsive and have pulses. These people clearly could benefit from rescue breathing from bystanders. (Some of the unresponsives I respond to are dead and only a few of these are recoverable).
Unfortunately the one size fits all training is probably not the best approach. I think, given the stakes, it is probably worth teaching the willing-to-learn lay person a tiered approach.
Here’s how that would work: If you can’t remember what to do or are uncomfortable doing something, at the least, do chest compressions. If you want to check for a pulse and can find one and are reasonably certain the patient is not dead, do rescue breathing if you have a face mask. If you work in a setting where people overdose frequently (halfway house for example) or if a family member of yours is an opioid user, learn how to use a bag-valve mask and have one on hand next to your naloxone.
Bagging may not be the easiest skill to acquire, but if people have a reasonable belief they may need to use it someday to save someone they care about it, we should make certain training is made available to them, as well as opportunities to practice this life-saving skill.
***
* Here is a capnography strip that shows passive ventilation during CPR.
Tuesday, April 10, 2018
Follow Up
Overdose on Babcock Street. In an alley behind a building. Fire is there before us. A familiar scene. As I approach I can see them hunched over the patient, the bag valve mask out. They have already given her four of narcan. I stand over them looking at the patient. I can’t see her face because the mask obscures it, but I notice that she is quite tiny. I look at her neck then and can see the butterfly tattoo sticking out from under her winter coat. It is Veronica. I last saw her a month and half ago, and had wondered what was going on with her. Did she go back to Woodbury to stay with her sister as she always does when she tries to get clean? Or had she died alone in an alley such as this one? At least I know she is alive. I have the firefighter stop bagging for a moment, and can see while she is still unresponsive, her respirations have picked up. The ground is cold, so we lift her up onto our stretcher, and then bag her on the way to the ambulance. We load her in back, and I barely have her hooked up to the capnography, when she opens her eyes with a violent start. She looks at me blankly.
“Veronica,” I say.
She tears the cannula out of her nose. She squirms and tries to undo the belts.
“No, no,” I say.
“Get it out of me! Get it out of me!” She shouts.
My partner, who has already started driving to the hospital asks me if I need a hand.
I am six eight, two hundred and thirty pounds. My patient is maybe four and a half feet and eighty pounds. “No, I’m okay,” I say as I parry off the blows and kicks she directs toward me. “Help me! Help me! Get it out of me! Get it out of me!” she screams.
Two police cars are following us as is there practice. I can understand it with regular size people, but this seems unnecessary. I am glad she is so small because I would be in for an ass whupping if she was normal size. She is very, very pissed. The last time I saw her I gave her a orange, a big Cara Cara orange that are so sweet. It was my only one, but I had been glad to see her on the street and to chat with her to see how she was doing and give her encouragement, and I knew how much she liked oranges. Now, she still does seem to even recognize me, or if she does, the prior gift of the Cara Cara orange has bought me no mercy or kindness from her. “Help me! Help me!” she screams. “Get it out of me! Get it out of me!”
By the time we make it to the hospital, she has exhausted herself so that she just lays on her side panting, and then she vomits all over herself and the stretcher.
I was all for the move to the new 4 mg intranasal (IN) naloxone because I thought it would be great for lay people and first responders who either don’t have ambu-bags or are not that experienced with them. The 4 mgs would restore the overdosed person’s respirations sooner and help ward off hypoxic injury. But the truth is, now it seems every overdose I go to, I get there just in time for the person to either try to kick my ass or to vomit on me.
4 mg IN, which is the equivalent of 2 mg intramuscular (IM). may just be too much for some people.
I check on Veronica at the hospital several hours later and am glad that she is still there. She looks wiped out and is very pale. She tells me she told them she wasn’t ready to go back on the street. I don’t blame her because when we brought her in, she didn’t have a cent on her. Her purse was empty. Not a penny in it. And no ID. Robbed again.
She tells me they are going to transfer her to the psych wing because she told them she wanted to kill herself.
“I’m glad you’re getting help,” I say.
She tells me she had gone back to stay with her sister and as always it lasted about a month before they had enough of each other and she came back to Hartford and started in on the heroin again.
I kid her about how crazy she was when she came around from the narcan. She smiles and says, "The Narcan always makes me crazy."
“Crazy,” I say. “You went complete ape shit on me.”
“You didn’t have to give me so much narcan.”
“I didn’t give it to you, the fire department did. That’s the only size they carry. I would have only given you a little, you know that.”
“I am always violent when I get the narcan. I don’t react to it well.”
“At least you’re alive,” I say.
She shrugs. The shrug saddens me as I sense she truly is ambivalent about living or dying.
The next day, I am off. My partner texts me that he is transporting her from the psych wing to a substance abuse facility. I text him “Tell her I am proud of her.”
He texts back later “She said thank you.”
In EMS you always want to know the followup, the rest of the story.
Will she beat it this time? Can she stay clean? Can she find a new life for herself? Or will I see her walking Park Street again? Hanging with the dealers who like to watch her dance? Will I have to hold an ambu-bag mask over her face again? Or will I or some other medic find her cold and stiff, her spirit long flown away?
Sunday, April 01, 2018
Undetermined
Opioid deaths are generally classified as accidental overdoses. In 2017 Massachusetts began reporting opioid deaths as “All Intents” where they previously reported them as “Unintentional/Undetermined.” They point out that adding suicide deaths only marginally adds to the count. By their statistics only 2 percent of the total opioid deaths were confirmed as suicides.
Massachusetts Opioid Death Data
Connecticut reports opioid deaths under the term accidental drug related deaths. If a person left a suicide note, and then injected themselves with heroin, they would not count in the state’s totals. In most cases, it is hard to say with determination the overdose was a suicide.
An article published on March 28 in Medscape asks “How many Opioid Overdoses Are Suicides?” It offers fairly persuasive arguments that the numbers are much higher than reported.
How Many Opioid Overdoses Are Suicides?
Dr. Maria Oquendo, the past president of the American Psychiatric Association, is quoted as saying based on published studies, the suicide rate could be anywhere from 24 to 45 percent of all opioid deaths.
Should this change the way we view the current crisis? I don’t think so. There is a strong link between addiction and mental illness. I have read many articles that speculate that many users use not just because their brain has been rewired by the opioid overloading their circuits, and replacing the normal human drives for food, sex, and protection of our children with the need to use heroin, but because fundamentally many people use opioids to escape loneliness, shame, and despair.
One argument made along these lines is the fact that supposedly 90% of Americans addicted to heroin in Vietnam came home and were able to kick the habit because they were put back in places where they had strong support networks, families and jobs so they could function as members of society.
What Vietnam Taught Us About Breaking Bad Habits
The other argument involves the famous rat park study. Previous studies showed rats would drink drugs until they died. Another researcher on learning that the rats, social animals by nature, were kept confined in small cages with no interaction with other rats, went ahead and built a rat amusement park where they had food, running wheels and lots of companionship including rats to mate with. Guess what? The rats drank 19 times less opioid solution than the rats that were kept in isolation. Even rats that had been in isolation and were addicted, when put in the rat park, stopped using the drugs.
What did that experiment show? Isolation and despair led to addiction while social interaction helped avoid it.
When we treat users like human garbage and berate them, and then release them from the ED two hours later in withdrawl with the instructions to stop using heroin, how can we expect them not to use a drug that if only for a short while will make them forget about how bad their life has become?
I think many people addicted to drugs who have fallen to the bottom may not have the strength to climb back up. Some may just give up. Maybe one night, instead of doing five bags of No Evil, they decide to do ten. Goodbye world.
Accident or suicide? You can call it undetermined. But either way, another human being is lost to us.
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