Reflections

Thirty three years I’ve been in EMS now and if there is one line of advice I have for people starting out in the field, or just for life in general for that matter it is:

Don’t Be an Asshole

EMS is stressful and we are constantly in situations that may put us in conflict with others.  I sit in EMS rooms and listen to people bitch about coworkers, patients, patient’s families, dispatchers, nurses, doctors, police, fire, bystanders, management, the union, their spouses, the government, their sports teams, their health, the weather, etc.  Serious negativity.

Sure some of it is blowing off steam, but when everybody does it, expected conversation comes to be about who is having the worst day, who can be more negative about life.  You carry that attitude onto a scene and someone gives you a hard time, and it can quickly becomes about standing up for yourself by putting others down.  I told that nurse where to go.  I gave it right back to that patient’s family.  I told that addict to stop using drugs and wasting my time or he’s going to end up dead and good riddance.

I had to pull a young woman aside and talk to her about that.

Can’t we all just get along and show some empathy for our fellow human travelers on this earth.  Can we at least replace insults with humor?

When I had a negative partner, it inevitably turned me negative and I always went home in a bad mood.  The best partner I ever had was an older woman at the time who put cheery stickers in the ambulance, and always had nice things to say to everyone and was always to the patients even the grouchy, miserable ones.  I loved working with her.  She didn’t wear me down.  I had another great partner who was always quick with a joke, who knew how to defuse tension, and who made coming to work fun just like two buddies hanging out, marveling at the crazy wonderful and diverse world we find ourselves in. Now, I work in a fly car by myself. It is lonely at times, and if I feel negative, I can only blame myself.  And if I am positive, then good for me.  Be happy.

I’ve started watching this show on AppleTV called Ted Lasso.  It’s about a man (a coach) who is optimistic, who believes in giving everyone the benefit of the doubt, who has a big heart, knows that no one is perfect, including himself, and has the emotional intelligence to recognize it is not all about us, but more about what we can do to make others’ lives better.

I want to be like this man.  I am trying but not always succeeding.  Yesterday I was abrupt with a woman, who screamed at me, her spittle coming close to my face, for not putting oxygen on her family member, who was having an anxiety attack.  “He doesn’t need it,” I said.  “His oxygen is 100% and his lungs are clear.  He’s speaking in full sentences.”  “Well, I’m in the medical field, too.  You need to do something.” I said nothing more to her, but I could have been more reassuring, my tone less strident.  Later, a  man leaned out of a second story window and told me I was too slow getting out of my vehicle, not understanding I had to put myself out with dispatch, unfold my long legs to step out of the car, put on a face mask, then open up the back hatch to grab my house pack, my heart monitor and unlash an grab an oxygen tank, and then navigate and uneven cracked stairway up to the building door.  “Hey, I shouted to him.  “I’m the first one here, cut me a break!”  I didn’t need to say that.  I should have just left it alone.

On the positive side, all day long, I let cars cut me off.  I waved them in.  I looked every first responder in the eyes and focused on them when they gave me their reports.  I said thank you to many people.  All of my patient handoffs at the hospital were professional with some joviality thrown in.  I responded to a woman down, only to find the woman alert and crying sitting on the curb, leaning against a street sign.  She did want to go to the hospital and apologized for bothering me.  She said she needed detox, but did want to go to the ED because she would have to lie and tell them she was suicidal, which she wasn’t.  I gave five dollars and wrote her walking directions out on how to get to the harm reduction center where they could help her.  I didn’t blame her that she never made it there. Instead of immediately exciting a house after calling the time on a woman who sat cold, stiff and lifeless in her favorite chair watching TV,  I stopped and said a few words to her son. I asked him what he most remembered about his mother and listened as he told me of how she sang to him when he was a child.  I didn’t get angry when the dispatcher didn’t acknowledge my requests to go in for my crew change like an old partner of mine used to. She was probably busy with work I could not see. On the third request she answered and sent me in.   Dispatcher is a thankless job.

When I finally made it to the base, I gassed my vehicle up, restocked my supplies and turned the car over to my relief.  After I punched out, I stopped at the grocery store and bought chocolate for my wife and ice cream for my daughter.  When I got home, I did not snap at them when they did not acknowledge my “I’m home!”  I showered and sat down with them, and when their show was over, we watched another episode of Ted Lasso, where he makes a surprisingly kind and human gesture to someone expected. 

When I come home on Friday’s, my wife knows I can be touchy.  The pace of the city and being in the rapid response car is relentless and at my age it tires me out, and when I am tired, I can get a headache and be quite irritable, but I wasn’t last night.  I was grateful for my life and family and for work that is rewarding and for those in the world who show the way, how to be good to others and not be an asshole.

As we watched Ted Lasso, I asked my daughter what she thought of him.

“He’s a good guy,” she said.

“Damn straight, he is!”

Thank you all.

High Dose Naloxone

This week I was asked by the Connecticut Alcohol Drug Policy Treatment SubCommittee to comment on the new FDA approved high dose 8 mg naloxone product, Kloxxado, from the EMS perspective,

 Here’s what I told them:

Three Points

1. High dose naloxone has no place in EMS/First Responder arsenal.

2. It has not been proven that higher doses of naloxone are needed to reverse fentanyl overdoses.

3. High dose naloxone is more likely to cause precipitated withdrawal than traditional doses.

Point 1:

We in EMS are taught to assist ventilations and administer naloxone at the lowest dose possible to achieve spontaneous ventilation/oxygenation. The goal is not to fully wake the person up, but simply to restore their ability to ventilate/oxygenate themselves. I typically administer naloxone at 0.1 mg/min when I have an IV or 0.4 -1.2 IM if I don’t. I give 1.2 mg for patients who are blue and apneic. 0.4 if their breathing is agonal. I rarely ever give more than 0.4 IV and rarely need a second dose if I deliver it IM.

Our local fire department carries the 4 mg IN and if I am on scene before they have given it, I tell them to hold off, and just bag the patient until I can give a more moderate dose. Too many times I have arrived after they have given it, only to have the patient sit up and vomit towards me.

Point 2:

The two studies the drug companies seem to use most that show EMS is using more multiple doses than in previous years did not take into account the route (IV, IM or IN), what the doses (.04 or 4 mg) were or time between doses (1 -5 minutes) or who had administered the doses (layperson, PD, Fire, EMS).

Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing 

Who receives naloxone from emergency medical services? Characteristics of calls and recent trends

Other research has shown despite increasing fentanyl presence, more naloxone has not been needed for reversals.

Naloxone Dosing After Opioid Overdose in the Era of Illicitly Manufactured Fentanyl

Fentanyl: a comparison of blood fentanyl concentrations and naloxone dosing after non-fatal overdose

Amount of naloxone used to reverse opioid overdoses outside of medical practice in a city with increasing illicitly manufactured fentanyl in illicit drug supply

A word on naloxone dosing:

The number of doses does not equal the amount of dose. 4 doses of 0.1 IV is much less than 1 dose of 4 mg IN.

It is not uncommon for a bystander to dose, the first responder (police/fire) to arrive and dose, and then EMS (ambulance) to arrive and dose all within a few minutes. Had a paramedic arrived first, the patient likely would have only gotten on 0.4 mg dose and the patience to bag the patient until he began breathing on his own.

It is not uncommon for bystanders to empty all their available naloxone into unresponsive people. We regularly receive reports of people getting 16 mg and 20 mg total doses from collected bystanders.

It is also not uncommon for people who are “dosed” (depressed consciousness) to receive naloxone when naloxone should be reserved for severe respiratory depression/apnea.

Point 3.

High Dose naloxone is more likely to cause sudden severe opioid withdrawal, including agitation, restlessness, aggression, body aches and cramps, diarrhea, nausea and vomiting, excessive sweating, and increased blood pressure.

In Connecticut, we examined the rate of side effects (nausea, vomiting, agitation) from single dose intranasal naloxone administration for suspected opioid overdose in Hartford, Connecticut for the period of June 1, 2019 to December 31, 2019.

Here’s what we found:

33.5% of suspected opioid overdose patients suffered adverse effects after receiving a single dose of intranasal naloxone.

20.5% of those who received 2 mg IN had side effects. 

38.1% who received 4 mg IN had side effects.

6 patients who received doses of 0.5 mg and 1 mg via the intranasal route suffered no adverse effects.

SWORD February 2021 Newsletter 

Given the increase in side effects, high dose naloxone may cause hesitancy in people who use opioids to administer the antidote to their friends. I have been on many scenes where people in withdrawal are extremely angry at their friends for having administered naloxone, as they kneel on the ground puking and cursing, and I have seen how this has deeply bothered their friends, and likely caused them to wonder if they did the right thing, if maybe they should have waited or tried more stimulation instead of robbing them of their high and putting them into excruciating withdrawal.

I told the committee these are the decisions that need to be weighed:

Will increased side effects from high dose Naloxone cause hesitancy to use naloxone in overdose? 

We should listen to People Who Use Drugs.

Is there convincing data to show that 8 mg IN will save people that 4 mg IN will not? There is not.

Currently we say wait 3 minutes between 4 mg IN doses. If we go with 8 mg, are we saying to those who carry 4 mg that they should give both nasal injectors at once? I don’t think so.

Who is pushing the need for higher doses? Pharma versus Harm Reduction. Most harm reductionists I know are against the high dose naloxone, while Big Pharma is pushing for the higher dose products. A couple of weeks ago, I met with a representative from a well known Pharma company who wanted to hear from me about how to combat the synthetic opioids that require more doses.

I told them much of the above, as well as sending them a copy of an excellent opinion piece by Lucas Hill published in the International Journal of Drug Policy

Increasingly powerful opioid antagonists are not necessary

Kryptonite

 

(An excerpt from a fictional work in progress.)

Prologue

Hernando already had a 200-gram bag of heroin on the table, as well as a smaller baggie of fentanyl, a canister of baby formula, four packages of Benadryl, and several small open cardboard boxes, each holding 600 of the blank glassine envelopes they would be putting their product into. Enrique helped Hernando package the heroin to be distributed to the dealers Hernando had below him. In return, Enrique got a break on his own supply.

Hernando used to do a 40/60 cut of the heroin with the baby formula, but Enrique had convinced him to do a 50/50. The better the product, the quicker they would sell out, and the faster their brands and reps would grow. There was so much quality on the streets these days, no one wanted to buy shit. Now that Hernando was also getting a few grams of fentanyl to mix in, their brands were banging, although Hernando always urged caution, and resisted all of Enrique’s attempts to move to an even bigger fentanyl presence. Fentanyl’s the future, Enrique told him.  He argued that the fiends loved the rush fentanyl added, and the fact that it lasted three to four hours before they started feeling sick again (compared to heroin’s six to eight hours) would only increase sales. But Hernando countered that it was better to be the longest-selling dealer than a flaming star. Kill too many of your customers and not only would your business drop, but the judge would drop the hammer on you. Hard time.

They put the heroin in a coffee grinder to break it down into as fine a powder as possible, straining it again in a sieve, and then mixing it with the baby formula and Benadryl. The Benadryl had been Enrique’s idea. It added another pleasing rush, and with all the competition out there, they needed to stand out. He and Hernando made an additional batch that they mixed with brown sugar.

Hernando was very accommodating to his customers. There were many who stayed away from white heroin for fear of the fentanyl, which was fifty times stronger than heroin, but was indistinguishable from heroin by sight. Some dealers were starting to not even sell heroin at all. They just threw a healthy sprinkle of fentanyl in with the cut. It got the job done. Many customers, who had overdosed on white heroin or who were scared over the loss of friends who had died from fentanyl-laced heroin, were just focused on maintaining normalcy. For them, ordinary heroin was preferable to recapturing or exceeding that first great high. They had learned to be disappointed, and now they just wanted to be alive and not sick. Others who were afraid of fentanyl made certain they used smaller amounts of a new brand just to be sure of its potency. Many told tales about waking up hours later with a needle still in their arm. Others woke up in an ambulance, their high robbed by Narcan, their extra bags gone. If they had been in a car, their car was towed and impounded, or left in an unsafe area subject to easy vandalism. One by one, they were learning to be cautious. Still too many users were greedy, and did not moderate enough. Whether it was to escape their suffering or to end it, it was the way of the world.  That’s fiends, Enrique thought. Really, that’s all of us.  Living on the razor edge.  Keeping the ambulance people working.

To the white batch, they added the fentanyl. Hernando watched Enrique closely to make certain he mixed it evenly, but Enrique was a master of sleight of hand, making certain a section of the pile wasn’t all the way mixed, and that was the dope he would use for his own packing and it would be of a higher potency.

“I’m watching you,” Hernando said. “I know you spiked the last batch of your Kryptonite. You’re one heartless motherfucker for being so young.”

“No, I think you’re just selling to the same old tired fiends. I’m getting all the new blood that isn’t cynical to the product yet.”

 “It doesn’t bother you when they take their last breath?”

“It’s not that I don’t warn them. My packages don’t say: ‘Love & M&Ms.’ They say: ‘Kryptonite! It knocks down Superman. Even if you’re wearing a cape, you best look out.’”

 “Only truth is you’re going to pay for it. We all are. Some sooner and that’s going to be you, my cousin.”

 They used 0.1-gram spoons to parcel the combined product into each of the glassine envelopes. Enrique had a 0.15-gram spoon that he’d bought on Amazon that looked identical to the 0.1-gram spoon that Hernando provided. He would switch spoons out when he was packing his product, but he would be careful not to overfill. He figured he would only add an extra 0.02 to his envelopes. He had added the requisite amount of baby formula to the initial mix so the count would even out. A little extra powder, a little extra potency. People would be saying that he was the Man.

 “I might as well tell you now: you sold your last bag of Kryptonite,” Hernando said.

 “What are you talking about?”

“Don’t you watch the news, man? They showed your bag in the papers. It’s time to distance.”

“I saw that. Kryptonite! It looked good. I’m going to start a scrapbook.”

“You’ll be peeking out of jail bars, you keep selling it. “

“Risk of the game.”

“For a smart boy, you’re stupid. Somebody’s got to look out for you. Mario came by a couple hours ago complaining about you taking his business, making his threats. He’s selling Superman, and you go and antagonize him by coming out with Kryptonite. He’s still mad you came out with Lebron when he was selling Kobe, and your Lebron packs twice the punch.”

“Lebron throw down,” Enrique said. “He posterizes any fiend that gives a go.”

“I know your rap, but Mario got to be respected. I said I’d talk to you and, as a peace offering, I sold him your stamp for $300.”

“$300, that’s my stamp!”

“And it’s my $300 for you overmixing the fentanyl. I saw you pull that move again. Don’t think I don’t know you.”

“Fuck.”

“I’m doing you a favor on account your momma was my favorite tia, and out of respect for your old man, an original bad man, and crazy in the head like you.”

“Mario’s gonna sell all cut and call it my Kryptonite. That’ll tarnish my reputation. And how am I going to stamp my bags? My new designs ain’t arrived yet.”

“I got you covered.” He tossed a plastic STAPLES bag on the table. A rubber stamp set was inside. “$11.99. Ten stamps. I’ll give you your first choice.”

“Are you kidding me? I’m not representing any of those. A+, check mark in a box, light bulb, a ladybug, ‘Great Job.’ Who’s going to buy that except some eighty-year-old school teacher?”

“It isn’t the brand, it’s what’s inside, and the brand just reminds them they got it from you. You and your art. It isn’t the art they’re loving, it’s the product. When they’re done, the product is in their blood making all their worries vanish, and your bag—it’s crumpled up and thrown out the car window, lying on the cold ground.”

“No, you don’t understand the fiend. The picture of that bag is imprinted on his brain like a picture postcard of a girl in a bikini at the ocean. It’s a pleasure memory. You stick a fiend in one of those MRI machines and the doctors go ‘Oh my goodness! Look at that!’ Amid all the black and white and grey medical image, right there in the middle of the brain in full Technicolor is a cowering Superman himself. Kryptonite! It’s so real in the fiend’s mind, it isn’t just blue and red, there’s yellow in there too. And Superman’s moving. He’s going, ‘That Kryptonite is strong. I can’t hold out much longer. My eyes growing dim!’ They’ll write research papers about the phenomenon, no doubt.

“Quality and design go hand in hand. Mario’s going to be selling Kryptonite, I’m going to be selling ‘Good Work’ and my beeper’s gonna stop ringing. I’d rather sell blanks than one of these stamps.”

“Do with it what you want, but like I told you, the police are looking for Kryptonite. And the Boogie Man is no doubt out there reconning. Dudes getting fucked up. Dimes dropping. Goldman’s out there holding his press conferences, and the jail filling up past capacity. Best stay low under the radar. Plus, they’ve got that new law, they can charge you now they link up a dead body to your brand, and catch you selling it. Listen to me, use one of these stamps or sell blanks like I do.”

 “Blanks! Blanks are for nobodies!”

“And get yourself a new burner. You’re getting a lot of calls?”

“I had to turn the phone off.”

“You know everyone’s calling you.”

 “Most everyone wants my Kryptonite.”

“Police get your number, they’ll call to set up a buy.  ‘Hello, we’d like to buy some, err Kryptonite.  Just a couple bags.  We’re not cops.  We’re fiends, yeah.  We’re fiends, just looking for some bags of that, what’s that brand?  Kryptonite.  Yeah, Kryptonite.’  Then the next thing you know, they have you on the pavement, in a headlock with their knee digging in your back.  And their bad cop breath enveloping you in a cloud of badness that don’t clear till years gone from your soul.”

While Enrique pretended to be pissed, he had to admit that was a worry he sometimes had. He had done time in juvie, and a couple overnights in the High Street lockup when caught up in sweeps, so he fully expected to find himself back inside for a fair stretch in the future. Build up some more street cred. But what Hernando said made sense. That was part of Hernando’s job—to keep trouble on someone else’s block, oversee the peace and ensure that his territory was productive, that enough profits went to those above him to keep him on the favored list.

They were all cogs in the machine, Hernando a bigger one than Enrique. Hernando tried to keep Enrique happy, but he also tried to keep him small to keep him safe. Hernando had four underlings who sold his product for him so he never sold retail himself. Besides those four, he was also an enforcer over four other dealers, including Mario, who was second in line for Hernando’s post. If Hernando moved up, Enrique would have to report to Mario, the fuck. Something needed to change there, for certain.

Enrique was an individual not well made for the work structure. Hernando was always warning him about his bags drawing too much attention, which was not good for anyone. But Enrique sometimes fancied the idea of being the independent hero, the wanted man like his father had been back in the day when his Last Call stamp proved to be just that for a few too many customers, though it was the rival Kings who got him, not the law. Enrique would be more elusive. He imagined police looking for the mastermind behind Kryptonite, and just when they are about to pounce, he’d switch brands, and they’d be back to ground zero. They would try to get to him through his customers, but his customers protected him because he always had the strongest stuff for their fiend cravings. They’d easily give up other dealers and shit brands, but they wouldn’t reveal the secret to their Man.

Maybe it was okay Mario was taking on Kryptonite. Let him take the fall. Enrique laughed to himself. Sucks to be you, he’d say to Mario when they perp-walked him down Lafayette Street to the courthouse. “You just don’t want to be looking at murder,” Hernando said. “That’s what I’m saying.”

 Enrique was not one to dwell. He loved that Kryptonite stamp, but in the meantime, he had to get product out. After they had packed all of Hernado product, Enrique set about packing the rest for himself. For his bags he decided he would go simple like that special exhibit he had seen today at the Wadsworth Athenaeum. Enrique had been going to the Athenaeum since he was a kid when his Dad had worked there briefly as a security guard. He loved everything from the Egyptian Mummy to the crazy Revolutionary War battle scene that ran almost the length of the wall to the Hudson Bay Last of the Mohegans landscapes. He’s stars for hours at the Picasso. He loved the modern art and the impressionists. He even liked the crazy shit like the paper-mâché of the fat lady sunbathing in the lawn chair. It was all good.

Today the special exhibit had large white canvases with words boldly printed on them in black: PEACE. OPPRESSION. HATE. LOVE. ENVY. KNOWLEDGE. SEX. There was no subtlety. Stark statements. Made you think. That’s what art did. A part of him wished he had come up with the idea himself. HEROIN. SPOON. TOURNIQUET. HIGH. OVERDOSE. DEATH.

He set the letters up in the stamper they sometimes used and started stamping the blank bags. Two simple lines.

Dead

Men

Now that was a statement. Bold. Simple. Artistic. After he’s stamped them all, he packed, sealed and folded each bag, and then put a rubber band around ten, making a bundle. Every five bundles made a brick. $5 a bag. $30 a bundle. $125 a brick. Every bag kissed by the reaper.

City Scene

 A firefighter has already bandaged the patient’s head by the time I arrive in the fly car.  The man sits on the front stoop looking like the fifer in the revolutionary war painting of the three marching wounded soldiers the way his head is wrapped.  The firefighter points out the puddle of blood in the road and explains how witnesses say the man tripped on the curb and hit his head.  “He has a pretty deep gash.”

“How’s his mental status.  Is he all there?”

“No, he’s out of his mind.  He’s on PCP.”

I nod.  That would explain why the man mutters to himself and grabs at invisible bugs in the air.

“She’s on PCP, too.” A short woman in the pink dress stands next to the man.  She opens his tattered wallet that she has fished out of his pants pocket.  She takes out the only cash – a dollar bill—and puts it in her bra. 

“Is that his wallet?”

She looks at me like she is not certain I am standing there — like maybe I am a seven foot lizard, or more reasonably just a hallucination. She goes back to looking through the wallet, slowly pulling out and staring at each card.

“Do you have his ID in there?”

The woman pays me no attention

“That’s his wallet,” the older man who called 911says.  “Put that dollar back and find his ID and give it to the man.  Give it to the man, now!”

 “Are you okay?” I ask the patient.  “Do you know where you are, sir?”

“Yes,” he says.

“Where’s that?”

 “I’m good.”

“What’s your name?  Do you know what day it is?”

“Yes.”

“Are you going to tell me?”

“I’m good.”

“Okay, we need to take you to the hospital as soon as the ambulance gets here.  You have a head injury.”

He doesn’t respond.  I don’t think he even knows someone is standing next to him. 

The woman now has the man’s state card out.  She leans down.  “Beanie, Beanie, what’s your PIN number? Tell me your PIN number.”  She holds the card out in front of him.

“Don’t tell her,” the old man says.  “She’s going to take your money.”

“Beanie, your PIN number, tell me your pin number.”

I can hear the ambulance siren approaching.  “We’re going to take you to the hospital. You need to get that head looked at.”

“I’m good.”

I take my cell phone out and turn the camera on in the selfie mode.  “Look that’s you,” I say.  “You’re all mashed up.”

He looks at the person on the screen — a man with a bloody bandaged face, but says nothing.

“You fell and busted your head.  Look at all the blood in the road.”

 “I’m not going to the hospital.”

 “That’s okay. We’ll take you to the ER instead. That’s the better place for you.”

“Nothing wrong with me. I’m good.”

The ambulance stops in the road, its red lights flashing.

I motion to the medic in the passenger seat to come over.  I am going to tell him his patient has a head injury, and is also on PCP.  It will be a challenge getting the man on the stretcher.

The medic rolls down the window, “Can’t,” he says.  “Dogs.”

A brown and white pit bull is jumping up against the driver side door.  In the middle of the road a second pit bull stares at the ambulance front grille.

The medic shrugs.

“Damn,” the old man says.  “That girl left the gate open again.”

“Beanie, Beanie,” the woman whispers.  Her lips are inches from the man with the bandaged head’s ear.  “Tell me you PIN number.  Tell me your PIN number, Beanie.”

Reasonable People

 

When I started as a paramedic in Hartford in 1995, I thought drug users had character flaws and belonged in jail. Last week at a panel discussion in Hartford I stood up before National Drug Control Policy Acting Director Regina LaBelle, United States Senator Richard Blumenthal, United States Representative John Larsen, and the Mayor of Hartford Luke Bronin. I urged them to consider decriminalization of drug use, creation of a safe, regulated drug supply and establishment of safe injection sites.  I told them I believed the War on Drugs had been a failure and that while we all recognized now that this crisis is a public health problem, not a law enforcement problem, therefore, we needed to take major Public Health ACTION.  People, who we recognize suffer from the medical disease of addiction, have no choice but to go to Park Street or some other place where illegal drugs can be had. They buy the drugs that are offered, but they have no way of knowing the dose they are getting.  Fentanyl test strips can tell a user if fentanyl is present, but not how much fentanyl is in their $3 bag.  Dealers have not found a way to mix the drugs to guarantee a predictable dose.  Fentanyl due to its tendency to clump results in the chocolate chip cookie syndrome, except you have no way to tell that your bag contains a giant chip (clump) of fentanyl that can kill even the most experienced user if they use alone and are not found before the fentanyl stops their breathing and then hypoxia stops their heart.

It used to be that most people who overdosed did so because of tolerance issues –they just got out of jail or rehab or ended a period of prolonged abstinence and when they tried to use their usual amount, they overdosed because their tolerance was low.  Now it seems that overdoses are random.  While people are still overdosing due to tolerance issues, many steady users are overdosing because they take what appears to be their normal amount, but their same amount of white powder contains an unexpectedly higher (and undetectable) percentage of fentanyl and they overdose and die if no one finds them in time.

From a public health point of view if we want to save lives, we have to find a way to ensure people are able to accurately know the dose they are taking.  Trying to get fentanyl off the street through interdiction at the border has not worked.  I suggest a new approach where we offer a safe regulated supply to qualified users.  Instead of buying street fentanyl with its unpredictable dosing people in the program can go to a clinic similar to a methadone clinic where they can get medicinal heroin or dilaudid which they can consume in the presence of a health care provider who can also talk with them about their medical and social issues.  This approach is evidence-based and has worked successfully in other countries from Canada to Portugal.

Back during prohibition many people died or were blinded or suffered other serious maladies due to bootleggers adding wood alcohol to the liquor they sold.  What is happening today is similar but on a far larger scale.  The corpses pile high with no end in sight.  We have the ability to change this deadly trajectory.  Methadone and suboxone work.  So also would legalized regulated and prescribed heroin and dilaudid.  

If you were charged with finding a way to end the opioid death toll, what would be your best bet?  Have a person buy their dope on Park Street and inject down in the bushes of the ravine off Park Terrace where the next day I stand over their cold body and call the time?  Ashes to Ashes.  Dust to Dust. Or have that person use in a clean well lighted room where the dose is measured and the health care provider watching over them has naloxone in hand if needed, as well as a listening ear and the ability to help them find services if they are ready to accept them?

If your daughter was addicted (following a car accident, or simple experimentation) and today has a choice between going to Park Street and buying two $3 bags of Devil’s Son containing who knows what dose of fentanyl or going to a safe consumption site and receiving medical-grade heroin, what would you want for her? 

While years ago, I would have not considered this, today, based on what I know about addiction, based on the stories told me by my patients who use drugs, based on the love we should all hold in our hearts for the health and people of our communities, based on the history of what has not worked and what has, I think it is time reasonable people begin this discussion. Decriminalization. Safe Supply, Safe Injection Sites. Let’s start saving lives.

Emerald City

She took the Dilaudid pill a friend offered her twelve years ago when she was sixteen.  Her sister had recently died and her young life, filled with depression and anxiety, had lost its only source of light.  The pill made her feel well in a way she had never felt before.  She liked who she was when she was on opioids. She had friends. She felt joy again.  Four years later she tried heroin for the first time because it was so cheaper and more accessible.  Two years later she graduated to injecting.  She’s been to rehab five times with no success. She’s tried methadone and suboxone.  No luck.  She is on Vivitrol now, but as the monthly shot wanes, she always finds her way back to the city.  She injects herself with heroin because it soothes her anxiety and cushions her in a cloud of calm.  She injects cocaine because it makes her feel invincible.

The guy she was with in the hotel room called 911 when he came out of the bathroom and found her unresponsive on the carpet with the two syringes on the bureau and the torn heroin bags branded “Emerald City” and the small plastic bag with some cocaine powder still in it.  

She was blue and agonal with vomit on the rug next to her.  With some stimulation, bagging and a small titrated amount of naloxone, we brought her around.  She didn’t want to go to the hospital at first, but we convinced her of the need to be evaluated.  Her heart was racing in the 140’s and her oxygen saturation was only in the high 80’s.  We were concerned she may have aspirated.

The now silent man fetched her purse and slippers and we put them on the back of the stretcher.  With a blanket I covered up her tattooed back and shoulders, but not before complimenting her on her artwork.  The artist had drawn a magnificent mountain top with elaborate etchings of trees, eagles, deer, and stars, along with the words: “The journey to the top is my soul.”

This is the third time she has overdosed, but the first in three years.  I give her my harm reduction talk about the dangers of fentanyl, how it mixes poorly so you never know how much you are actually getting in each $3 bag.  None, a regular dose or a lethal one.  It was a good she was not alone.

We talk more. She answers my question about how she got started, and she tells why it is so hard to quit. When I ask her who the man in the room was, she just shrugs.  Some guy.  I get her demographics.  She lives in a small town forty minutes from the city.  She asks if she has to give me her emergency contact.

“No,” I say.  “Not if you don’t want to give it.”

“I don’t want my parents to know.”

“They don’t have to.  It’s your choice.”

“I don’t want them to lose faith in me.”

I ask her about her relationship with them and she begins crying.  “They love me,” she says.

She tells me how supportive of her they have been, how much they care for her and want her to win her battle.

At the hospital, I tell the girl’s story to the nurse but the nurse just rolls her eyes.  It is busy in the ER and she has no time beyond a basic report.

I wonder where the girl is tonight.  Is she home with her parents?  What will they think when she asks to go out?  Will she just walk the quiet small town streets, struggling for the strength to stay the sober course, to keep her journey on the straight and narrow.   Or is she back here in the city, at another hotel with a nameless man?  The needle in her arm, the heroin easing her skittishness, keeping the darkness at bay, the cocaine rush making her feel invincible — up on the mountaintop now, her soul dancing under the stars? 

.

Hoop Dreams

 

I am sixty-three years old, six foot eight.  I used to be six nine and a half, but life has beaten me down.  Over thirty years in EMS has flattened my spine to the point that some days I can barely feel my legs.  I have no business being back on a basketball court, but I eagerly lace up my new Lou Williams’s size 14s, put on my Washington Generals tank top and head to the park where I will play a pickup game with men half and even one third my age.  I don’t have a lot going for me except my height.  I am slow, not just in speed, but reaction time.  The youngers have found they can attack me with jukes and jives and I am too slow to block their shots when they come at me, and if I go out to challenge their outside shots, they fake me and drive around me, rising to the rim before I even get turned back toward the basket. My balance has already caused me to fall once chasing a ball, scraping my knee, elbow and shoulder and nearly falling another time except for a helping hand of another player to grab me and steady me. I can’t jump.  Once I could dunk.  Now while I stand and can hold onto the bottom of the net with both hands, I can’t jump high enough to touch the rim, while the diminutive point guard on the other team does pull ups on it.  And while I may be in okay shape for sixty-three, I need to sub out frequently because I don’t have the lungs of a thirty-year old.  But I am not completely without value.  If I find the right spot I can hit a jumper.  While slow, no one can block my hook shot and sometimes if I run the court on a fast break, while my defender slacks, I can get open for a pass with an easy layup.

That’s what I play for — to make the baskets.  I try to tell my daughter of the joy I feel when the ball rips through the net.  I know each basket I make could be my last.  I could fall and break my hip.  I could take an elbow to the chest and break my ribs,  I could fracture my hand grabbing a rebound.  I could die in any of a number of ways I have seen people die in my work as a paramedic.

I stopped playing basketball years ago because I did get injured.  I broke a finger going up for a rebound, and while I worked through it, it was painful and I had to develop a new way of holding the IV catheter when I tried to cannulate a vein.  Once, our company, which does standbys at the civic center was granted use of their court at noon one day.  We played a game between company divisions in front of 16,000 empty seats.  I scored twenty points, but took a headbutt to the chest in a scramble for a loose ball, which I believe may have cracked my sternum as I couldn’t sit up in bed for over a month without holding a pillow to my chest, and if I tried to do a pushup, I felt as if my chest would crack in two.  I also dislocated my pinky diving over the courtside chairs trying to save a ball from going out of bounds.  That was my last game for almost twenty years.  I couldn’t risk getting hurt at basketball and missing extended time at work. I had a family to feed.

But taking my daughter to her basketball games and practices in recent years has rekindled the fire.  It also helps that I have a desk job that provides most of my income with my street time now only 10 hours a week, I am no longer entirely dependent on my physical health to get my paycheck.  While my daughter practices with her team inside the gym, I shoot alone on the outside playground. In the rain.  Just like when I was a kid, I imagine myself in the NBA with the clock running down and the ball in my hands, and my teammates depending on me.

I should probably be doing something else with my time, like writing my next book or producing more blog posts or working on a work project or lifting weights, running, stretching or swimming, instead of dribbling a basketball, shooting 50 free throws and then 25 three point shots, but spending a good part of the time chasing after errant rebounds.

Sometimes my daughter will come out and shoot with me.  We had a free throw contest the other day.  First to 10. I missed my first shot, then she hit twelve in a row.  My daughter is 13 and really good.  Last Sunday, as the only 8th grader on a high school travel team, she knocked down three threes in just a few minutes time, where a year or so ago she could barely make the distance.  “Dad,” she tells me. “I love the weekends because I get to play basketball.”  She is talking about a game with officials on the floor of the Bristol Sports Armory and other local arenas where she and her older teammates will play against challenging teams, and win or lose, there will be moments of victory (as well as defeat), memorable moments of a great pass, a spin move to the hoop, or watching a three rip through the net.

I wonder what she will do when she grows up.  I hope she will find work that will bring her as much happiness as basketball does.  That’s why I have always loved being a paramedic.  Sometimes on calls, it is just like playing sports before a crowd  Pressures on, eyes are on you, you have to perform.  You can’t let the pressure get to you.  There is the same camaraderie with your crew or your partner as you had with your team.  I try to teach my daughter that sports is about life lessons, things you can use in the real world, but sports, I am realizing is also an end in itself, a pure joy.  Sixty-three, slow, old, hard of hearing, tired, weak legs,  a cough that rattles the earth itself, but I grab the rebound,  I dribble to the corner,  I turn and shoot. The ball arches through the air.   It rips through the net.

I am alive.

Dopesick

 

“Dopesick” is a new eight-episode series dramatizing the start of the opioid overdose epidemic that originated with Purdue Pharma’s marketing campaign for oxycodone .The series is populated with a fictional cast of characters, including a country doctor (Michael Keaton), a young woman injured in a coal mining accident and her parents who struggle to understand her addiction, an earnest young drug salesman, two US attorneys and a DEA agent (Rosario Dawson) who fight to combat the powerful drug company and Purdue’s bought and paid for allies in the FDA and Congress.  I’ve seen seven of the eight episodes, and I can tell you this is riveting TV that will move, startle and anger you, and I hope by the final episode, inspire you to help change this country’s approach to the epidemic.  The producers and writers did an amazing job taking the facts of the epidemic and turning them into compelling drama that should engage a wide audience.

What Purdue Pharma did was criminal, and it unleashed on this country a tragedy of epic proportions.  As a paramedic, with each corpse I stand over and run my six-second strip of asystole (flatline) before announcing the time of their death presumption, my own rage grows.  This series aims squarely at the Sackler family, in particular Richard Sackler (Michael Stuhlbarg), as the bad guys, but also directs its wrath at FDA and DEA officials who went easy on Purdue before joining Purdue in high paying private sector jobs.  Why no one from Purdue has ended up behind bars while users, who sell $3 bags to support their addiction, are locked away for years is stunning to me.  It is a testament to the power and the influence of money on our political system.

Unfortunately, exposing and damming Purdue Pharma doesn’t end this epidemic.  The dead remain in their graves with countless more ghosts joining them with no end in sight, souls lost forever to the living world.  There are more parts of this epidemic to follow, the rise of heroin after Purdue comes out with a tamper-resistant oxycontin, and the current and most dangerous wave of fentanyl poisoning the drug supply and turning each hit into a game of Russian roulette with the reaper.

Dopesick should convince those who watch and hopefully those in power that most of those affected by this crisis were afflicted through no fault of their own.  They got hurt or sick and trusted their doctors and trusted their regulators and elected officials to protect them, but instead they suffered addiction, stigma, jail, failed rehabs and death.

We have a chance in America to fix this and end the deaths if we pursue the scientifically evidence based avenues of decriminalization, safe injection sites, medical opioids, and a safe legal drug supply.  Instead we are likely to get more arrests, more jail time, and more deaths by following old and failed, but politically expedient policies of the past.

Watch Dope Sick.  Follow Michael Keaton’s journey, feel the heartache of parents, witness the  Richard Sackler dark villany, cheer for Rosario’s passion.  Then commit yourself to educate your neighbors and community about stigma, harm reduction and call for a shift in resources from the criminal war on drugs to a humane public health approach based on science.

Dopesick premiers on Hulu on October 13, 2021.  It is loosely based on the book Dopesick by the journalist Beth Macy.

https://youtu.be/JYU1kzGn4rk.