Don't Use Alone

 

61 people died of heroin overdoses in Hartford in 2016 (according to numbers released by the state Medical Examiner's office on friday), up from 37 in 2015.  Based on the first six months of the year, the state estimated 888 people would die statewide, but when the final numbers came out last Friday, the number was  917.  This represents a 25% increase over last year, which was itself a 11% increase over the year before.  Of the 917 who died, 479 had Fentanyl in their system.  In 2012 there were only 14 Fentanyl deaths in Connecticut.  Here are the year by year numbers:

Fentanyl Deaths in Connecticut

2012-14

2013-37

2014-75

2015-188

2016-479

Last week I responded to an unresponsive in an area known for drug overdoses.  When I arrived in the 2nd floor apartment, I heard  a person say the man had a pacemaker.  I found a man on his side on a mattress in the living room.  His head was bluish purple, he had vomit on the side of his mouth and pillow.  He was not breathing,  I felt for a pulse on his thick neck, but felt nothing.  We began CPR.  Thirty seconds later, the man gave an agonal gasp.  We stopped CPR. Still no breathing or pulse.  The monitor showed a low voltage paced rhythm.  More CPR.  A few more agonal breaths.  I had the Narcan out and while, Narcan has no role for someone in cardiac arrest, I was not certain he actually was in arrest -- I just couldn’t feel his pulse.  Instead of giving it to him up the nose, I put a needle on the Narcan and gave him an IM injection.

More compressions, more agonal breaths,  and then at last a pulse.  His ETCO2 is 87.  We keep bagging him.  Soon it drops down to the low 40’s.  Two minutes later he starts moving his extremities and opens his eyes.  He is diaphoretic; his hands are shaking.  I don’t normally give 2 milligrams IM.  I prefer the IN route, but this guy was either already in arrest or close to it.

He admits to snorting ten bags of heroin. I find the torn empty bags stuffed in a small cardboard box with his cigarettes.   He has been out of rehab for a week, and this was the first time he has used.  He just felt like it, he says.  I ask him how he got started.  He says he has been using for three years.  There was so much heroin in the neighborhood, he just thought he’d try it.   He is my age.  58.  

I tell him if he is going to use after not using for awhile, his tolerance is going to be low.  I tell him he should never use alone and if he is going to use after not using for awhile, he needs to use less.  He nods.  I tell him where to get Narcan.  The needle exchange van goes to Albany and Bedford Monday through Friday from 11:00-12:45.  They will give him free Narcan and train him how to use it.

There are four or five other people standing in the room now, surprised that their friend is up and talking.  You need to have Narcan, I tell them.  I have Narcan, the woman who called 911 says.

"Why didn’t you give it to him?”

“I thought it was his heart.  He didn’t tell us he was using.”

“Well, at least you called 911.” I said.

“He could have told us he had some heroin,” she said.

“Next time, tell them,” I say to the man, “or at least lay some Narcan by your pillow so they’ll get the hint.”

I have been doing a lot of thinking about the opiate overdose crisis.  It shows no sign of relenting and few things seem to be working.  I don’t know if it is a failure in the system or a failure of human nature.

People getting out of rehab and people getting out of jail, and people who have enforced abstinence on themselves are at the highest risk of suffering a fatal overdose.  In Connecticut, prisoners are all given Narcan when they get out state prisons.  I am guessing people leaving substance abuse treatment facilities are told that if they use again, they should just take a tester short, start small and work their way up, but maybe they are told nothing at all.  I mean they did just graduate from rehab -- let’s look on the bright side -- you are clean!  Hooray.  But we know relapse rates are high.  Maybe we should be giving them Narcan too.

Narcan is readily available in Connecticut.  The needle exchange vans pass it out, you can walk into a pharmacy and they will write you a prescription for it and if you have insurance, the cost is little or nothing to you. There was Narcan in this man’s apartment or at least the apartment where he was crashing until he could get on his own feet.  They had the Narcan but didn’t know to use it.  Were they properly trained in the symptoms of an overdose -- cyanosis, pinpoint pupils, vomiting, respiratory depression, etc?  Or did they really expect the dude would announce he was going to use, and then of course have no expectation that the others in the house would want him to share.  I mean they are putting him up in their house.  He really ought to have been sharing.

I tell users all the time, never do opiates alone, but getting someone to do it with you means sharing, and addicts may want to keep for themselves what they worked hard to get.

I have seen heat maps that show where the overdoses in Hartford are, and they square with what I have seen.  Why do we map overdoses?  So we know where to target resources.  The needle exchange vans are close to two hot spots.  The police certainly do their job of trying to get product off the street, and each week we see pictures in the paper of guns, cash and heroin bags spread out on a table for the typical bust shot.  But people keep dying and heroin is as prevalent as ever.

Do we leaflet the area?  Do we stand on the corner and make public speeches about the horrors of opiates?  Maybe we buy a giant billboard that instead of saying “Just say NO to Drugs,” says “There is a lot of bad dope out there that may kill you.  Always do a tester shot first.  Try not to use alone.  If you have just gotten out of rehab or jail, your tolerance is low.  Just do a little to start.  Have Narcan available.  Call 911.  You won’t be arrested.  Your life has value. Stay safe!”

***

Shortly after writing this, I am called to an OD.  I ask the woman who flagged me down if he is still breathing as I get my gear from the side door.  The woman says she doesn’t know.  They hadn’t seen him for a week, so they went in his apartment and found him.  “Third floor,” she says.  He’s not moving.  I can smell the body as I go up the stairs toward the rented room. Like each of the last three ODs I have been on, the room is spare.  He has been dead for awhile.  Next to the body are two unopened packages of the new Narcan nasal spray.  He got the part of the memo about having the Narcan out, but must have missed the "Don't do heroin alone!" nugget.  The paperwork says he was given them when he was discharged from rehab in late November.  It looks like someone may have taken one out of the box, but the intruders did not open it.   Clearly they arrived too late.  Too late to save him at least.  There are no drugs in the man’s apartment and no money in the man’s wallet.

 

Harm Reduction

 

Two words people in EMS interested in battling the opiate overdose epidemic should know are “HARM REDUCTION.”

According to the 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.”

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

We give someone Narcan and then we find the same person oded later that day.  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.

Across the country harm reduction organizations run needle exchange programs, provide Narcan and Narcan training to target populations, and offer straight nonjudgmental talk to substance users.

Check out the website of the National Harm Reduction coalition at:

Harm Reduction Coalition

Browse some of their publications:

Publications

I highly recommend H is for Heroin, which is a guide to the dangers of heroin for heroin users.  In particular check out page 23, with its tips to avoid overdosing.

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.

Ask your patient:

Do you know where to get clean needles?  Never share a needle with someone else.

Do you have Narcan?  If not, do you know how and where to get it?

Don’t do heroin alone.  Have Narcan readily available for your friend to use on you or you on your friend.

If you haven’t used for awhile (You are just out of prison or rehab or a period of abstinence), do a smaller amount because you no longer have the tolerance you did and you may overdose.

The heroin out on the street today may contain Fentanyl or even Carfentail, a drug used to tranquilize elephants.  If you are going to use an unfamiliar batch, do a small amount to start.  You can always do more later.

Be careful mixing heroin with benzos or alcohol.

If someone overdoses call 911.  Unless you are dealing drugs on the scene, you are immune from prosecution.

If you are ready for help, here's a toll-free number you can call:

In Connecticut - 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 user, that user may pass on to another user, who will then be saved, even the original user succumbs.

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

It may not be as dramatic as defibrillating a fifty 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.

Harm reduction troops, carry on.  Many of us in EMS are learning to walk your path.

Here's a link to the local Harm Reduction Coalition in Greater Hartford.

Greater Hartford Harm Reduction Coalition

Novel Vagal Maneuver

 I never had great luck with vagal maneuvers.  Admittedly when I was a new medic, I didn’t particularly want them to work.  I wanted to give Adenosine, and watch the strip suddenly go asystole and then some wild funky beats before correcting to a nice sinus tack in the 120’s, way better than the 200’s I encountered.  Paramedic as savior!  I remember once how upset I was when I encountered a man in an PSVT in a doctor’s office.  As I got out my IV kit, the doctor ordered me to just take the patient to the hospital so they could see the rhythm for themselves.  Okay, I said, fully determined to work my magic in the ambulance.  Unfortunately for me, carrying the man down the stairs, caused a brief jostle and wallah, he was out of the PSVT.  Drat.

In time though I collected the experience of patients’ extreme uncomfortableness with Adenosine.  They’d clutch their chests in terror as their hearts stopped.  Two actually told me they would rather be shocked than get that drug.  Another pleaded with me not to give it to her, and even though she was in a clear PSVT, I went with Cardizem instead, and it worked, gradually slowing her rate from the 200s to the 90s.  She was very thankful. 

So eventually I began always attempting the vagal maneuvers.  Hold your breath and bear down, cough, blow through a straw, carotid massage, face in ice for the younger patients.  But the vagal maneuvers never worked for more than a moment and the patients often looked at me like I had two heads.

Then I read about a new vagal maneuver in the American Journal of Emergency Medicine.

Novel vagal maneuver technique for termination of supraventricular tachycardias

 Pretty simple.  You sit the person up, and then have them lay backwards.  How hard is that?

We get called to a school.  16 year old cranking at 250.  Diaphoretic, chest pain.  Never happened before.  Nurse tells me, she has tried vagal maneuvers with no results.  Let’s try this new one, I say.  And so we do it.  (Except I get it confused with another one, and in addition to having her lay back, we also lift her legs up.)  We do this in front of an audience of maybe twenty people, teachers, nursing staff, firefighters.

Here’s how it went:

Awesome.  Thank you very much.  Drop the mic.

Patient instantly feels better, and has no recurrence.  I tell everyone about it.

Couple weeks later.  We have a 350 pound man heart going at 180 with a regular narrow complex.  Vagal maneuvers have not worked from the first responding medic.  Patient has a history of rapid heart rate, sometimes relieved by meds, others by electricity.

The other medic says, “You want to try the new vagal maneuver you told me about?”

“Let us do so,” I say.

We explain what we are going to do.  Since he is lying sprawled across the bed and he is very big, we have a hard time sitting him up.  He moans and groans and flops.  We finally have him semi-sitting up.  We lay him back down and lift his legs up (there we go again with the lifted legs).  His heart keeps going at 180.  He yells at us to get him to the hospital.  The man’s family and the fire department look at us like we each have three heads.

We earn back a little bit of trust when 25 and 25 of Cardizem works after a failed 6 and 12 of Adenosine (the Adenosine replete with the clutching the chest I’m dying drama so pronounced that we can't get a look at the underlying rhythm due to all the artifact).

Narcan 4 MG

 I was a big initial fan of the intranasal atomizers both for pain management and opiate overdoses.  I liked them for pain management for their quick access.  I often gave an intranasal dose, and then after getting an IV, gave the rest IV.  Overtime I noticed quite a difference in response between the two methods.  IN might touch them; IV almost always worked.  Recently I have switched to IM for the quick first dose.  Sure it involves a needle stick, but the onset is quicker and it seems more effective.

I have continued to use intranasal Naloxone as my first line for opiate overdose accompanied, of course, by bag valve ventilation, but I have been having second thoughts about the IN route of late.  I have always preached patience, and when I give Narcan IN, my patience is usually always rewarded with a calm, almost placid patient.  Many of my peers have told me they prefer 1.2 mg IM as their starting dose.  That’s what I used before IN came out.  True, it does return their breathing sooner and almost always wakes them, but sometimes it causes symptoms of withdrawal.  I have preferred the more delicate approach, sometimes giving only 0.5 IN in each nare, followed by an IV dose of 0.01 (yes, 0.01) every minute titrated to effect.

This approach works well in the unresponsive patient who may be breathing six times a minute.  I am not so certain it is the appropriate approach for the cyanotic patient breathing at 0-2.  Sure, I can wait on scene bagging for 15 minutes, but bagging is hard to do well, easier in some patients than others.  For these patients now, I give the full 2 mgs IN and am prepared to give a second dose IM if I have not gotten an IV after a few minutes.  I am even considering going back to the 1.2 IM right off the back.

As a paramedic, I have the luxury of multiple options that I can tailor to each individual patient.  EMTs, first responders and the lay public don’t have that ability, and consequently their patients may not be coming around to breathe on their own as quickly as they could.  No doubt this slower response may have an impact on those patients already at risk for anoxia.

I was recently at a statewide conference on opiate overdose prevention and was seated at the table with a salesman for Narcan, who was talking about his company’s product which delivers 4 mg of Narcan IN.  I told him how I thought that was too much for an initial dose, and that we tried to give as little as possible.  Too much can cause withdrawal as well as lead to violence.  While I told him I loved IN Narcan, 4 mg was just too much to start with.  He told me the naysayers were all the wrong side of the fence.  He offered to put me in touch with police and fire chiefs in Massachusetts who loved the product.  I said telling me I was wrong was not a persuasive debating tactic and that while I am sure the police and fire chiefs are nice people, I would prefer to hear from ED doctors.

I enjoy a good argument and appreciate the finer points of debating.  In the end, what is important is not whether I was right or wrong, but whether in the exercise brings me  closer to the truth.  After doing my own review of the product, I have come to believe it should be not just in the layperson’s arsenal, but in the bag of all first responders and EMTs.

Here’s what convinced me:

We currently squirt 1 cc of drug up each nostril.  Each nare is only built for 0.25 ccs.  When I give IN Fentanyl for pain, patients often complain of the drug going into the back of their throat.  I have also seen it run back out of their nose.  No way are they getting all of the drug.  The new product has 4 mg in 0.1 mg.  It is a true nasal spray.  Even at that the bioavailability is only 46%.  In other words, giving 4 mgs IN is the equivalent to a little less than 2 mg IM.

What is the bioavailability then of the atomizer 1 mg in 1 cc in each nostril? Certainly much less.  With the run off in the back of the throat and back out the nose, the 2 mg dose could be as little as 0.2.  Maybe that is why my patients are so placid, and I have never seen withdrawal when given IN alone.

Even the guy who invented the atomizer, admits this new product is a better delivery system.

Intranasal.net

Editorial comment: Even though  I invented the MAD nasal, began the research on nasal naloxone in the 1990s and have used this therapy for 18 years (so have a bit of a historical bent towards the original method of delivery), it seems pretty apparent to me that this new product is probably a better method for delivery of nasal naloxone than the way we have posted here on this website for the last 7 years. The new formulation is more appropriately concentrated, it has a pre-attached atomizer and because of the recent price increased in generic naloxone (single supplier cranked the price last year) this new formulation is not only better formulated, its also less expensive.

I had heard tales of my peers responding to scenes where first responders equipped with Narcan atomizer set up had difficulty putting the device together.  I recently saw it myself on a scene where the responder handed the poorly assembled device to me and said you do it.  The three working parts, the bristojet, the screw in vial and the atomizer were together but not solidly.  I had to refit them properly.

I have also heard drug users tell me they had difficulty putting the devices together when suddenly having to use them on a fellow user.

In a recent study of the new 4 mg nasal device, 90% of people were able to administer it effectively with no training.

So, now we have a device that is FDA approved and is easier to use.  But still what about that dose of 4 mg (even if it is only the equivalent of 2 mg IM)?  Is the dose too much?

The salesman’s argument was that all the stronger Fentanyl based derivatives require more Narcan than regular heroin.  I had heard that, but that had not been my experience.  We have lots of Fentanyl here.  Maybe it is my patience, but I am usually able to get people back with only 2 mgs.  I hear my fellows say they have to often use 4.  I think maybe region wide, the larger doses are tied to the IN dose of 2 mg not really being 2 mgs.  Maybe 6 mgs of Narcan IN with an atomizer is still less than 2 IV.  I searched the literature to see if there were studies that showed that Fentanyl requires more Narcan than heroin.  And while I could find nothing, I attended a toxicologist’s talk and posed the question.  Yes, the answer was, while Fentanyl may be a 100 times stronger than heroin, it should require more Narcan than heroin due to the stronger binding of Fentanyl to the brain’s receptors.  Not 100 times more Narcan, but it would be reasonable scientifically that it would require more.

Finally, I had a physician friend query colleagues of his across the nation whose systems have gone to the 4 mg IN initial dose to see if they have had withdrawal problems, and the answer was no they hadn’t.  They were very pleased with the device.

So, I am for it.  I am for it for it for laypeople for its ease of use and its strength of dose to get OD patients breathing sooner, and keeping them from suffering anoxic injury or death.  I also support it for first responders to get the patient breathing on the their own sooner, and help prevent extended one man bagging, which is often not done well, and even if done well, is not as effective as a person breathing on their own.

The Connecticut statewide medical advisory subcommittee on protocol revisions last week passed the proposal to update our statewide treatment protocols to enable a 4 mg Naloxone IN first dose for opiate overdose.   It still needs to approval by the statewide EMS Advisory Board and the Commissioner of Public Health, but I expect it to pass easily.  Bravo to the committee.

 

Hear the Drumming

Another three dead of heroin overdoses in Hartford in the last 16 hours.  The slaughter continues.  Hartford led the state in overdose deaths in 2015 with 56.  The 2016 numbers, which are not complete, are estimated to be in the high 70s.  Already there have been 5 known heroin deaths in 2016.   I recently did a cardiac arrest of a male in his 40's just out of rehab, found dead on the couch.  No heroin paraphernalia was seen, but who's to say the scene wasn't sanitized before we got there or maybe he snorted outside and walked into the house and collapsed.  Not certain if he ended up as a medical examiner case, but if he did, the evidence will be in the blood, and his name will be added to the tally.

Next week, at our hospital EMS CME, a death investigator from the office of the state Medical Examiner will be speaking to us about heroin and fentanyl.  I am very excited to hear her talk.

I am encouraged that people are the crisis seriously.  From police to health care workers to elected representatives, an extraordinary number of people are paying attention and working together to try to find a solution.

I think it is time to take our thinking to the next level.  Years ago, needle exchange programs were very controversial.  They have proven their worth in helping halt the AIDS epidemic.  I think it is time we consider safe areas, monitored by medical personal, where addicts can use.  There they can get counseling if they want it, and maybe get into rehab.  If they are not ready for it, at least if they OD, they can be revived before hypoxia kills them.

Dead people can't recover.

Three Dead From Suspected Overdoses Within 16 Hours In Hartford

Listen to Hartford Deputy Police Chief Brian Foley describe the change in the police department's attitude toward substance users.  The Hartford Police Department gets it!

You can follow D/C Foley on twitter at D/C Foley.

***

Greg Friese of EMS1.com added a message about Boston's safe haven for users.  Thanks, Greg!

Boston to offer a safe place for heroin users to be high

Peace to all.