Diploma

 

The man is on the nod, the only thing keeping him up is the fence he is leaning against. When the police officer tries to extricate him from the fence, he falls back and the officer has to lower him to the ground. I set my red bag down to get out my ambu-bag, but I can see the man is still breathing regularly. I shake his shoulder. He opens his eyes. No need to get out the Naloxone. I lift him up under his arms, while my partner grabs his legs. We get him on the stretcher. He nods back out. We find an orange capped syringe in his left front pocket, and some white powdered residue in a small plastic baggie in the right front pocket. The officer gets the man’s ID out of the wallet he finds in the man’s back pocket. He says he’s going to run his name for warrants.

We wheel the patient over to the ambulance and load him in the back. He is SATing at 97% and his ETCO2 is 48. The ETCO2 slowly climbs into the 50’s as he starts to hypoventilate, but with a little shake, I stimulate him enough to get it back down into the 40’s. While waiting for the officer to return with the man’s ID, I look through the backpack for medical information. There is an embossed certificate for successful completion of a 30 day residential treatment program with the man’s name on it, and an accompanying letter that attests to his meeting all the demands. There is a sheet of paper with his medical history which simply lists broken bones. There is an empty prescription vial for Suboxone. 42 count. Take three strips once a day. I count the days from his release from his treatment program when the prescription was filled until today. He ran out yesterday.

The officer comes back and says he got a hit on the warrants. He takes out his cuffs, and I look at him with a look that says, “Really?”

He says you never know with these people. He has to at least put something on. He cuffs one wrist to the stretcher. The man doesn’t even notice he is being cuffed. I don’t really blame the cop. We all have procedures we have to follow that don’t always seem to make the most sense. Once I did a transport out of a correctional facility for a man with no legs. They still had to put the chains on.

I monitor the patient’s breathing on the way to the hospital. I like talking to my opioid patients to learn their stories, but there is no conversation between us. He is too much on the nod to talk, but still ventilating well enough to not get Naloxone. I’d like to know more about how he came to be leaning against that fence, to hear his story of how he became a statistic in this great opioid war. The only things I know about him are he has suffered broken bones, he graduated from a 30 day treatment program, he was proud enough of himself that he kept his diploma, he appears to have been on Suboxone for 17 days, and then this morning, he injected heroin, and while it wasn’t enough to stop his breathing, it was enough to incapacitate him against a fence. When he comes out of his high, he is going to jail. 30 days or 90 days or a year or however long he’ll be locked up for, he’ll get out and have to start all over again.

I hope he can find a better support system than he had this time.

 

Hartford Opioid Crisis Interview

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.

 

 

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.

No evidence of compensatory drug use risk behavior among heroin users after receiving take-home naloxone

Are take‐home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria

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:

 

 

 

 

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.

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?