Who Narcan Saves

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

Narcan saves lives.

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

Narcan does not save patients in true cardiac arrest.

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

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

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

Here’s what Narcan does do:

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

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

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

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

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

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

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

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

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

 

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

Oxycontin Worldwide

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

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

Read the entire investigative series:

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

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

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

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

Bravo LA Times for bringing attention to this issue.

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

Hartford Police To Carry Narcan

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

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

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

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

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

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

So welcome to the battle, Hartford Police!

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

A Life Saved

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

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

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

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

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

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

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

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

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

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

Hartford Cops: Rash of Heroin Overdoses Part of Upward Trend

Bad Batch?

THE NEUROBIOLOGY OF SUBSTANCE USE, MISUSE, AND ADDICTION

 

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

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

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

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

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

Here's the jist:

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

This from the Surgeon General's report:

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

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

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

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

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

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

Peace to all.

Graphic from Facing Addiction in America.

The Opioid Refusal

 The Opiate Refusal

Called for ETOH.  On arrival found 28 year old male slumped on park bench, GCS-3, respiratory rate -4, cyanotic around lips.  Does not respond to stimulation.  Given 2 mg Narcan IN by FD just prior to our arrival, ventilated with ambu-bag using two person method.  Initial ETCO2-94.  Sinus at 88.  BP 130/70.  No signs of trauma.  Pupils pinpoint.  Heroin bag “New arrival” observed in grass near bench.  ETC02, came down to 45 within 2 minutes, respiratory rate increased to 14.  Patient opened eyes shortly after on stimulation.  Sits up on own.  Denies heroin use or opiate use.  Denies any medical problems.  Tells us to “F-off.”  Leaves AMA despite attempts to advise patient of risks of refusing up to and including death.  Seen walking away  with and cussing out woman who FD said had flagged them down when they arrived at park.

The Insulin Refusal

Called for unconscious.  On arrival found 43 year old male slumped over on bench at bus stop, skin cool, clammy.  GCS-3.  P-88, strong.  BP 150/90. RR-16.  Sinus.  BS – 37 by finger stick capillary blood.  IV # 18 in left FA.  Given 15 grams D10 IV drip.  Patient awakes on stimulation, able to state name and recognize surroundings.  States he did not eat lunch as he was busy at work.  Has had trouble of late controlling sugar.  On insulin.  Not on any long-lasting oral meds.  Post D10 BS – 142.  Patient refuses further treatment or transport, but agrees to drink orange juice provided by my partner who purchased it in Dunkin Doughnuts.  Patient also eats sandwich from his bag.  Calls his girlfriend who arrives after ten minutes and promises to watch patient at her home.    Agrees to check sugar regularly and follow with PCP about episode and to call 911 should there be any change in condition.  Signs refusal.  Girlfriend signs as witness.

The Opiate Refusal of the Future

Called for heroin overdose.  On arrival found 28 year old male slumped on park bench, attended by girlfriend, who states patient ODed after injecting 2 bags of New Arrival heroin, which she describes as pure white powder.  GCS-3, respiratory rate -4, cyanotic around lips.  Does not respond to stimulation.  Given 1 mg Narcan IN by FD just prior to our arrival, ventilated with ambu-bag using two person method.  Initial ETCO2-94.  Sinus at 88.  BP 130/70.  No signs of trauma.  Pupils pinpoint.  ETC02, came down to 40 within 3 minutes, respiratory rate increased to 14.  Patient opened eyes shortly after on stimulation.  Sits up on own.  Admits heroin use.  Denies any medical problems.  Thanks responders and girlfriend for helping.  We provide patient with home Narcan kit, information on use, as well as information on where to find substance abuse treatment.  Instruct patient and girlfriend to never do heroin alone, and to always have Narcan handy.  Provide warning about dangers of New Arrival brand, as well as all white heroin, which may contain Fentanyl or other Fentanyl analogues that can be particularly dangerous even to experienced users.  Offer transport to ED repeatedly, patient refuses, but again expresses thanks and promises to follow up with PCP, and will have 911 on speed dial, as well as Narcan handy if he ever uses heroin again.  Understands that Narcan he was given may wear off before heroin does.  Girlfriend promises to stay by his side and call 911 should there be any change in condition. Signs refusal, girlfriend signs as witness.   Seen walking arm and arm with girlfriend across park in direction of local substance abuse/rehab kiosk.

Peace to all.

Bart Simpson Does Heroin

 Bart Simpson is in his parent's Subaru parked to the side of a gas station in Hartford, Ct near the highway ramps.  The car is running, in drive, his foot is on the brake.  He is slumped forward against the wheel.  This has aroused the attention of passerbys who have called 911.  An ambulance arrives within minutes.  The paramedic and EMT get out and try to open the doors which are locked.  The EMT bangs hard against the window, while the paramedic, who has gone to the passenger side, bangs on that window.  He also notices through the tinted windows a second person in the passenger seat, also slumped over.  The banging causes Bart to stir. He opens his eyes, and appears frightened.  He moves his hand to the drive control, but then realizes he is already in drive.  He tries to go forward, but a bus is blocking the intersection and now a police officer is also there yelling and banging against the car. "Stop the car!  Stop the car!"

Bart puts the car in park, and freezes a moment.  The people are shouting and banging against the car. He looks like a trapped animal.  Finally, slowly, he surrenders.  He unlocks the door. The responders open it quickly and yank him out of the car.  The police officer has him put his arms behind his back.  There is shouting.  "Where's your sharp?  Where's your sharp!"

The paramedic opens the passenger door now, which unlocked when the driver's door opened.  The man slumped in the passenger seat, looks up slowly.  His face is hardened and weathered. His pupils are pinpoint, drowsy. The medic recognizes him as an addict who he has seen humping up and down the streets and through the parks of the city. Another officer is there and hails the man by name. "Hey, Charlie, what are you doing in this car? Who's your friend?"

"Bart," he says. "Bart."

"Bart?  Really. What are you giving Bart a tour of the city, huh?  You a tour guide, showing him all the neighborhoods? Is he buying your heroin for you?"

The paramedic sees the needle on the floor of the car and reaches in and picks it up. He takes it back to the ambulance, and disposes of it in the sharps box.  Both passengers are out of the car now and being frisked.

Bart is a short, skinny, pale faced boy of 19 from a suburb.  He is wearing blue Flintstones pajama bottoms, a New York Giants t-shirt and sneakers without socks.  His hair is dirty and matted.  He is crying as the officer shouts at at him.  He finally admits to their doing two bags of heroin.  On the floor of the car are two torn bags.  One says SONY, the other is red and possibly says The Flash, although the stamp is faded.

Charlie is trying to persuade the officer to let him retrieve his backpack from the car because it contains all he owns in the world.  He says he doesn't need to go to the hospital.

Amidst the chaos, Bart ends up in the back of the ambulance, his car gets hooked to a tow truck, and his passenger takes off down the street.  No one is arrested.

In the ambulance, the paramedic tries to console Bart.  His parents are going to be so disappointed in him, Bart says.  He was doing so well.  He was on Suboxone and hadn't used in months.  If only Charlie hadnt called him.

The medic finds out how Bart knows Charlie.  Bart happened to be in a car in Hartford another time also at a gas station after having bought a couple bags of heroin from a contact a classmate had told him about.  Charlie saw Bart sniffing the drug so he came over and suggested that Bart might want to try injecting.  The high is much better he told him.  Soon the two of them were meeting.  Charlie would provide the drug. Bart would pay for them, and Charlie would help Bart inject to make certain he found a vein.  Today Bart paid Charlie $25  for half a bundle. A bundle is typically $35-$40 and contains 10 bags, each about 0.1 gram of heroin (cut with various amounts of other products such as fentanyl, baby formula, rat poison, sugar, and who knows what else).  The medic tries to do the math for Bart.  

"So you guys did two bags?  You paid him $25?  Where are the other three bags?"

Bart looks confused.  

"And let me ask you something," the medic asks. "You both injected right?"

Bart confirms.

"But I only found one syringe," the medic says.

There is silence.

"Tell me you didn't," the medic says.

More silence.

"You two shared the same needle?"

Bart nods glumly.

"Jesus Christ!" the medic says. "You can't do that."

"He only had one needle."

The medic wants to say what were you thinking, but he knows addicts don't think.  The wiring in their brains has gone haywire.  They lack the ability to judge risk.  "Do you have Narcan at home?" the medic asks.

"No."

"You need to have Narcan with you wherever you go.  Your parents need to have it in your house."

"But I was in recovery. I wasn't going to do heroin anymore."

"That doesn't matter. People relapse despite best intentions. You need to get it and your parents need to have it.  And you need to use clean needles.  Your pal Charlie in all likelihood has Hepatitis C and maybe HIV.  He has been around the block.  Addiction is hard, but you need to protect yourself."

Bart returns to sobbing and the medic hands him a Kleenex and feels bad for upsetting him. At the same time he believes the young man needs serious counseling. He has no doubt that Bart's parents love him, and he knows that Bart and his parents face a long road ahead.  

"You can't recover if you're dead," he says. "We need to get you help."

The medic asks Bart, as he asks all of his addicted patients, how he got started on his path.

"I tore my ACL skateboarding three years ago," Bart says.

"Your doctor prescribed you pain meds?"

"I got hooked on them."

"You took more than you should?"

Bart nods. "They made me feel better."

The path he traveled others had tread. Buying pain meds was expensive.  He was introduced to heroin, which he could snort, and which was cheaper. He started coming in to Hartford. Then he met Charlie and his habit became serious. His family put him into rehab and when he got out he was on Suboxone. Suboxone is a opiate that lasts much longer than heroin.  It moderates the cravings, and can be helpful to many people to keep them away from the much deadly opiate. He said he was doing real well.  Just the day before, he had helped his grandfather paint his garage. Then Charlie called, and Bart slipped up. He couldn't resist the thought of getting that heroin high again. Now he was in the ambulance, his parent's car was on the back of a tow truck, and when they found out, they were going to be so disappointed in him.

Bart blubbered.  A nineteen year old boy in blue Flintstones pajama bottoms, paint still on his hands from helping his grandfather.

The medic and his partner help get Bart into a room in the ED, and find him a blanket and pillow, and wish him well.  They remind him about the need to have Narcan available, and to use clean needles, and to never shoot up alone.

The medic tells the ED nurse that Bart has no Narcan at home and that he shared a needle with a known IV drug abuser, who may in fact be Bart himself ten years down the road.  The medic asks that the messages about Narcan and the need for clean needles be reinforced by the ED team.  The young nurse, who is very busy, says  "That's rehab's job. And he should know better."  She later apologizes to them for her comments (overheard by a supervisor), saying she was under stress.

The crew is worried that Bart will simply be observed and then discharged, but he is admitted to the substance abuse wing. While he is being admitted, he tries to escape.  He flees the hospital shirtless wearing just his blue pajama bottoms. But it is very cold out on this November day, and he has nowhere to go. He turns around, and knocks on the ED door.  They take him back in.

Facing Addiction in American

 

On November 17, 2016, the Surgeon General of the United States issued a report, Facing Addiction in America. The 400 plus page report is a fascinating read that draws on the latest research and data to describe the current opioid crisis, the science behind addiction and the best prospects for treatment and prevention.

Landmark report by Surgeon General calls drug crisis a moral test for America

Consider these facts:

Seventy-eight people die of an opiod overdose each day in our country.

Only 20% of people who need opiod use treatment are getting treatment.

The estimated cost to the country of opiod drug abuse is $193 billion a year.

Heroin overdoses tripled between 2010 to 2014. Heroin overdoses are 500% higher than they were in 2014. Overdoses were more than five times higher in 2014 (10,574) than ten years before in 2004 (1,878).

"How we respond to this crisis is a moral test for America. Are we a nation willing to take on an epidemic that is causing great human suffering and economic loss? Are we able to live up to that most fundamental obligation we have as human beings: to care for one another? Fifty years ago, the landmark Surgeon General's report on the dangers of smoking began a half century of work to end the tobacco epidemic and saved millions of lives. With The Surgeon General's Report on Alcohol, Drugs, and Health, I am issuing a new call to action to end the public health crisis of addiction. Please join me in taking the actions outlined in this Report and in helping ensure that all Americans can lead healthy and fulfilling lives."

-Vivek H. Murthy, M.D., M.B.A. Vice Admiral, U.S. Public Health Service Surgeon General

The chapter on the science of addiction is fascinating and makes the case for addiction and substance misuse to be largely the result of disease and not character flaw. (More on this in a later post.)

You can download the report here:

Facing Addiction in America

While the report largely ignores the role EMS can play in the fight against the opiod epidemic, I found this statement compelling and can apply to our treatment of these patients we see most everyday.

"This Report calls on a range of stakeholder groups to do their part to change the culture, attitudes, and practices around substance use and to keep the conversation going until this goal is met. Prejudice and discrimination have created many of the challenges that plague the substance use disorder treatment field. These factors can have a profound influence on individuals’ willingness to talk to their health care professional about their substance use concerns; to seek or access treatment services; and to be open with friends, family, and coworkers about their treatment and recovery needs. Changing the culture is an essential piece of lasting reforms, creating a society in which:

* People who need help feel comfortable seeking it;

* There is “no wrong door” for accessing health services;

* Communities are willing to invest in prevention services, knowing that such investment pays off over the long term, with wide-ranging benefits for everyone;

* Health care professionals treat substance use disorders with the same level of compassion and care as they would any other chronic disease, such as diabetes or heart disease;

*People are celebrated for their efforts to get well and for their steps in recovery; and

* Everyone knows that their care and support can make a meaningful difference in someone’s recovery.

In addition to facilitating such a mindset, community leaders can work together to mobilize the capacities of health care organizations, social service organizations, educational systems, community based organizations, government health agencies, religious institutions, law enforcement, local businesses, researchers, and other public, private, and voluntary entities that impact public health. Everyone has a role to play in addressing substance misuse and substance use disorders and in changing the conversation around substance use, to improve the health, safety, and well-being of individuals and communities across our nation."

EMS Fights Opioid Epidemic

 Fighting opiate addiction is every bit as important as fighting the other diseases we encounter -- STEMI, stroke, trauma, sepsis and the like.

There is a tremendous article on the  JEMS website by Dr. Alex Garza and Dr. Sophia Dyer about EMS joining the fight against the opiate epidemic in a broader way than just responding to overdoses and administering Narcan.

EMS Data Can Help Stop the Opioid Epidemic

Read it, and then consider what is happening in your EMS system.

In ours, we are treating increasing numbers of patients addicted to opiates, some who get Narcan, some who don't, some who go to the hospital, some who refuse at the scene.  We see them all, but not all of them get into the system to get help.  Like those scene refusals, many of those who go to the hospital, leave AMA before they get a chance to get counseling.  While not all of them will desire or enter counseling, the health care system should at least be there near to the time of overdose offering help.

The fight against opiate addiction involves many players in the community.  EMS needs to be at that table, sharing what information we have and asking how we can best help -- through data collection to provide real time surveillance, through counseling patients who refuse transport, providing education to family members and friends on overdose scenes about where they can get Narcan for the next occurrence or where they can go to get counseling or into a treatment program, or as some cities are doing, providing Narcan to family members, prealerting EDs to arrival of opiate overdose patients so counselors can be available to provide intervention, and I am certain there are other ways we can help.

I am very excited to be attending such a meeting in Hartford this week, anxious to hear about the efforts community groups are making in the fight, and anxious to hear how we in EMS can best help.

I will report back on the meeting, and other efforts I learn about.

If you haven't already done so, seek out education on the nature of the opiate epidemic and of the disease.  The JEMS article is a great primer.

Election Day

 A 10-year-old girl was shot in the face in Hartford yesterday. She wasn’t walking down the street or riding a school bus, she was in her own home when the bullets raked through the front door. She doesn’t live on a busy street like Park Street or Albany Avenue where criminal activity can be going on at all hours of the day. She was on a quiet residential street with sidewalks and front lawns and single family homes. Clearly she was not the intended target of the bullets, just collateral damage. This isn’t the first time a child has been struck by a bullet in this country much less the first time in Hartford. Kids getting shot is pretty commonplace in urban American. Still I thought for certain it would be a big story of the national news. I envisioned the presidential candidates talking about it in their final speeches before the country. Sadly it is hard to find more than a brief mention of it a day later. An AP wire story, two minutes on the local news the night it happened, and it is already on its way to being forgotten.

A half mile away on the Avenue, the dealers are selling heroin bags with fairies on them.

People can complain all they want. They can rant against Washington. They can call one candidate corrupt and the other a spoiled imbecile. They can choose not to stand during the national anthem. But for damn certain everybody ought to vote Tuesday.

10-year-old Hartford girl shot in the face

Bad Batch?

 Hartford Cops: Rash of Heroin Overdoses Part of Upward Trend

 After a lull of a few weeks, the overdoses started going out again this week.  An hour after I left work Tuesday night, there was a triple OD that is widely being reported in the news, along with two other overdoses not long after.  The papers haven’t reported it, but I know of an additional overdose earlier in the day, who required two mgs of Narcan intranasal to resuscitate as well as a presumption the next day that the medics believed to be heroin related -- a young person with a heroin history found cold and stiff alone at home with no apparent trauma.  That person once toxicology reports are in may well be be added to the list of heroin deaths in the state that is estimated to reach almost 900 this year.

The police are working overtime to determine if this is due to a new bad batch of heroin (perhaps with Fentanyl) or just an anomaly.  My money is on a bad batch.  The police released pictures of the two brands found at the scene.  One skull and cross bones, which has been all around town for almost two months, and the second -- RR Rockafeller, an Australian apparel maker insignia, which is new this week.  The police say they not only want to find and arrest the dealers behind the heroin, they want to alert the substance abusing public to be careful.  I applaud them for this!  Police departments all over the country are recognizing that heroin users are a vulnerable population who need help rather than scorn.

Users will act in two ways due to the publicity.  Some will seek the brands out, hoping it will give them the El Dorado high they have been looking for since they were first seduced by heroin.  They may be cautious about using it, but some will get greedy and no doubt do too much.  These are people whose brains are not functioning properly due to the circuitry damage the disease has inflicted in their heads.  Other users will take caution.  They don’t want to die, they just want to get through the day.  These people need to be warned.  Fortunately the police are working with community groups to get the word out and help keep people safe.  

As far as EMS, we need not only to keep doing our job as we have been, but we need to explore other avenues to help.  These include:

1. Providing overdose information about how to obtain and administer Narcan to people who are on scene at the overdose (Provided your hands are not full resuscitating the patient.
2. Consider initiative that other states have embarked on -- allowing EMS to Pass Out Narcan to family members or friends and neighbors

Trick or Treat

 

Some heroin dealers in Hartford have switched up their drug stamps to celebrate Halloween. Drug Users are being treated to brands such as Killer Clowns, Freddy vs. Jason and Casper (the Friendly Ghost).

The question for the users on Halloween (and one every day they buy): is their special envelope a trick or treat?Are they getting heroin? And what is it being cut with? Brown sugar, baby formula, Benadryl, rat poison, caffeine, paracetamol, chloroquine, quinine, flour, chalk, talcum powder, sucrose, starch, powdered milk, acetaminophen, Fentanyl, or Carfentanil? (1) Will the bag get them high or will it kill them?
I wonder when they buy, did the dealer wear a Scream mask? Was he dressed like a killer clown? Did he wear a Donald Trump mask, or was he dressed like Superman? Did he hang skeletons and carve and light jack o'lanterns to guide the drug users to his evil drug lair?

And when the drug users look at themselves in the mirror on Halloween, do they hope that it is all just a scary dream that they will wake up from and everything will be normal again? Instead of finding themselves alone in a public restroom, will they be in their own bathroom off the master bedroom where their pretty wife waits for them, and their darling children are asleep nestled in their bedrooms of the house built with hard work and sweat.

All just a dream

Just a dream.

Please just be a bad Halloween dream.

(1) Wouldn't it be nice if heroin dealers had a better business accreditation in which they certified their product was free of impurities? Users then wouldn't have to play Russian Roulette every time they scored. I am not there yet, but every day I grow closer and closer to thinking we need a model where addicts are allowed to purchase their dope in an inspected pharmacy and use in a clean setting, oversee by medical people with access to narcan and substance abuse treatment.

he Wolf and the Sheepdog

 

In the Looney tunes cartoon, Ralf E. Wolf and Sam the Sheepdog go to work each morning, exchanging greetings while punching the clock.

"Morning, Ralph," the dog says.

"Morning, Sam," the wolf replies.

Then it is down to business. The wolf spends his hours trying to steal the sheep and the sheepdog spends his hours trying to stop the wolf.

At the end-of-the-day when the factory whistle blows, Ralph and Sam punch out, wishing each other good night, before heading home presumably to their families, a hot dinner, and a sound sleep. They return the next day to do it all over again.

It is a vision of the world that I would like to believe in. I sometimes think of Hartford in the same terms. In the morning at the bakery on Park Street, there are drug dealers, drug users, police and paramedics all in line for their coffee, doughnuts, or breakfast sandwiches. Everyone is convivial. Then it is off to work.

The dealers try to sell their product, the cops try to stop them. The users try to use, and we try to see that no one gets hurt.

When I respond to the city lockups or even on arrest scenes where we are called to evaluate a person in handcuffs who may have fallen during a foot pursuit, there is often a common courtesy, even friendliness, among everyone in the same way that players from rival sports teams may chat at halftime or during timeouts. This, of course, is not always true as there are often times where there is a certain chest-puffing, accompanied by profanity and anger, between victor and the fallen. Still, I like to think there is a comradeship of us all belonging to the same city and same species. I remember after the UConn Men's basketball team won their first national championship in 1999, shocking the world by upsetting Duke, everyone in the jail house was in high spirits, cops and robbers both, saying "How bout those Huskies!"

An idealist, I believe we are all, at essence, just people, following the course of our lives that we don't always control. I was more likely to become a paramedic than a drug dealer. The cop came from a family of cops, the drug dealer from a family of drug dealers, the drug user found himself there after an accident, prescription painkillers that he grew too fond of, or maybe a childhood of abuse that rewired his brain and made him less likely to make the proper choices. I, of course, ended up there because I watched the TV show Emergency and had a crush on Dixie McCall.

As a paramedic, I have had, in my ambulance, injured cops, shot drug dealers, overdosed users, and fellow EMS responders with blown-out backs. They are all patients and I treat them the same. We have conversations, we talk about our families. I believe there is a fundamental goodness in most of us.

But clearly there is darkness in the world. There are cops who cross the line, there are paramedics who don't give a shit, and there are drug dealers without conscience.

I am going to take the position that not all drug dealers are evil at core. Bear with me on this. There are some dealers who I believe are honest businessmen who just want to make a living, and who adhere to basic principles. They provide a product to people who would be sick without it, people who come to them freely. They pay their associates fairly, they charge fair prices, and they deliver the product they advertise. They don't rip their customers off. They develop a clientele, who they look out for, sometimes extending credit during hard times, maybe giving them an extra bag at Christmas or on their birthday. These dealers do not want their patients to die.(1) They want them to be Happy, to feel Passion, to find Peace. These dealers and there may only be a few -- I do not know --are a different breed from those who have only darkness in their hearts. Those dealers are the ones spiking select doses of their heroin with fentanyl to deliberately cause fatal overdoses to increase advertising for their brands. Those predators are the ones who put Carfentanil in their bags a drug that could kill not only the patient, but the cop, the medic, the lower level drug dealer selling it on the street and the child who picks up the wrapper with the panda bear on it . They are the villains who cross the line in the same way a rogue police officer delivers an unnecessary beat down or a paramedic lets a patient die out of laziness or spite. There was no pure evil in the Looney Tunes world, but that was after all just a cartoon.

1) Writing this, I had a vision of a benevolent dealer who along with the bundle of Crazy Monkey gives each customer a small plastic shopping bag containing clean needles, Narcan, and pamphlets about where to get substance abuse treatment.

Carfentanil

 

It hasn't come to Hartford yet, but EMS in states such as Michigan, Ohio, West Virginia and Florida have encountered patients who have overdosed on heroin laced with Carfentanil, an opiate of the synthetic fentanyl family that is 10,000 times stronger than morphine and usually used to tranquilize elephants.  Carfentanil is basically a chemical weapon of mass destruction that drug dealers are getting from Mexico via labs in China to give their heroin an extra kick to help increase their profits.  The drug is so powerful it poses a threat to police and EMS responders if they come into contact with it either through touch or inhalation.

Drugs like Fentanyl and Carfentanil made in a laboratory are a much cheaper, cleaner way for the drug trade to maximize their profits than to have to rely on growing acres of opium and harvesting them, and all the handoffs required to get from the foreign poppy field to the USA city streets. Cut your heroin with baby formula and sprinkle some fentanyl on top to boost the potency.

While these new opiates have increased the rate of overdose deaths, this is not particularly bad news for the dealers.  In the Northeast where most dealers brand their product with their own stamp, such as Black Jack, Ferrari, and Night Owl, a death or two and a spat of overdoses can do wonders for a particular dealer's brand.  I recently watched an episode of Drugs, Inc. called Heroin Island, covering drug dealing in New Jersey and Staten Island, New York. In the episode, a dealer admitted to pouring liquid fentanyl into random bags of a new batch of heroin to achieve just that effect  to cause an overdose or death and highlight word of his brand's potency  to generate more business.  Here in Hartford, I have had addicts ask me what the hot brands are.  When I have asked them if they are worried about Oding themselves, that is not much of a fear for many of them.  They are not looking to off themselves; they are just looking for high grade dope to give themselves a better high.  For many addicts, the longer they do heroin, the less shooting up is about getting high as it is about feeling normal again, chasing away the sickness of constant withdrawal.  They long for the first glorious experience they had with the white powder that still eludes them.

I doubt this will change should the King Kong sleepy time powder come to town.  Heroin does, after all, rewire the medulla oblongata to disable the addict's ability to think rationally. It's all about the next fix. The future isn't really a concept for them beyond a few hours.

The Cafentanil story, the use of chemical weapons grade powder as an additive to your product with the intent of killing some of your customers to boost marketing and profits, is chilling.  But when I think about it longer, I don't know if it makes me inclined to reserve a special place in hell for these dealers. Where they are going, they will have company. How different are their practices from those of mainstream business who ignore or hide evidence of their products causing cancer, heart disease, obesity, or are known to them to be unsafe, capable of killing or maiming? At least you can't accuse the heroin dealers of false advertising, particularly when they brand their product with deadly slogans and imagery like Strike Dead, R.I.P, Dead Man, Black Widow, Pray for Death, and Skull and Cross Bones.

Elephant tranquilizer carfentanil linked to 19 deaths in Wayne County

Deadly Opioid Overwhelms First Responders And Crime Labs in Ohio

Heroin Is Being Laced With a Terrifying New Substance: What to Know About Carfentanil

Deadly Powder Overwhelms First Responders

Opioid Epidemic Fueled by Carfentanil Imported from China

 

Election Forecast

 

The early returns are in. Heroin addicts in the greater Hartford area have cast two votes for Donald Trump (Using empty heroin bags I found in an area commuter lot as a proxy).

Questions.  Did the dealer stamp half his bags with Donald Trump and the other half with Hillary Clinton in order to provide proper choice to all his clients. I got Clinton and I got Trump, what do you want? You're a libertarian?  F-you.  Its Trump or Clinton, make up your mind or move along!"  If he only has Trump and the user is a Hillary Supporter, does the Clinton backer say, "Well, I've got the shakes and I'm gonna be sick, but under no circumstances will I buy Donald Trump heroin. Guess I'll have to just deal with withdrawal on my own or until my dealer gets some Hillary in.

When given a choice between the two, who would you expect a heroin user to really prefer? The candidate who promises hard time for drug offenses? Or the one who promises free room and board at a rehab facility of their choice?  A possible fellow criminal or a fellow non-taxpayer? Did this heroin user or users even know who Donald Trump is? Is the heroin user a business professional who had to shoot up in the commuter lot to have the strength to go to work? Or did they meet their dealer on their lunch hour? Or were they divorced and out work and living out of their car because heroin had caused them to throw everything precious to them away in pursuit of the next fix? Do they say to the dealer "F -Donald Trump and F-Hillary Clinton, I just want the heroin."

Let's say the dealer only has Donald Trump. So what was he thinking? In what way is the dealer using Donald Trump for his heroin marketing? Does he really love Donald Trump and think Trump is an marker for excellence in the same way some dealers put A+, check mark, "Great job!" or a light bulb on their bags? Maybe the dealer thinks Trump represents a strong military so instead of putting an AK47  or Trojan helmet he puts Donald Trump. Maybe because of Trump's casinos, he fits in with the gambling theme seen on so many bags like Money Bags, Black Jack and Lucky 7? Maybe he is putting Trump on his heroin bags in the same way other dealers put on the Grim Reaper, Bio Hazard and Skull and Cross Bones? Or maybe he stamps "Donald Trump" on the bags to send the same message other dealers send when they put OMG on theirs? Maybe his pitch is simply "Trump -- it will F-you up!"

Ah, to be omnipotent and all-knowing.

Come election day we'll see if the heroin bag indicator proves to be a positive or negative forecast, and in the meantime, you can count on Medicscribe to keep you updated on the latest counts.

Got Narcan App

 

Last year we heard about a CPR app that alerted people who knew CPR to nearby cardiac arrests so they could race to the scene and perform bystander CPR, potentially saving precious minutes that could mean the difference between life and death, or between anoxic brain injury and the life of a taxpayer.

This week I read that the FDA has opened up a competition for software experts or software laymen to develop a similar application for opiate overdoses. A sort “Got Narcan? app” where if someone came upon an opiate overdose they could activate the app, sending out a signal to anyone will a cellphone and access to Narcan to grab the kit and atomizer and hustle to the scene.

Searching for naloxone to cure a heroin overdose? The FDA wants an app for that.

FDA launches competition to spur innovative technologies to help reduce opioid overdose deaths

There is already an app for that. It’s called 911.

Reading the article though, it did make some sense. They give the example of an apartment building where a neighbor could arrive quicker than the ambulance. An apartment with perhaps a clientele into tattoos and Kurt Cobain music. (They may have Narcan, but don’t strike me as candidates with lightening response instincts)t. Or I suppose, say someone discovered someone passed out and blue in the ladies room of the McDonald's. Hit the app, and you never known with heroin addiction as widespread as it is, perhaps several diners may have Narcan on them. Not just addicts, traveling in twos, but family members of addicts who live in fear of coming upon a loved on Oded. Car stopped at the intersection in front of you, not going even though the light turned green. Twenty-five year old driver slumped over with agonal resps. Grab your Samsung phone or any mobile phone and hit the new Narcan app. Oh wait, grab the Narcan you carry in your glove box, next to your CPR mask, and registered handgun (those of you who are always prepared).

The Got Narcan app is easy to make fun of, but it is just another example, not only of the seriousness of the opiate crisis, but people’s fear in the face of the growing dragon, the opiate epidemic.

The Price is Right

 

I have been writing much lately about heroin with the backdrop of Hartford's Park Street which is one of many epicenters of the current heroin epidemic. Today, I am going to briefly change the backgrounds. Instead of Park Street with its back drop of bakeries, bodegas, Spanish restaurants, and young tattooed men, with crooked baseball caps, standing in the doorways minding their own business, we are going to your typical elderly housing/assisted living facility. Imagine a room of geriatrics in the common room, with their walkers on tennis balls or canes at the side of their chairs. Imagine perhaps also a 50 gallon aquarium, with clean bubbling water and a large lazy fish or two.

Now let us focus on our subject -- a Caucasian woman of 62.  She is obese, maybe two hundred sixty pounds, her hair is grey and tied back behind her head in a pony tail.  Her clothing is threadbare and could use a laundering. She has two canes beside her with which she walks slowly and painfully on skinny legs that can barely support her girth. Instead of the fish tank, she and her mates are watching The Price is Right.

The host challenges a contestant to guess the price of the next item -- not a toaster or blender or even a new TV.  The item is --wallah! -- a bag of heroin.

While the contestant ponders on TV, the guesses start from others in the common room. $50, $100,

Our heroine shakes her head. Well, it depends, she says. The going rate is $5. If you are buying a bundle and you're a good customer, your dealer might give it to you for $4 a bag if the junk's not primo.  Course if you're a sucker, or live in the suburbs, and your friend/dealer is jacking the price he paid on Park Street like that mutherfucker Monte did to me for six months so he can afford his own habit, you might be asked to pay more.

I said I would change backdrops so I am going to do that again. Let's lift the geriatric common area backdrop up, and then lower behind a new backdrop. Lower Albany Avenue in Hartford.  Six in the morning.  Still dark. Our old lady and her canes sit on a concrete barrier near the bus stop. She fell walking down the avenue and her leg is killing her. 10 of 10 pain. It doesn't help that she's been up doing crack cocaine all night. When my partner asks her about her medical history, she says arthritis and cardiac arrest. The cardiac arrest was from an overdose earlier in the week in the South end. She says her chest is still sore from the CPR. They intubated her and also gave her Narcan. (Hopefully not after the intubation).

We ask her if she remembers what the bag of heroin she overdosed on looked like. She says it was white -- no stamp.  She says she bought it from a King, who was not her regular dealer. She only bought two bags and it knocked her out. She says it was white heroin. We show her the pictures of some of the bags we have been seeing lately. She nods her familiarity with some and others she says she has not seen. She says the generic one was particularly strong and there is also a potent batch going around in yellow bags with no markings.

We ask her how a 62 year old woman from the suburbs came to be buying heroin in Hartford.  She says she has bad arthritis and the medicine her doctor gave her was expensive and after awhile, didn't help.   Monte, the maintenance guy who sometimes sold her Percocets offered her heroin. He wanted $10 a bag.  She learned she could get it herself for $5 a bag. A girl in her beauty salon with tattoos gave her a beeper number she could call for a hookup, and she'd take the bus in to meet the man. $5 a bag was cheaper than $30 for a Percocet 30mg.  Of course now she is homeless (she maintains a friend's suburban address for her mail), has hep c, and sore ribs from the CPR she got on the day she couldn't find her regular dealer, and ended up getting the white heroin from a Latin King.

I ask her how she knew she bought it from a King. The Latin Kings used to boldly wear their colors-black and gold, but they have gone somewhat underground now so as not to stand out to law enforcement or the public (should they want to use a stolen credit card or commit another nonviolent crime). Better for business.  They still control much of the drug trade in the city. By the tattoo on his arm, she says. A lion with a crown. Plus everybody knows the Kings rule the Park.

Street gangs tone down use of colors, tattoos

I bet she would beat her old neighbors in the elderly housing common room at Heroin Jeopardy.

Yes, Alex, I'll have gangs for $400."

Their colors are blue and red?

Who are the Los Solidos.

Drug Administration for $500.

Skin popping.

What is injecting drugs under the skin rather than in a vein?

Packaging for $300.

5 Bundles

What is a brick?

She could buy a lot of $5 bags with her winnings.

Plus some crack cocaine to share with the old North end dudes she was partying with last night.

* Recently several drug dealers have been charged with murder for selling drugs that caused a fatal overdose as the guy who boasted of his "KD" stamp found out last April (see below Hartford article). Some dealers have responded by going to blank bags so it is harder to be linked to the killing powder.  Some have speculated it may eventually lead to the demise of stamped bags.

Prosecuters Charging Drug Dealers in Heroin Deaths

The New War on Drug Dealers

After Two Deaths, Feds Charge Alleged Hartford Heroin Dealers

 

I mentioned that we had a patient this week who said she stayed away from the white powdered heroin because of her fear of Fentanyl.  Powdered Fentanyl is white and very hard to distinguish visually from white powdered heroin.

A number of years ago drug dealers started enhancing their heroin with Fentanyl. Fentanyl is stronger than heroin, so adding it was a good way to boost the reputation of their product. Deaths increased as users were hit with more potency than they expected, or in some cases, the heroin and Fentanyl were not evenly mixed and so even a user with high tolerance might die with the syringe in their arm if they got a hot spot of disproportionate Fentanyl in their buy.

The deaths and subsequent warnings of dangerous heroin only drew more users to the brands as many users sought the powerful mixtures. More dealers began adding Fentanyl to their batches. Also, while years ago, it was common practice to cut heroin to increase profits, many dealers now keep their heroin strong in order to compete with the Fentanyl brands as well an ever increasing supply.

Fentanyl can be obtained in two ways.  The low rent way to extract it from Fentanyl patches. The other way is to make it in a lab or get it from a lab. Most of the street Fentanyl in the United States now comes from labs in Mexico or China, and is smuggled into the country in the same matter as heroin.  Because it is stronger, more can more smuggled for the same potency. The prevalence of Fentanyl is increasing to such an extent that some law enforcement officials have on occasional found 100% pure Fentanyl being sold as heroin.

This week in Hartford, a SWAT team broke into a drug dealer's home and detonated a flash grenade to stun the suspects who were known to have firearms.  The explosion aerosolized some of the Fentanyl and heroin in the apartment and 11 of the team members were hospitalized for nausea, dizziness and vomiting. This bust yielded over 50,000 bags of Fentanyl-laced heroin.

11 Hartford SWAT Officers Exposed To Heroin, Fentanyl During Drug Raid

The woman we talked to used the bag stamp system to know which brands to avoid as she was not a death seeker like many users. 

Back in 1991 when Tango and Cash stamped heroin bags that were laced with Fentanyl were killing people on the streets of Hartford, the New York Times wrote about officials driving the streets using loud speakers to warn people about the deadly mixture. At the same time, the alerted junkies suddenly sought the brand out much like Super Bowl tickets or people today seek the latest I-phone.

Toxic Heroin Has Killed 12, Officials Say

While our woman friend avoids the dangerous Fentanyl mixture, others seek it. This is reflected in the branding. I found a heroin bag labeled "Dead Man," another bag had a picture of the Grim Reaper on it and the words Strike Dead. Some bags just have a skull and crossbones on them.  This does that necessarily mean that those brands are the baddest of the bad.  It could just be marketing.  A user who trusts their regular dealer will hopefully learn what brand will fit their needs.  

Another problem with Fentanyl for the user (besides higher risk of death) is that it does not last as long as heroin.  Users need to fix again sooner and end up having to buy more. I suppose the dealers are willing to lose a few clients to overdose to gain the added volume from other customers.  Talk about business ethics. 

The picture in the paper of the Hartford bust and the 50,000 bags of heroin all laid out on a table seems like a lot, but if a user had a two bundle a day habit - 20 bags, 50,000 is a year's supply for just 7 addicts.  I don't think the users in Hartford will have to look too far tomorrow to get their fix. Someone on Park Street will be hawking Undertaker,Six Feet Under, or Dead Man. And money will change hands.  

And another 911 dispatch will go out.

EMS Distributes Naloxone

 

Paramedics in North Carolina and in Cleveland, Ohio are providing Narcan kits to high risk patients in their communities.

Cleveland EMS Providers to Distribute Overdose Kits

N.C. County Allows Paramedics to Provide Precautionary Narcan Kits

My partner and I often spend time on heroin overdose calls educating the patient's family, friends or bystanders/social circle on the availability of Narcan (where to get it -- local clinic, pharmacy, etc) and how to administer it. We recently had one patient's neighbor (who had found his friend unresponsive) express gratitude for our lesson and say he would immediately go down to the clinic and get a kit. A woman this week told us she had Narcan in the bathroom, kitchen, living and bedroom in her apartment, and had one kit always in her purse (which unfortunately had been taken from her while she nodded off in the bushes -- thus prompting the 911 call for the woman unresponsive). Leaving a Narcan kit with people who were present at an overdose scene makes clear sense.

If we had Narcan kits that we could give out, we could easily disburse them to high-risk individuals.

In North Carolina, EMS is giving Narcan to patients who refuse treatment. I have not had a patient in years who refused treatment after Narcan.  Many years ago when my practice was to give 1.2-2.0 mg IV, I did have quite a number of patients refuse. Well, instead of saying, I refuse, they used more colorful language as they ripped the IV out of their arms and walked down the street the colorful language continuing. Now, I mainly use Intranasal (IN) Narcan or IV at very low doses (0.1 increments), and my patients are much more subdued, and go to the hospital. The ones that refuse are the ones who are simply on the nod, and who wake with stimulation (like the woman in the bushes, who actually was roused by a bystander as we arrived, and started walking down the street on her own, although she did stop and let us talk with her).

If opiate overdose patients are going to refuse transport, leaving them Narcan as well as persuading them to have a friend watch them for awhile seems reasonable.

We did have an very interesting conversation with the woman, who not only told us what brand of heroin she had used, she provided commentary on a number of different brands we had seen. She told us that she avoided Chief and OMG because they were white heroin known to be mixed with Fentanyl. She preferred the brownish powder. Every time she foolishly tried white powder brands, she said, she ended up surrounded by firefighters and EMS. She wasn't looking to die nor was she looking for a magic high. She just needed her daily fix, and for that she had to walk to Park Street everyday to meet her guy.

She got hooked on heroin because it was cheap and she had issues of loneliness and self worth that had caused her to seek escape. She uses heroin every day now. It is as much a part of her life as getting up in the morning, drinking water, eating her daily bread, and forgiving her trespassers.

Kudos to North Carolina and Cleveland.

Park Street

 

I only went to one heroin overdose this week and one PCP overdose.  The heroin overdose was on Park Street in the South end and the PCP was on Capen in the north end.  You get get called for an overdose on Park Street and it is pretty much always heroin.  You get called for an overdose at Garden and Capen, it is going to be PCP. The North end is mainly black, the South end Hispanic.  The blacks control the PCP trade, the Hispanics most of the heroin. There is some mixing, but that is pretty much the divide. You go to Keney Park in the north end, and you find lots of tiny empty clear plastic baggies with no markings. PCP. Not too many heroin bags. You go to Pope or Colt Park in the South and you will find empty glassine envelopes with stamps on them marking the heroin brands.  In just one month of looking, I have already counted 96 different brands (some of the envelopes are likely months old (one was branded Super Bowl 50), others freshly tossed from the car window where the junkies sit low in the seats shooting up, and chilling before driving off).  Some brands I have only found one of, others are scattered everywhere, often in clumps of five or more bags.  I find it fascinating to see what brands are the hottest. Black Jack gave way to OMG, which gave way to Chief, Public Enemy, and now to Fastrack, which we found in nearly every location we looked last week.  Who knows what next week's hot brand will be?

The heroin overdose I went to was a woman I had treated before. She had gone into a public restroom and not come out. When the first responders got there, she was unresponsive and blue. The fire department gave her 2 mg of Narcan IN. By the time we got there, she was already in the back of the BLS ambulance, breathing on her own, and rousable with a good shake. She was in her thirties, wearing a short skirt and a low cut top with a pushup bra. At one time had obviously been good looking, but there were hard miles on her. She had cellulitis and abscesses on her arms and a bad ankle that had never healed right from a fall. When we put her name in our laptop, her address came up in as a Hartford suburb, but she said she was now homeless. I tried to ask her some questions about what brand she had used, but she kept nodding off. She was at least able to identify the Fastrack brand from the picture I showed her on my iPhone and say she heard it was dangerous. She told me she bought from her usual dealer.  I asked her again what brand she had used, and she said she was trying to remember, then she nodded off again. I let her sleep. Her ETCO2 was 42 and her SAT was 96 on room air, her respiratory rate was 14. Power to her. At the hospital, they said they were going to give her more Narcan. I guess they were pretty full and didn't have a sitter to watch her sleep in case she started hypoventilating again. 

The first time I picked her up was in front of the shelter at Hungerford and Park. The police officer who flagged us down said she was drunk. She was motherfucking him to beat the band. My BLS partner said he would tech the call, and after having teched the first nine of the day, I let him. I drove to the hospital and saw him typing the PCR on the computer. When we hit the hospital, and pulled the stretcher out, she was cyanotic, and breathing maybe four times a minutes. I shook her shoulder and she roused enough to tell me to fuck off. I saw the fresh needle mark on her right hand then, the pin point pupils, and was upset with myself for just assuming she was drunk and not taking a closer look just walking to get in the driver's seat when my partner offered to do the call.  

I debated pushing the stretcher back in the ambulance and giving her Narcan then, but since she was rousable we just brought her in.   Unfortunately the triage line was long. Every couple of minutes I had to shake her hard to get to breathe. After awhile, she stopped swearing at me, and I had to cut to the front of the line and ask the triage nurse for either Narcan, an ambu bag or permission to go back out to the truck to get my gear and treat the patient in the their waiting line. They wanted us to bring her to the critical room, but I said she just needed a little Narcan so they finally gave me an ambu bag and a room down the hallway where a nurse practitioner asked us what the dose was. We told her to start low. They gave her 0.4 IM, and took over bagging.  I thought next time I would just go back out to the ambulance and get my gear.  We saw our patient later smoking a cigarette in front of the ED, the hospital ID bracelet still on her wrist.  She didn't recognize us.

I wanted to go back and talk to her after we left her in the room this last time, but we didn't get back to that hospital till four hours later and she was already gone.  I went back to the restaurant where she had ODed in hopes I could find the wrappers in the bathroom, but they had a men's and a women's bathroom, and you had to get the key from the guy making the sandwiches.  I chickened out and asked for the men's room key after buying a turkey sandwich.  I suppose I should have just come out and said I wanted to look in the woman's room to try to identify the brand the woman had ODed on.   I did find two wrappers in the men's room, but they were blank.  Not all the bags have stamps on them.

I have seen her a few times walking along Park Street, particularly in the early morning when the bakeries are just opening up.  They sell pressed bologna sandwiches real cheap and there is often a line out the doors. One of the bakeries sells a pernil (pork) cubano for only $3.  I try to get one if the line isn't too long.  Some mornings they sell homemade tamales wrapped in corn stalks. $0.75. They are run by honest people, and feed many in the community.  There is drug dealing close by but that comes with the territory of Park Street.  Everyone likes sandwiches and cheap coffee and a friendly smile in morning.  Cops eat there, EMS eats there, working folks eat there and drug dealers, junkies and the homeless eat there. We all have our roles. Such is the community of Park Street, the community of Hartford.

Public Enemy

 

Last week I speculated that despite increased access to Narcan, the opiate epidemic would continue to rage with deaths in 2016 exceeding those of 2015.

Narcan Thoughts

Sadly, this was borne out in just released data from the state medical examiner. Through the first six months of 2016, 444 people died of fatal overdoses in CT, which projects to at least 888.  729 died in 2015.

A story in the Hartford Courant lays much of the blame on Fentanyl , which was involved in 25.8% on the deaths in 2015, and already in 50.2% on those in 2016.

Fueled By Fentanyl Spike, Overdose Deaths Continue To Climb In Connecticut

How powerful is a drug that you know can kill you easily, and yet you still take it -- often alone with no one to watch over you?

It isn't a slow death like that one inflicted by cigarettes or gluttony. Most of us have encountered the dead with the needle still in their vein.

To many people giving Narcan to EMTs and to family members was a drastic step, unheard of a few years ago. Maybe we need to think even bolder.

Maybe we should as some other countries do and have safe havens where junkies can go for their daily fix and be observed by medical personnel with Narcan at hand. They can get access to people who will try to convince them to get treatment.

William Proxmire, a former United States Senator, who was a big advocate to eliminate wasteful spending, used to say, " a million dollars here, a million dollars there, and pretty soon you are talking about real money."

To paraphrase for the opiate epidemic. "A hundred opiate deaths here and a hundred opiate deaths there, and pretty soon you are talking about a massacre."

Here is an interesting article on heroin safe havens.

Boston's Safe Space for Heroin Users

"It's not that we don't want people to be drug free. But dead people don't recover." -Barbara Herbert, the president of the Massachusetts chapter of the American Society of Addiction Medicine

Public Access Narcan

 

Medical emergencies, like cardiac arrest, anaphylaxis, heroin overdose, (and being bitten by a Black Widow spider), require quick treatment to save a life.   Our public health system recognizes this.  We have AEDs, epi-pens and now increasing access to Narcan. All great initiatives.  Before I advocate for public access anti-spider bite kits, let me address Public Access Narcan.

Public Access Defibrillators are put in spots where patients are more likely than others to suffer sudden cardiac arrest.  We see public access defibrillators in airports, casinos, health clubs and in town halls, outside the tax assessor's office.  Epi-pens are given to school nurses in case students with allergies to substances like peanuts have sudden anaphylaxis. These devices have been credited with saving many lives.  I wonder how effective or realistic a public access Narcan program would be. I would not put Narcan in health clubs or outside the tax assessor's office, but I might consider putting it in the bathrooms of establishments like fast food restaurants and laundromat in certain areas of town.  I have not yet responded to an overdose at a school, but there have no doubt been overdoses at schools, likely more than sudden cardiac arrests.  If they can have AEDs and epi-pens in schools, they surely have room for a dose or two of Narcan.  I would put Narcan there, and I would put Narcan by the clerk's desk at low-rate motels. I would put Narcan on city buses (done a few on these) , and in the gazebos of city parks. I'd even put one in the Zion Hill Cemetery based on the drug paraphernalia we saw when we drove through it one morning last week before the daily caretakers had swept the place.

I am very impressed that Massachusetts is able to record and report on the number of patients who receive Narcan from EMS responders. It likely wouldn't be too hard to track the zip codes and addresses of all the Narcan administrations.  Certain blocks could qualify for a Narcan alarm box on their street corner. Of course, you would need to configure the box so when activated, it would notify 911 to get EMS rolling. If the address was near a bar or nightclub, you could even consider putting Narcan in vending machines in bathrooms next to the condom or tampon machines.

In Connecticut Narcan is sold over the counter in pharmacies and often given away free at inner city clinics. But for those who frequent the night, maybe Narcan could be made available at grocery and convenience stores around the clock. They could sell it by the register or perhaps in another place people likely to deal with a heroin overdose might look, next to the ice machine.

I have never treated a patient bitten by a Black Widow spider, but I did treat a patient who used the powder that came in the pictured glassine bag.

The Finger

 I have been injured seriously enough to miss work twice in the last two decades.  Neither time was I injured on the job.  The first injury was playing softball on our ambulance team (back when we had one). I went from first to third on a single, and as the third base coach signaled me to slow, I stumbled coming into the bag, lost my balance, and landed on my outstretched hand, breaking a small bone in my wrist that required me to wear a cast for six weeks.  

A year or so earlier, I had broken the ring finger of my right hand at the top joint, playing basketball (going up for a rebound -- the ball hit the tip of my outstretched finger), but never had to miss work, as I was able to wear a splint that only immobilized the top joint, and enabled me to to still do IVs, lift and carry.  My finger is still slightly bent to this day.

I stopped playing basketball (for fear of injury) after that until a few years ago when our company, which does standbys at the Civic Center, organized a basketball game between divisions to be played on the Civic Center court (albeit before 12,000 empty seats).  I was enticed to join the team thanks to my height (6-8).  While I enjoyed myself and did quite well, largely thanks to hustle (I was running half marathons at the time and could easily out run most of the other players), I took a head butt to the chest in a scramble for a ball, that knocked the wind out of me.  I was able to keep playing, but it left me unable to sit up in bed at night without using a pillow to splint myself and it prevented me from doing push ups as I felt like my chest was going to split in two.  My diagnosis -- I think I cracked my sternum.  I never saw a doctor about it, but it was almost two months before I was pain free.  Still, I worked through it.  Never missing a day.

Recently I sustained another sports injury. I mainly swim now for competition, and in the last event of my last meet, I slammed my hand into the electronic pad at the finish (I had been upset that in two earlier races, the electronic pad had me slower than the hand timers who had clocked me in personal records.  So I hit the pad a little harder than I should have.  I did not feel any pain, but soon noticed the last joint of my middle finger flexed, but could not extend.  I had what is called a Mallet finger -- a ruptured tendon. My initial splint immobilized the entire finger, leaving me unable to work for two days until I saw a specialist who fashioned a splint enabling me to work, as long as I tape it up well. I can still do IVs and lift, but when I lift, I cannot use that finger which remains in a modified bird position.  I have to wear the splint for 6-12 weeks in hopes that the tendon will reattach.  If I move it too early, it is back to square one and another minimum of six weeks is required.  I have banged it a few times and had it squeezed twice in a wrestle with a patient, but for the most part I am hopeful it is healing. Surgery is an option, but the splint method actually has a higher cure rate that the surgery.

At work, we have a time clock where when punch in or out, you put in your Kronos number, and then place a designated finger tip on the scan button. When you first logged in to the new system, it let you choose which finger you wanted. Most people chose their middle finger. I thought about it, and while I appreciated the humor, I did not choose my middle finger.  I did the pointer finger instead.  And while I admit, there are days when I want to give the bird to work at the end of the day, I still maintain respect for the work.

When I was a kid, one of my favorite tales from the excellent American Folklore picture book I had was the story of Joe Magarac, the man of steel. Joe was the best worker in the steel mill.  He could do the work of twenty men. Then one day, there was talk of closing the mill, so Joe jumped into the vat and melted himself down into steel, and his steel was of such high quality that they built a new steel mill with his steel and everyone's job was saved and the town prospered.

I am not saying that we should all sacrifice ourselves for our companies (neither should we give them the finger).  If we do sacrifice ourselves, it should be for the idea of work and the idea that work and caring about your work has value.  Caring -- no matter what the object -- is what brings value to our lives.

Narcan Thoughts

 

A story on the news this week said the Hartford Fire Department has saved 136 lives with Narcan since they began carrying it last November.  They have used it 172 times with 136 positive results, according to the article.  (Kudos to an outstanding department!) The story also mentions the Connecticut State Police have saved 100 lives with Narcan since October 2014.  Google almost any fire or police department in the state who has started carrying Narcan and there are glowing reports of lives saved by their members.

Hartford Firefighters Save 135 from Opiate Overdoses

Connecticut had 415 heroin deaths in 2015, and over 600 fatal opiate overdoses of all types.  I have seen nothing to suggest that the number is declining in 2016.

Neighboring Massachusetts had 1,379 opiate overdose deaths in 2015, an increase of 7 percent over 2014.  According to MA state data,  Narcan was administered to 9,128 EMS patients in 2015.

Mass EMS Stats

The articles claiming lives saves to each administration of Narcan are a bit overblown.  Clearly not every patient administered Narcan by first responders would have otherwise died.  First responders do carry ambu-bags and paramedics are often only minutes behind.  Despite this, there is little doubt in my mind that first responder Narcan has been a successful program.

For all the high numbers of first responder administered Narcan in the Hartford area, paramedics and EMTs administer Narcan at even greater numbers than the first responders.  While the fire departments often beat us to the scene, it does take a few moments to access and assess a patient, and once we arrive, they defer to us.  I have on one occasion told them to go ahead and give their drawn up dose.  I have only once told a fire department (not Hartford) the Narcan they were getting ready to administer was not needed.  (The patient while altered was arousable with stimulation).  And I have yet to see and only rarely heard of a fire department inappropriately administering Narcan in our area.  I am thrilled the fear some had of inappropriate administration doesn’t appear to have come to fruition.  

I will be curious to see what the final fatal opiate overdose numbers will be for Connecticut in 2016.  I suspect they will be higher than 2015 despite the life-saving  first responder Narcan program  such is the rate of overdose we are seeing.  Sure, we had periods of increased overdoses due to bad batches of the drug hitting the street in the past, but nothing sustained like we are seeing with the current epidemic.  Narcan alone cannot put an end to the slaughter.  On the fatal overdoses I respond to, the patient has almost always overdosed alone and has been found far too late to be saved.

Last week, I observed a heroin addict prepare to shoot another up in an alleyway just off Park Street as I walked past with my just out of the bakery hot-pressed Cubano sandwich.  My height enabled me to better see what others might not have.  I hesitated.  The one with the USB cord wrapped around his arm saw me and told the other to hold up.  I felt like I had stumbled onto a tribal ceremony.  The man with the syringe, seeing my uniform, said, “No worries.  He's EMS.  We are safe with him here.  Yo,” he called to me.  “Thank you for what you do.”

“Okay, okay,” the other man said, holding his shaking arm out.  Just give it to me.”

“You have Narcan?” I asked, somewhat stunned by the scene, their brazenness and my sudden inclusion in their moment.

“Yeah, man.”

“All right, Be safe,” I said, and resumed walking to my parked ambulance just down the street.  Later, I almost wished I had asked if I could observe out of curiosity, but lines are lines, and while impartial, I did not want to imply sanction.

My partner and I did a walk by later and found the alley empty, except for a spoon, a saline vial, and torn heroin bag wrappers.

If I had any advice to people doing heroin (aside from don’t get started), it would be don’t do it alone.  Have Narcan handy.  Don't wait to call 911.  Never give up on treatment.