Bare Your Arms, Country

It’s back.

Two weeks ago, our hospital had 0 COVID patients admitted down from highs of 55 in April and 44 in December.  Just like that we are back up to 12 in just a couple days.  Elsewhere in Connecticut, the head coach of the woman’s top ranked basketball team missed the opening round of the NCAA tournament with COVID.  Some girls my daughter plays basketball with had to quarantine due to exposure to people with COVID and on the COVID ACT Now, map, Connecticut has again turned red, signifying.

From all I have read, the cause is likely the arrival of the COVID variants that are more infectious than the original COVID.  We are all hoping that our high and ever increasing vaccination rate (33% 1^st dose/18.6% fully vaccinated) will soon overcome the variants, but we can’t be certain.

Daily coronavirus updates: COVID-19 hospitalizations rising in Connecticut as variants spread; vaccine distribution skewed toward white residents

I am worried about the number of people who are still refusing to get vaccinated.  It was a huge relief for me to get my shots, and I hope others will soon make the decision to bare their arms for their country. 

Podcast-Saving Lives and Learning a Lesson About Addiction

 

Just out, an interview I did with the Addiction Podcast about my new book, Killing Season; A Paramedic's Dispatches from the Front Lines of the Opioid Epidemic.

Peter Canning – Saving Lives as a Paramedic and Learning A Lesson About Drug Addiction

Opioid Epidemic/COVID Interview

An interview with me talking about the opioid epidemic in the shadows of the COVID pandemic appeared this morning on This Week in Connecticut with Dennis House.

Local paramedic’s first-hand look at the deadly toll of drug use amid the pandemic

Killing Season will be out on April 6, 2021.

Preorder Killing Season

Two Reasons

 By all accounts, the opioid overdose epidemic is getting worse.  A recent study published in JAMA which analyzed emergency department visits (ED) found overdoses were up 29% from March to October of 2020 versus the same period for the previous year.  

Opioid overdoses 29% higher in 2020 than before the pandemic: Study

Fatal Unintentional Drug Overdose Report Key Findings of Drug Overdose Decedents, 2019 – January 2021

Connecticut has released its final numbers for 2020.  Overdose deaths reached a new high -1374, up 14.6% from the previous year.

Connecticut Accidental Drug Intoxication Deaths Office of the Chief Medical Examiner

If we want to decrease opioid overdose deaths, we have to understand why people die from these deaths, and then take bold steps to address those causes.

As a paramedic who has responded to opioid overdoses with increasing frequency over the last twenty-five years there are two mains reasons why people die.

1. They use alone.
2. They use a tainted product.

Naloxone has been credited with saving countless lives, but if there is no one around to witness an overdose and then administer the naloxone, no amount of naloxone will save the victim.  A review of fatal overdoses based on the EMS reporting to the Connecticut poison control center found that while 59% percent of overdoses occurred in residences, 82% percent of fatal overdoses occurred in residences.  In 95% of these cases, the person overdosed alone.

People overdose because the product they consume is stronger than they anticipated.  This can happen due to lowered tolerance.  The patient just got our or rehab or jail or is using after a sustained period of abstinence.  The other reason is an unexpectedly strong product.  This is the true danger of fentanyl.  On much of the east coast, heroin comes in powdered form.  Dealers have found that is cheaper to either lace their heroin with fentanyl or replace it entirely with fentanyl.  Fentanyl which is 50 to 100 stronger than heroin is thus 50 to a hundred times smaller in size thus easier to smuggle.   $4 bag of fentanyl is not 50 to a 100 times stronger than a bag of heroin.  It just has less active ingredient.  With less active ingredient, there is more cut, which makes it harder for dealers to get an even mix.  Additionally fentanyl has been noted to clump, creating a chocolate chip cookie effect.  A user make get 1% fentanyl in their bag or a clump of 10% fentanyl, which could be fatal even to an experienced user.  In the past, users needed to be warned of bad batches on the street—unexpectedly high strength drugs.  With fentanyl, any bag has the potential for being lethal, even if the overall strength of the larger batch is low.

So what bold action do we need to take to solve these issues.

Why do people use alone?  Because law and stigma drive them into the shadows.  When we treat addiction as a crime instead of a disease, and when we shame users instead of treating them as members of our community deserving of the same love and compassion as anyone else who is vulnerable, they are are going to hide their use, and they will continue to die alone behind locked doors, in dark alleys.  I have long advocated safe injection sites.  Keep people from dying alone.  If any of my three daughters became addicted to heroin, I would insist they shoot us at the kitchen table rather than hidden in their bedrooms.   I have been on too many scenes where parents have found their children dead behind locked doors, and others where children, cast out by their families died alone alone under bridges.

What do we do about the product strength issue.  Legalize, regulate and tax drugs so people have access to medicinal quality opioids.

These are bold initiatives that few politicians dare speak of for fear of the political climate.  But if we want real solutions to prevent death, this is how.  End the War on Drugs.  Bring the drug use out of the shadows.  Bring our loved ones back into our community.  Embrace all with love and caring.

 

Wild Rescues

I just finished Wild Rescues: A Paramedic’s Extreme Adventures in Yosemite, Yellowstone, and Grand Teton by paramedic Kevin Grange.

Kevin Grange is an excellent writer and Wild Rescues is great book that delivers on its promise.    From the moment he drives up to Yosemite in a snowstorm to start his job as a ranger paramedic to his responding to a search and rescue for a missing and badly injured hiker in the Gran Tetons, it is as if you are there with him, gradually becoming more confident in your demanding job, taking in the glory of El Capitan, keeping a watchful eyes on the grizzly bears, and learning the fundamentals of  wilderness medicine.   Grange has an easy going narrative style aimed at the common reader while still having the medical depth that will appeal to emergency medical services professionals.  I now understand the unique challenges of wilderness medicine, where the extrication plan is as big a part of the patient’s treatment as the hands on medical care.  I have never been to Yosemite, Yellowstone or Gran Teton, but Grange does a wonderful job of capturing their majesty, as well as the culture of the people who live and work there as park ranger paramedics.

The book is coming out on April 6, 2021 from the Chicago Preview Press.  I recommend it, and if you haven’t read his first book, Lights and Sirens: The Education of a Paramedic, I recommend that as well.  

Here is a link to the book's web site:

Chicago Review Press-Wild Rescues

Custody

 There is a bill in the Connecticut legislature to allow the police to take into custody anyone who overdoses and is resuscitated with narcan, who then refuses to go to the hospital.  The proponents of the bill speak of a 72 hour hold in a clinical setting to keep the person from going back out to the street and overdosing and dying. 

The proposal is known as Brian Cody’s law after a young man who died of an opioid overdose at a young age.

I provided written testimony against the bill.  While I understand its intention, I felt that it might have the negative effect of inhibiting people from calling 911 if one of their friends overdosed knowing it would lead to being taken into custody.

Here’s what I wrote:

WRITTEN TESTIMONY for PUBLIC SAFETY AND SECURITY COMMITTEE

Of Peter Canning, Paramedic, Emergency Medical Services (EMS) Coordinator UConn John Dempsey Hospital

In Opposition to Raised HB 5583: AN ACT CONCERNING EMERGENCY INTERVENTION BY A POLICE OFFICER WHEN A PERSON SUFFERS AN OVERDOSE

Public Hearing: March 2, 2021

Good morning, Senator Bradley, Representative Horn and distinguished members of the Public Safety and Security Committee.  I am Peter Canning.  I have been a paramedic in Hartford for over twenty-five years.  I am also the EMS Coordinator at UConn John Dempsey Hospital and have been actively involved in the EMS Statewide Opioid Report Directive (SWORD) tracking and collecting data on opioid overdoses.  I am testifying today to oppose H.B. 5583 AN ACT CONCERNING EMERGENCY INTERVENTION BY A POLICE OFFICER WHEN A PERSON SUFFERS AN OVERDOSE.

According to SWORD data 95% of all nonfatal opioid overdose victims that receive an emergency medical response are currently transported to the hospital (1).  Only five percent of overdoses victims refuse transportation.  If a person is alert and oriented with stable oxygen saturation, after we give them a talk about the risk of not going to the hospitals for further medical evaluation, they can legally sign a refusal of transport.  Those who are not alert and oriented or who are unstable, are always transported.

Most people who have been revived from an opioid overdose that are transported to the hospital are evaluated and discharged from the Emergency department within a couple of hours.  We studied this in the Hartford Opioid Project, the predecessor to SWORD, and found 86% of those patients transported by ambulance to the ED were discharged from the ED (2).  This included those who leave against medical advice.  It is important to understand that not all patients who seek rehabilitation once they are in the ED are able to be immediately be placed in a rehabilitation facility.  Many are sent home with a list of rehabilitation facilities and phone numbers to call in hopes that a bed may open up for them if they still desire to enter rehab.

Fortunately repeat overdoses are not common. We studied this for the first seven months of the SWORD project, and found only 11% of all patients in our data base suffered 2 or more overdoses in the seven month period (3).  Our conclusion was the assumption that opioid users overdose repeatedly appears false.  Clarifying this stigmatizing inaccuracy is important in understanding opioid overdose and directing resources towards addressing it.

Most opioid overdoses are accidents not willful events.  Overdoses occur for two primary reasons.  One, the person who overdoses has a lowered tolerance due to recent abstinence caused by time in rehabilitation, prison or by abstinence of their own choice.  With lowered tolerance, many people cannot handle the amount they were previously used to using, and thus overdose.  The second reason for overdose is the potency of the drug used.  This is where fentanyl comes into play.  Because fentanyl is 50 to 100 times stronger than heroin, far less active ingredient is used when mixed with cut or fillers.  If batches are not properly mixed, which happens with fentanyl due to its tendency to clump, a $4 bag can easily contain a lethal dose even for an experienced user. 

Harm reduction workers, which include many of us in EMS, warn people not use to alone.   We also urge people who use opioids to carry naloxone and to immediately call 911 if someone they are using with begins to show signs of overdose.  I worry that if this bill passes, knowing that their partners will be taken into custody, people may fail to immediately call 911 when someone is overdosing.  They may hope that their naloxone alone will reverse the  overdose, or if they lack naloxone, they may first try home methods of drug reversal such as throwing ice in the person’s pants or putting them in the shower or bathtub.  If their efforts fail and they then decide to call 911 as a last resort, precious time will have been lost before EMS is able to arrive to try to resuscitate them.  We may be too late.  I believe, however well-intentioned this bill is, more people may die if this bill passes than be helped by it.  I urge you to vote against it.

1. Connecticut Statewide Reporting Directive data. June 1, 2019-February 28, 2021. Nonfatal transports.
2. Canning, P. McKay, C, et al.  “Coordinated Surveillance of Opioid Overdoses in Hartford, Connecticut: A Pilot Project.” Connecticut Medicine, Vol 83, No. 6, 293-299.
3. Canning, P, Doyon, S, Hart, K. Kamin, R., Kosciusko, M, Frequency of Multiple Opioid Overdoses per Individual in Connecticut During Seven Month Period, Abstract - New England Regional Meeting of the Society for Academic Emergency Medicine (SAEM) 2020

You can read the testimony of others here:

Proposed H.B. No. 5583 Session Year 2021  Public Hearing Testimony

I was asked to write the testimony on short notice.  I thought about writing about how on many scenes police already force people to go to the hospital with the hospital or jail choice.  Those people often leave AMA the moment we take them out of the ambulance at the hospital.  Other testified that the science shows people don't do well in forced rehab.  And as I mentioned there aren't enough beds as it is for people who want help.

Support Harm Reduction.  Battle Stigma.  Increase funding for services.  Treat Addiction as a disease.