Killing Time

 

A new legal strategy is to charge drug dealers with homicide when one of their customers fatally overdoses and it can be proven the customer bought the fatal drug from the dealer.

In Rhode Island this week a 25-year-old dealer was convicted of selling $40 worth of "Diesel" to to a 29-year-old customer who died 4 hours later.  The dealer was sentenced to 40 years in jail (with only 20 to be served).   One way to look at this is it sends a message to the dealers that they better think twice before they sell heroin in Rhode Island.  They are tough and bad ass on crime there.  They do not tolerate drug dealing.

You can read more about it here:

Drug Dealer Sentenced To 20 Years For Murder After Customer’s Fatal Overdose

In the story the dealer expresses regret.   “The actions that I did that day, I never meant to hurt nobody,” he said.  He apologizes both to the mother of the victim and his own mother.

The story mentions that the victim had just been discharged from drug treatment because her insurance would not pay for coverage past 30 days.  Having been in treatment, her tolerance was no doubt low and she likely did the same amount of heroin she used to do before going in to treatment.  People coming out of treatment are among the highest at risk for fatal overdoses because of their lowered tolerance.

52,000 American died last year and while I do not hold the 25-year-old drug dealer as an innocent participant, to me he bears a lot less responsibility for the death than the heads of the pharmaceutical companies who admittedly lied to the doctors and the public about the addicting properties of the drugs, and the DEA who approved the manufacture of increasing millions of kilograms of the prescription painkillers even when they knew the massive supply of painkillers was going to sketchy wholesalers who were flooding the black market with the pills, addicting and killing thousands of Americans while fueling an unprecedented heroin epidemic.  I know of no drug company executive responsible for the epidemic who has even spent one night in jail.  Sure, they were fined millions, but they made billions.

My main fault with the 25-year-old drug dealer was that he sold Fentanyl as heroin*, although it is not clear that he knew this himself.  How high on the chain was he?  Did he buy, cut and package the drug himself or was he given the powder by a higher up and told to sell it and bring back most of the profit to be passed up the line.  Of the $40 he received for the drug, how much profit did he make?  Certainly not the billions the drug companies made.  And clearly the victim was aware of the risks, although as an addict, she was likely powerless to rationally weigh them -- something known to the policy makers who created the system that kicked her out of treatment before she was ready.

Will the 20-year sentence slow the overdose death rate in Rhode Island?  We will have to wait and see.  I think it is less likely to slow it than increasing treatment options would slow the epidemic.  If the 25-year-old dealer had decided to work at McDonald's instead of in the drug trade, I think the 29-year-old user would have likely found someone else to sell her what she craved.

Here is an apocryphal story:

An old man sits on a bench in front of the courthouse, and sees the District Attorney.  “How goes the war on drugs?” the old man asks.  The DA says, “Great, we put twenty dealers away this week.  Sent them all to prison.”  The old man sees the DA the next week and says, “How goes the great war on drugs?”  “Outstanding,” the DA replies.  “We put thirty-seven dealers away.”  This goes on week after week, the numbers of arrests go higher and higher.  Finally, one day the DA answers the old man, “Best week ever.  We put away one hundred and seventy-eight drug dealers just today alone.”  The old man laughs and says, “Pretty soon, no more prison cells."

* He could have also have been more honest in labeling his product, calling it "Strike Dead," "Killing Time," "The Reaper," "Skull and Cross Bones," or "Dead Men," although likely his competing dealers had already claimed those brands.

Fountain

 

In Connecticut we are in the midst of hospital wars.  It is a very competitive market and all of the hospitals fight to attract patients.  You can see it on the billboards that line Interstates 91 and 84 with hospitals proclaiming themselves the best at heart care, stroke, trauma care or declaring they are the safest or provide the shortest wait times.  It can be seen even in EMS CMEs where medics and EMTs were recently treated to a lavish meal at one of the city's finest restaurants complete with free valet parking to hear a specialist tout a hospital's latest capabilities. (The event was subsidized by a vendor).  But nowhere is the battle more evident than in the TV commercials where hospitals tout their state of the art technology, their beautiful grounds and rooms, and the attractiveness (and wisdom) of their staffs.  It can make going to the hospital look almost like a trip to the Bellagio or some fine hotel with lavish fountains that go off at regular intervals.

Last Tuesday, my last call of a three day tour (I work three consecutive 12-hour days), we are in the triage line with our emotionally disturbed patient, coming on on a police paper.  I drove, my partner tecked so I don't have many of the details other than the young man is hearing voices and occasionally punches himself in the face, but for the most part he has come willingly.  No restraints, chemical or physical, were required.  We have been in line maybe 20 minutes so we are no longer outside the hospital or in the foyer, but within sight of the triage desks and the patients waiting in chairs and outside the first provider exam rooms.  My partner is waiting to give his report.  I stand by the head of the stretcher, checking my i-phone for the time.  Hopes of getting out early are lost.

An old woman on a nasal cannula sits on a chair outside an exam room and is suddenly yelling at me.  "Stop that!  Stop that!  Do something!  Do something!"  She looks very angry.  I have no idea what she is upset about.  No one else seems concerned.  Is she just another psychiatric patient hearing voices and talking to herself.  "Stop!"  she shouts.  "Have you no decency!  Stop!"

I look at her closely.  Her anger is not abating.  Then I look at our patient. He had his penis out and is urinating straight up into the air.  The golden liquid is arching up , then falling back down splattering on the patient himself.  A fountain.

"Do something!" the old woman shouts.

For a moment, I think "What do want me to do?  Is this my fault?"

But then I realize, I can probably take some action to alleviate her distress.  I grab a sheet from the back of the stretcher and throw it on top of the patient's offending part.  "Knock it off!" I say.  He mumbles something incomprehensible, then punches himself in the face one time as if he is admonishing himself for his bad behavior.

The woman is still glowering at me.

"Sorry about that," I say.

What I really want to say is: "So they left that part out of the commercials."

It is an hour before we get the patient off our stretcher and leave him in the psych ward where the staff are wrestling with another man and from deep in the bowels of the ward we hear another patient chanting  "Bin Laden!  Bin Laden!  Bin Laden!"

Welcome to the ER.

Clean the stretcher, sanitize the straps.  We get out an hour late.  The ambulance goes back into service with a new crew, ready to take the citizens of the area to the destination hospital of their choice.  Enjoy your stay.

3 EMS Models of Opiate Intervention

 

Opiate users who suffer a non-fatal overdose are at the highest risk for having a fatal overdose.

Many of these people are hard to reach by traditional substance use and health care professionals.  EMS can make a difference with this population.

Whether the patient refuses further care and transport at the scene after being resuscitated or whether they go to the ED and then check out AMA, EMS has the opportunity to intervene.  Here are three models an EMS system should consider.

Provide Treatment Information. 

If there is a toll-free number for substance use help in your state, as there is in Connecticut, give them that number, or give the number of the local harm reduction coalition.

In Connecticut call 1-800-563-4086.

Department of Mental Health and Addiction Services Access Line for Opioid Users

Greater Hartford Harm Reduction Coalition

Give your patient information on where to obtain treatment, and/or if they are not ready for treatment, provide them with information on where they or their family members can obtain Naloxone.

In Connecticut, you can walk into a participating pharmacy and get an immediate prescription for Naloxone.  If you have insurance, the Naloxone you receive can be had for a small co-pay or even free.

Naloxone in Connecticut

If your patient was sharing needles, tell them where they can get clean ones.

In Hartford the Needle Exchange Van, which also provides Naloxone and Naloxone training is at the following locations Monday - Friday:

• 7:15 AM - 9:45 AM (Park & Hungerford St.)
• 11:00 AM - 12:45 PM (Albany Ave. & Bedford St. by CHS)
• 2:00 PM - 2:50 PM (Park & Hungerford St.)

Don’t be judgmental.  Remind your patients if they are going to use, they should never use alone.  They should avoid mixing opiates with benzos.  They should have a plan for an overdose.  If they are using heroin from a new source, they should consider doing a tester shot first to determine potency.

If, as in Connecticut, a person can call 911 to report an overdose and be exempt from criminal prosecution (unless they are selling drugs), remind them to always call 911 without fear of retribution from the law.

Leave Naloxone on Scene

More and more EMS systems are going to a model where EMS is allowed to leave Naloxone at the scene of an overdose.  You will need approval to make certain you are complying with state laws and your local medical direction.  We are working on a protocol for Connecticut, where EMS will be able to provide Naloxone, after documenting they have provided training to the recipient, and have recorded the recipient’s information in case there is a recall on the drug.

Paramedics in North Carolina and in Cleveland, Ohio are providing Naloxone 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

Link with Social Services

Link with local health and community professionals to provide follow-up visits to users who have suffered an overdose.

Here is an excellent article that describes how first responders in various parts of the country are offering noncoercive treatment help.

What's Next After Narcan?

Breaking someone from the grips of opiate addiction is difficult and we cannot expect every patient we make contact with will respond, in much the same way we can’t expect to bring back each patient we find in cardiac arrest.  But we need to try.  It’s what we do.  Every year, every month, every day that someone lives who might have otherwise died is a victory.  Let users know that they are not alone, that we are here ready to help.

 

 

Don't Use Alone

 

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

Fentanyl Deaths in Connecticut

2012-14

2013-37

2014-75

2015-188

2016-479

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

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

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

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

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

"Why didn’t you give it to him?”

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

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

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

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

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

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

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

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

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

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

***

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

 

Harm Reduction

 

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

According to the Harm Reduction Coalition, harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.

Harm reduction “accepts, for better and or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.”

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

We give someone Narcan and then we find the same person oded later that day.  Does that mean, we stop trying to save them?  Or does it mean we have to find other ways to get through to them?

If we can’t stop someone from using drugs that could kill them, we can at least try to help them mitigate the risks.

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

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

Harm Reduction Coalition

Browse some of their publications:

Publications

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

In EMS we often have the opportunity to educate our patients and to intervene at critical moments.  Patients who have suffered one overdose are at the highest risk for suffering a fatal overdose.  We may revive a patient who does not wish to be transported to the hospital, or even in the cases of patients who do, we can employ the concepts of harm reduction, to help gain a foothold toward eventually making a difference.

Ask your patient:

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

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

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

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

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

Be careful mixing heroin with benzos or alcohol.

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

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

In Connecticut - 1-800-563-4086.

Your life has value.  You can’t recover if you are dead.

Not everyone will hear the message, but some will.  The message we give to one user, that user may pass on to another user, who will then be saved, even the original user succumbs.

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

It may not be as dramatic as defibrillating a fifty year old who has just collapsed in v-fib cardiac arrest, or applying cpap to a patient in flash pulmonary edema, but never underestimate the power of words and of fundamental kindness to save another human being.

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

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

Greater Hartford Harm Reduction Coalition