Opioid Crisis National Roadmap- EMS Comment

 

EMS Encouraged to Comment on Opioid Crisis National Roadmap

These are my comments on the draft report developed by the Fast Track Action Committee (FTAC) on Health Science and Technology Response to the Opioid Crisis.

People who have suffered a nonfatal overdose are at the high risk of suffering a fatal overdose. A recent study out of Massachusetts suggested that one out of ten of these patients will die of an overdose within a year.(1) Since EMS has contact with these patients at a pivotal time in their live, EMS has an opportunity for intervention either through educating them (and their families)to rehab options or where to obtain naloxone and clean needles for those who are not ready to quit. Some EMS services even leave naloxone with users and their families.
The manner in which EMS treats these patients is also critically important. If EMS treats them as people who are suffering from a chronic disease as opposed to people with character flaws, then they can help reduce the stigma that any opioid users face that can be a barrier to them seeking help. Improved education for EMS personnel into the science of addiction is needed if EMS is going to play a role in helping people toward recovery.

Harm Reduction should be emphasized in EMS education and in EMS Treatment. In area of high intravenous drug usage, designated EMS vehicles or stations could function as a needle exchange site, providing users with clean supplies as well as information about rehabilitation. Clean needles and supplies will not only help the spread of disease such as AIDS and Hepatitis C, it can prevent endocarditis and other infections that are rampant in the user community.

EMS data offers as unique look into the epidemic and can provide real-time data surveillance and early warning of spikes in overdoses and bad batches if done properly. A study from North Carolina has shown the naloxone is a poor surrogate for tracking opioid overdoses because many overdoses do not need naloxone and that naloxone is often given to people who turn out not to have opioid overdoses. (2) A better way is to require EMS to install the data element “suspected opioid overdose,” and track this. In Connecticut, we have conducted a pilot study of using our Poison Control Center as a repository of EMS overdose information. In the pilot, EMS responders in Hartford called poison control shortly after each overdose they responded to, and answered a series of questions about the overdose, including patient demographics, place and route of overdose, whether naloxone was needed and in what dose, and identification of any paraphernalia. (4) The project is expected to slowly expand statewide, and will eventually be linked to the HIDTA (High Intensity Drug Trafficking Area) OD map software to show location of overdose. (3) The project was able to identify unique heroin brands linked to overdoses as well as information about users who thought they had bought cocaine, overdosing on opioids.

Emergency Medical Services, which has been underutilized in the fight against the opioid epidemic, can be a leader in the fight contributing surveillance, data collection, and early warning alerts, as well as education and harm reduction to the traditional role of emergency treatment.

1. 402 One-Year Mortality of Opioid Overdose Victims Who Received Naloxone by Emergency Medical Services
Weiner, S.G. et al. Annals of Emergency Medicine , Volume 70 , Issue 4 , S158

2. Joseph M. Grover, Taibah Alabdrabalnabi, Mehul D. Patel, Michael
W. Bachman, Timothy F. Platts-Mills, Jose G. Cabanas & Jefferson G. Williams (2018)
Measuring a Crisis: Questioning the Use of Naloxone Administrations as a Marker for Opioid
Overdoses in a Large U.S. EMS System, Prehospital Emergency Care, 22:3, 281-289, DOI:
10.1080/10903127.2017.1387628

3 https://www.hidta.org/odmap-training/

4. https://www.courant.com/news/connecticut/hc-news-hartford-overdose-tracking-numbers-20180912-story.html

 

 

Down Time

 

A few days ago on our employees only Facebook page, someone posted a picture another person had taken of one of our crews while they were parked by the side of a street. The driver leaned against the window, arms folded, eyes closed.  The passenger had his eyes open, but he was slouched down in his seat. They were clearly in rest mode, but it wasn't like they needed Narcan.  The comment was if they wanted to sleep, they should find a more secluded spot than a downtown street. The concern was every crew represents all of EMS, and the poster thought this crew looked unprofessional.

A fair point, perhaps, but I admit I felt bad for the crew to be shamed by a few fellow employees (the comments mainly agreed with the poster).  There are few days I have worked when either myself or my partner have not been guilty of shutting our eyes at some point in the shift. I can’t say there hasn’t been snoring at times. (Most in EMS work either mega-overtime or multiple jobs in addition to trying to raise families and fatigue in EMS has been well-documented in the literature). It's why I like to find out of the way spots. Not that we get a lot of downtime. Our service utilizes system status management so we are constantly on the go. If you are not on a call, you are headed to a posting location to wait for a call, and sometimes sent to another location as soon as you arrive at the first one. At least our management is not too rigid about where we post as long as we are in proximity to the stated posting location.

I am six-foot-eight and sixty years old so it is almost impossible for me to sit folded up in the passenger seat for too long. I have to get out and stretch. I bring a basketball with me and sometimes will find a court to shoot on (my radio on my belt), or I will just stand outside the ambulance practicing spinning the basketball on my finger. I took my daughter to see the Harlem Globetrotters last year and have challenged myself this year to master the finger spin. My goal is to have my picture taken with a Globetrotter with both of us smiling while spinning basketballs, during the pregame photo session. I have already purchased the “Magic Pass” tickets.

The other day, my partner and I were in Bushnell Park (covering downtown) and a local TV cameraman showed up to take some footage of the park ambiance and scenery. When he was done, putting his camera back into his truck, which was parked right behind us, he told me the film was for the weather segment. He said not to worry. He didn’t take any footage of me spinning the basketball as he imagined if my boss saw it, my boss would call me into his office and ask me to bring my basketball.  He thought he was doing me a solid, but I was disappointed. I had imagined calling my daughter and saying be sure to watch the weather tonight, you’ll see a basketball superstar doing tricks. The cameraman didn’t understand. The fact that I am standing outside the ambulance spinning a basketball doesn’t mean I am lazy or goofing off. It's just what I do sometimes while waiting for a call.

I feel the same about the crew that was getting some rest. What matters to me, at least, is not whether they are sitting bolt upright in the seats, eyes open, hands on the steering wheel and the map book ready to respond, but that when their number is called, they hear it, answer the radio, respond quickly and safely, and treat their patients with skill, kindness, and empathy.

Peace to all.

Fighting Fatigue in EMS

Fatigue in EMS

Harlem Globetrotters Magic Pass

Beautiful Boy: The Book

 

In the movies, the hero kills the monster after an exciting and lengthy battle. Then just as the winning team congratulates themselves on their great victory and now bright future, the monster raises its head again. It was not really dead! After a brief but tense battle, in which the hero almost dies, the final sword is plunged in the monster’s heart. The movie is over. The credits roll. Hooray. Peace on Earth. A predictable formula.

There is a new movie out about addiction. Beautiful Boy stars Steve Carrell, the comedian of The Office fame, who has made quite a number of excellent serious movies. The movie is based on the book Beautiful Boy: A Father's Journey Through His Son's Addiction by David Sheff about dealing with his son Nic’s addiction.

Nic is wonderful child, who suddenly turns into a crystal meth addict. It seems suddenly to the father, but it is a little more gradual. Unbeknownst to Dad, the boy starts smoking pot at 13. It makes him feel fantastic. He has some underlying and undiagnosed mental health—he’s bi-polar-- issues that the drugs help him deal with ( at least initially, before exacerbating the problem). He battles the addiction monster until at last it is slain and he is back in the family’s graces. Then predictably there is a scary relapse. But he again beats the drug monster. So far so good. But the book doesn’t end there, not even with the wonderful letter he writes to his family and little brother and sister about his love for them and the sorrow for all the troubles he put them through. The monster raises its head yet again. Not really dead.  And again, and again, and again. It happens so often I lose count of all of the relapses. Really? Not again. Ultimately, the boy, now a young man, ends up drug free for eight years and he is still apparently drug free as of the publication of the latest edition of the book.

I haven’t seen the movie yet, so I am curious to see how they will handle the real-life story that doesn’t fit the typical Hollywood plot.*

The book is worth the read, and it clearly shows how relapse is part of the addiction, and that finally, after years of struggle, it is possible to get clean. The son, Nic, has written two books himself covering the same material from his point of view. These books were written prior to the publication of Beautiful Boy. The first book, Tweak: Growing Up on Methamphetamines, ends with Nick clean. Predictably, the second book recounts further relapses. I have just finished reading Tweak, and am not certain I have the stomach to read the second. He writes very well – at times his book reminds me of Jack Kerouac for its adrenaline-fueled narrative of Nic’s adventures while high, but like his father’s book, after a while, it becomes tedious. Nick is not particularly likable, and while he accurately portrays the user’s self-centered need to stay high, it is a bit hard to take. You just want to shake him and say, get a grip. But again, that is the nature of addiction – people doing things that they know are against their best interest because their brains are diseased and they no longer think properly.

I am going to pass on Nic’s second book, We All Fall Down, but will definitely try to watch the movie. I am also currently reading the father’s second book Clean: Overcoming Addiction and Ending America’s Greatest Traged, which is about how the country can best treat (and prevent) addiction. It is well-done and quite scary for the father of a ten year old to read about all the dangers that may lay ahead of her in the world outside the cocoon of our happy home.

*I am hoping the multiple relapses will be in the notes at the end. It is hard enough to live through in a book, I can’t imagine the toll it takes on a parent to live through in real life.

 

Plateau

 

Plateau -(noun) “ a usually extensive land area having a relatively level surface raised sharply above adjacent land on at least one side.”

Plateau-(verb)- to reach a level, period, or condition of stability or maximum attainment,

Merriam-Webster

***

The United States Health Secretary announced recently that the opioid overdoses deaths appear to be plateauing across the country.  While some states have seen a decrease and others an increase, the overall numbers appear to have slowed after a parabolic rise.

Opioid Deaths May Be Starting To Plateau, HHS Chief Says

The credit can go to harm reduction programs, public health and safety efforts and community organizations who have worked hard toward solutions.

Good news certainly, but not cause to disarm.  The death numbers, even if they plateau, are staggering.  70,000 deaths in 2017. Many young people, who would otherwise have many years of life, family and contributions to society left, had they not been ensnared in this terrible epidemic, are vanished.

Ensnare is another word for the day.

Here are the synonyms (also from Merriam-Webster) - catch up, enmesh (also immesh), ensnarl, entangle, entrap, mesh, net, snare, tangle,trap

I recently attended an opioid overdose conference where one of the speakers, addressing her daughter's death, called her child's journey into opioids "an innocent entry" and an "impossible exit."

Powerful and true words.  

We don’t know what the future holds.  Will a new deadlier opioid emerge or a new combination of drugs?  I don’t know.

***

Things in Hartford were very quiet early this October.  I am involved in a process tracking opioid overdoses in our service area and we witnessed a lull in the first half of the month.  Overdoses were down 50%. Driving down Park Street, the ever present users on the nod seemed to have disappeared as if taken by spaceship.  What was going on? I inquired of neighboring services, asked at the hospitals and talked to users on the street. They all reported the same things.  Overdoses are way down.

Was it a turning point or a lull?

Then things started picking up again.  The nodders were back. New brands hit the streets, as well as some oldies.  Red Star. Power Hour. Pray for Death. Fuck You. Power Ball. One Way. Calls for overdoses went out.  Naloxone vials came off the shelves.  Users had their respirations restored with some denying they had used, some vowing to never do it again, and others choosing not to say anything in scenes that can only be called commonplace.

I did ODs three days in a row.

An old man sitting on the porch, unconscious.  In another world, I would be thinking stroke, diabetes or ETOH.  His wife, who called, sits at the table and shakes her head. “Heroin,” she says.  “He’s at it again.”

We nudge him and barely get  a response to pain. His pupils are pinpoint.  His SAT is in the 80’s. He has COPD.  His ETCO2 is in the 70’s.  We give him just enough Naloxone to, with O2, get his SAT into the low 90s, his ETCO2 in the high 40s and get him to at least mumble some answers.  Instead of an empty vodka bottle, by his chair we find a torn glassine envelope. A $4 bag of heroin is cheaper than a pint of vodka on the avenue, and the effect is more pleasing.  I don’t know the relationship between the man and his wife, but I suspect it is not what it once was in their younger days and heroin offers the old man a form of escape.  Today he just caught a bag with a hotspot.  At the hospital he is alert enough to admit he sniffs a little heroin now and then.  

A young man collapses on the sidewalk and gets from bystanders both IM naloxone in his thigh and an ice filled Slurpee in his pants.  He comes around with some bagging and another 0.4 mg IV from us before he is resurrected.  The crowd of thirty or so  all praise each other and EMS for another life saved, while the young man hangs his head in shame as a woman lectures him that this had better be the last time.

The third patient has no human audience for his overdose.  No disproving wife to call 911. No bystander to fill his pants with ice.  He dies alone witnessed only by the skulls on the torn glassine envelopes by his bedside.

***

48 Hartford residents died in the first six months of 2018. 68 people died within the city limits.

Whether is it stacking bodies to the sky or just laying them on an already high ground, it is too many.

Years ago, a United States Senator, William Proxmire, used to have a saying about federal spending.  “A million dollars here and a million dollars there, and pretty soon you are talking about real money."

To paraphrase for the opioid epidemic:  A thousand bodies here and a thousand bodies there, and pretty soon you are talking about a massacre.

 

Cocaine with Fentanyl

 

(Image from InspireMalibu)

When they can’t get a hold of their local dealer, the two young men come in to Hartford from the suburbs to buy cocaine. Bart boasted to a younger friend Milton that he could get any drug he wanted on Park Street. “Well, let’s do it,” Milton said.

It is true that Bart knows where to buy drugs.  What he hasn’t told Milton is that when he used to do heroin, he met a friend named Mark who would do the buying for him. And since he got out of rehab, he has only been using percocet.  He doesn't inject anymore because his veins are hard to find because of his chubby arms.  Only Mark could hit his veins and Mark has been no where to be found, which is a good thing as Bart can handle the Percocets better than he could heroin. Bart has also never purchased cocaine in Hartford, though he knows the same guys who sell heroin have coke. Bart sticks with his boast.  “Sure, let’s do it.”

They park Milton’s car on Zion Street. They get out and start toward Park. “You sure, you know what you’re doing?” Milton asks.

“Yeah, yeah, put your hoodie up. They got cameras all over the city.”

They walk into the November wind, hoodies up, hands in pockets.

The first guy standing outside the bodega says, “Yo, what are you looking for?”

“Coke,” Bart says.

“How much you want?” the man says.

They haggle briefly on the price. Bart gives the man what he asks for. He palms the cash and gives it to the man in a handshake that moves into an awkward embrace. The man nods to a young man sitting on a nearby stoop, who saunters over and shakes with Bart, slipping him the envelope.

“I told you, yo,” Bart says to Milton when they get back in the car.

“Cool,” Milton says.

Bart looks at the bag then. It is a glassine envelope like they sell heroin in, but inside the envelope is a small ziplock bag full of white powder. “Look at all that,” he says. “I told you it cheaper in the city.”

“Let’s go to Jeanna’s,” Milton says.

There is a girl Milton knows from the magnet school who has an apartment now on Sigourney Street.

“This isn’t enough for three,” Bart says.

“She parties, but she doesn’t do drugs. She’s cool, though.”

They ride over to her place, after buying a six pack of Modelo at the corner store for Jeanna. She buzzes them in, and she gives Milton a kiss as he squeezes her bottom. They make introductions, and then with Cardi B on the sound system, Jenna fetches them a paper plate. Bart spreads the powder into four lines, and hands Milton a broken off bic pen. “No, you do the honors,” Milton says. “You’re the man.”

Bart feels really good about the compliment. He leans over and the pen in his nose and the other nostril clogged off with his thumb, he inhales a line, and then hands it to Milton. The feeling is odd. There is a rush, and it is not the typical warp speed thrill. It is good and familiar, but not right. It is powerful and warm, but not what Bart was expecting. He feels faint, and starts to give himself up to the feeling.  he looks at Miltons and sees something is wrong.

Milton falls face forward, and hits the floor hard.  The girl screams.  Shit!  

Bart checks Milton’s chest. Oh, God.  Oh God.  Milton is gurgling and he vomits. Bart rolls him on his side, and shouts call 911!  The girl is crying. “Now! Now!” he says.

***

We arrive after the police and fire department.  A young bearded boy, who looks familiar to me, sits against the door in the hallway crying, and looking scared. A police officer stands over him. “Is this the OD?” I ask.

The officer shakes his head and nods into the apartment. On the living room floor a young man lays on his back, his arms outstretched. He is very pale. A firefighter stands over him trying to assemble an ambu-bag while another firefighter attaches the hose to the oxygen tank in his blue house bag. I see a discarded vial of narcan by the boy’s head. I look at him carefully. He looks dead. “Is he breathing?”

Just then, I see his Adam's apple move with one agonal breath.

The FD starts bagging him. I attach the ETCO2.  It is 100.

“Any paraphernalia?” I ask.

“They all deny drug use.”

I see a girl crying on the coach.

“What did he use?” I ask her.

“I don’t know. I just had a beer. He just fell over and his friend told me to call 911.”

His blood pressure is good, his heart is going at 112. Pupils are pinpoint.

I go out into the hall, and ask the kid. “What did he use?”

“I can’t answer that.”

“We’re just trying to help him.”

“I, I , think I need to consult with my lawyer.”

“You’re not in trouble. He’s not under arrest, is he?”

The officer shakes his head.

The boy avoids my eyes.

I go back in the room and see the boy’s end tidal is down to 50. I give him a sternal rub, but he doesn’t respond. The ETCO2 is now in the 40’s. I tell them to stop bagging. His respiratory rate is now 16. SAT is 100. ETCO2 - 42. He is stable.

I go back outside. “Your friend is fine. He responded to narcan. What did the bag look like you bought?”

“You can tell us,” the cop says. “You’re not under arrest. Its just to help your friend.”

The boy looks uncertain.

“You are going to be in trouble if you don’t help,” the cop says.

“It was a clear bag,” the boy says. “We just bought cocaine. He wanted to do some. It was his idea.”

“Cocaine, huh,” I say. “Seems there was probably some fentanyl in it.”

“It felt like percocet,” the boy says.

“How do you know that?”

“I use prescription pain meds,” he says.

“Does you friend do pills, too?”

“No, just cocaine, and he smokes pot.  We both do, a little.” 

“Maybe because he doesn't use pills is why he went out and you didn’t. Be careful what you buy these days.”

The friend finally arouses, but he is too groggy to walk. We stair chair him down the three flights and take him to the hospital.  

“What happened,” the boy says, in the ambulance. “Was I in a car accident?”

***

This isn’t the first time someone in Hartford has bought what they thought was cocaine, but it ended up either being heroin/fentanyl or cocaine laced with heroin/fentanyl.

It is almost impossible to tell white heroin, fentanyl and cocaine apart by sight.

What happened to the boys? Did the dealer think Bart said dope instead of coke? Did he sell him coke that he had spiked with a little fentanyl? Did someone higher up the chain do the same?  Or maybe it was contamination at the drug packaging site? Did they neglect to clean the grinder and the scale they used for fentanyl before they started in with their cocaine packaging?  A little cross-contamination?

There has been a lot of speculation about this issue. Here are two good articles about it.

How Fentanyl Is Contaminating America’s Cocaine Supply

Cocaine Deaths Are Rising At An Alarming Rate, And It’s Because Of Fentanyl

A friend of mine in harm reduction thinks it is accidental contamination. He says it doesn’t make sense a dealer would add fentanyl to the cocaine, which might kill his customer if they are opioid naive.

Deliberate or intentional, these overdoses are increasing. Not just in Hartford, but across the country.  Anyone buying or using cocaine these days needs to be careful. Have naloxone available just in case.  Don't use alone.  Do just a little at a time.  Call 911 if someone overdoses.