EMSA Dispatch! December 2016

NEWSLETTER

December 2016

 

— FEATURED ARTICLE —

 

Director’s Message: Howard Backer, MD, MPH, FACEPDr. Howard Backer

What is the Role of EMS in the Opioid Epidemic?

Although many medical providers were unaware of the developing epidemic, EMS personnel were probably the least surprised to learn of the surge in narcotic overdoses in the U.S.  According to the Centers for Disease Control and Prevention (CDC), the number of deaths from opioids (narcotics) quadrupled between 1999 and 2014, accounting for 60% of all drug overdose deaths.  At least half of the opioid deaths are now from prescription narcotics, including oxycodone (OxyContin), hydrocodone (Vicodin), and methadone.  The amount of these prescription narcotics sold has also quadrupled since 1999.  These prescription drugs have accounted for 165,000 deaths during the five year time period, averaging 78 deaths/day.  The victims are most often between 25-54 years of age, predominantly white, both male and female.  Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that two million persons in the U.S. abuse or are dependent on prescription opioids, and every day, about 1,000 persons are treated in the emergency department for misusing prescription opioids.1

Fentanyl is also becoming more common in the illegal drug market. It is attractive because it is a synthetic opioid that can be manufactured in illegal laboratories or diverted from pharmaceutical supplies.  Moreover, it is highly potent–50 times more potent than heroin and 100 times more potent than morphine.  The same properties that make it attractive for emergency medical use make it attractive for abuse–short acting and available in multiple formulations, including intravenous, transdermal, intranasal, and oral.  It is often mixed with heroin and/or cocaine or even added to counterfeit pills in order to increase the effect. Even more worrisome is the appearance of carfentanil, an even more potent version of fentanyl that has been used by veterinarians for sedation of large animals.  This opioid may be 10,000 times more potent than morphine. Since arriving on the streets, carfentanil has been blamed for hundreds of drug overdoses across the U.S.  Carfentanil is so potent and so readily absorbed through multiple routes that it can be used as a chemical agent in terrorism or warfare, similar to its use in the Moscow theater hostage crisis in October 2002. For this reason, it is banned under the Chemical Weapons Convention.  While highly controlled in the U.S., it is uncontrolled in other countries, including China, and can be ordered over the internet. This is leading to a surge in overdose deaths, primarily in the midwest and eastern U.S., and is expected to increase overdoses in California. There is a national effort to address this public health crisis.  In California, we are taking a multi-agency and multi-pronged approach that includes some of the following:2

Safe Prescribing

There are two initiatives targeting clinicians.  One is evidence-based prescribing guidelines to manage acute and chronic pain that includes alternative medications and interventions.  The CDC as well as the Medical Board of California have issued practice guidelines.

The other provider practice initiative is the use of prescription drug monitoring programs.  In California, the system is known as Controlled Substance Utilization Review and Evaluation System (CURES), run by the Department of Justice.  The purpose is to reduce prescription drug abuse and diversion without affecting legitimate medical practice or patient care.  CURES is an integrated database of controlled substance prescriptions from pharmacies, clinics, and other dispensers across the healthcare system that can be searched by prescribing providers for a specific patient.  This alerts the provider to patients that have received multiple prescriptions from different providers, in excess of apparent need. A new California law (not yet in effect) mandates the use of CURES by providers when prescribing controlled substances. This new law will not apply to paramedics administering pain medication in the field. CURES can also flag physicians for scrutiny who are outliers of prescribing compared to their peers. If found to be illegitimate prescribing practices, the providers can be investigated, educated, or have licensing action initiated.

Overdose Treatment

Emergency providers have long used naloxone to rapidly and effectively reverse narcotic overdose symptoms.  New laws in California and across the country expand the availability of naloxone to members of the public as well as to public safety personnel.  The concept is that friends and relatives or law enforcement are usually the first to find the overdose victims.  Any of these people can easily administer a nasal spray or auto-injector. While friends or law enforcement may resuscitate some patients with pure opioid overdose, there is a risk of recurrent respiratory depression from the more potent drugs as well as the risk of mixed overdoses that do not respond to naloxone and require EMS intervention and management. Furthermore, it is critical that EMS record all treatment provided prior to their arrival so that the entire clinical course is documented.

Education

Education strategies are needed for all stakeholders, but in particular to find effective interventions to prevent drug addiction. It is most effective to target these efforts to young people, but there is also a need for adults to understand the risk of addiction to prescription medications.

Surveillance

To undertake targeted prevention and intervention programs, it is necessary to understand who is at risk and where there are communities with higher incidence of both prescription and illicit drug use. The increasing number of deaths attributable to legally prescribed opioids in the suburbs as well as overdoses in the inner city is responsible for the heightened political attention to this issue.

Implications for EMS Personnel and First Responders:

Naloxone Dosage

The optimal application of naloxone in the field for overdose of a narcotic addict is to titrate the amount of naloxone to stimulate respirations, without fully reversing the effects and inducing narcotic withdrawal. We have all seen the patients after receiving a bolus of naloxone wake up angrily, rip out their intravenous line and leave the scene or the emergency department. When law enforcement is on scene, this can lead to a violent confrontation.

Highly potent narcotics have additional implications for EMS personnel. First, patients may require much higher doses of naloxone to counteract the respiratory depression; second, they may need repeated doses to keep from relapsing into respiratory depression. Some of the victims of carfentanil have required a naloxone drip in intensive care to maintain respirations.

It is important for EMS personnel to document prior doses provided by public safety or other bystanders/family on the ePCR. This will help measure the incidence of opioid overdose, the evaluation of appropriate naloxone use by these non-medical rescuers, and the amount needed that can provide an indication of the substance ingested or injected.

Given the large push to increase access to naloxone widely for public safety and the public, and the potential need for higher doses, there is a risk that we will see drug shortages emerge. We have not seen this yet, but we have seen a rapid rise in the price of naloxone. The price for injectable ampules has increased from about $1 to as high as $20 per dose. Nasal sprays now cost about $60 and the price of auto-injectors has increased from about $300 to $2,000.

Risk to Responders

Public safety responders are concerned over personal exposure risk from some of the substances that may encounter in the field; for example, some of the drugs, including fentanyl, carfentanil, and methamphetamine can be absorbed through routes other than injection or ingestion, including skin, mucus membranes, or lung, if aerosolized. This is a very low risk, and there have not been cases of responder toxicity reported. However, if the scene is heavily contaminated with unidentified powder, patient care personnel can protect themselves with standard personal protection equipment, including gloves, gown, mask and eye protection. Clean up of illicit laboratories creates a higher level of risk and requires a commensurate level of HAZMAT protection.

Awareness of Drugs in Community

For correct patient treatment, it is important to know what types of drugs are currently available in your community. Your law enforcement or emergency physician colleagues may have information on what is being sold and used.

Conclusion

EMS personnel have a key role to play in addressing the recent epidemic of narcotic overdose. The first step to be effective is to become knowledgeable.

[1] http://www.hhs.gov/opioids/about-the-epidemic

[2]  http://www.cdph.ca.gov/Pages/OpioidMisuseWorkgroup.aspx

— LATEST NEWS & EVENTS —

 

Emergency Response Agencies Conduct Mass Casualty Incident Drill

On Thursday, November 17, San Mateo County conducted a full scale multi-agency multiple casualty incident exercise involving a train derailment scenario. The San Mateo County EMS agency kindly invited two EMSA staff to observe the exercise held at the CalTrain spur in San Mateo.

Multiple fire, police and other county agencies were involved along with the local EMS providers, American Medical Response, and several area hospitals. The exercise included testing patient movement of up to 72 casualties, some transported from the incident site to local hospitals and others creating surge for the local receiving hospitals. Some of the volunteers participating as casualties were members of the county’s Disaster Healthcare Volunteers (DHV) program.

Over 100 agency personnel participated at the derailment site. CalTrain generously provided one locomotive and two passenger cars for the exercise. Fire personnel conducted the initial extrication, triage and treatment for the victims who were then moved to a casualty collection point. Fire and medical performed a unified command at their incident command post.

The exercise provided an excellent opportunity for county and local emergency response providers to hone their skills and to practice in the field together. It was a well planned and executed exercise.

2016 EMS Award Winners

2016 EMS AwardsThis year’s EMS awards ceremony will take place on Wednesday, December 14th at the iconic Marines’ Memorial Club & Hotel in San Francisco.

In the eighth consecutive year of this program, this year is particularly notable as we received more nominations and more sponsorships than in any previous year.

34 individuals, representing a cross section of California’s EMS personnel, law enforcement, civilians and administrative professionals will receive awards from EMSA Director, Dr. Howard Backer, and EMS Commission Chair, Dan Burch. In addition, 20 additional individuals receiving clinical excellence awards will have their framed certificates presented to them by their respective supervisors at their home stations.

View a complete listing and pictures of this year’s recipients on our 2016 awards webpage.

Preventive Health Training Project to Expand Training Throughout California

There will soon be a new training program available for child care providers to take their Preventive Health and Safety Practices (PHSP) training throughout the state.  Child care providers need eight hours of PHSP training in order to receive their licenses for child care. The California Department of Education (CDE) is providing grants totaling $1,529,275 for the new training program to be taught by the state’s Child Care Resource and Referral Agencies (R&Rs) in every county.  Training for the trainers will be administered by University of California, San Francisco’s California Childcare Health Program (CCHP), with the first train-the-trainer event expected in March 2017. Local training may become available to child care providers as early as the spring of 2017.

The project brings the EMS Authority, the CDE, CCHP, and the R&Rs together to work collaboratively to fill the gaps in child care provider training that occurred when the American Red Cross stopped providing their state-wide PHSP training in 2016.  There are 23 additional EMSA approved PHSP training programs that provide the training in several counties, but the addition of this new program will allow the training to be provided in every county.

As part of the project, CCHP will provide educational materials to instructors of the training, and will also provide technical assistance to support the instructors in their work with child care providers.  The CCHP will keep the materials up-to-date according to best practices, and the materials will be available on the CCHP website at no cost to the public and other training entities.  The CCHP has a long history of developing educational materials for the PHSP training.  They are the agency that wrote the original PHSP curriculum in 1998 when the training law established the seven hour, once-in-a-lifetime child care preventive health training.

Changes to EMT and Paramedic Regulations

As part of the public comment process, individuals are encouraged to submit written comments on the proposed EMT regulations during the 45-day public comment period, which runs from December 2, 2016 through January 14, 2017. The notice of proposed regulations, initial statement of reasons and the proposed regulation text are available for review here. Changes to the regulations include, but are not limited to:

  • Updating the reinstatement process
  • Adding Naloxone, Epinephrine and the use of glucometers to the EMT scope of practice
  • Update initial training requirements to include Naloxone, glucometers and tactical training
  • Removal of the skills verification form for renewal and reinstatement of EMT certifications

If you are unable to access the website and would like a copy of the proposed Chapter 2 regulations mailed, faxed or emailed to you or if you have any questions, please contact Corrine Fishman by calling (916) 431-3727, or by email.

Effective February 8, 2016, revised paramedic regulations have been posted on the EMS Authority’s

website. These changes were non-substantive. Sections within the chapter were reorganized for clarity and continuity. The paramedic regulations are currently under internal review for other necessary revisions. A workgroup of selected stakeholders convened to address these changes and next it will go to public comment. Send any requests, suggestions or input to Priscilla Rivera in EMSA’s Personnel Standards unit.

New Law to Allow Entities to Stock Epinephrine

Effective January 1, 2017, all ‘authorized entities’ in California will be permitted to use an epinephrine auto-injector (EA) to render emergency care to a person suspected of suffering from anaphylaxis.

Authored by Assembly Member Evan Low, this law permits any for-profit, nonprofit, or government entity or organization to obtain a ‘house’ EA prescription, so long as they employ at least one person that has completed an approved training course and have a current EA certification card issued by EMSA.

Visit our EA webpage for additional details on how to obtain an EA prescription for your organization.

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