|Director’s Message: Howard Backer, MD, MPH, FACEP
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
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.
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 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.
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:
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.
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.