Thoughts on this? Uber style Narcan delivery!

[Just Plain Ruff]

http://trekmedics.org/blog/uberdose/?utm_source=Trek+Medics+International+List&utm_campaign=ec960c617d-Uberdose6_11_2015&utm_medium=email&utm_term=0_115ff35e87-ec960c617d-84482817

To a certain extent, I think we all knew this was coming. For as long as there have been efforts to equip police officers and public transit workers with naloxone — “the overdose antidote” — to reverse opiate overdoses and resuscitate dying patients near instantaneously, it was almost a given that someone was eventually going to pipe up and say, “There should be an Uber for heroin overdoses.”

Well, now it’s happened, and I’m a bit surprised to know that it’s us saying this — and that it’s taken anybody this long to say it at all.

There should be an Uber for heroin overdoses.

For all opiate overdoses, in fact. For any overdose that could be reversed if someone nearby happened to be carrying naloxone (trade name “Narcan”) and got an alert on their phone that said “Somebody’s on the verge of dying around the corner and you can save their life right now.”

There should be an app for that.

It’s not all that far-fetched of an idea, really – especially if you’re a drug addict who’s watched friends die from an overdose, or a parent who’s lost a child.

Like bystander cardiopulmonary resuscitation (CPR) and the automatic external defibrillator (AED) before it, one could argue that it was only going to be a matter of time before common sense prevailed and the possibility of saving someone from a premature death by giving them a basic life-saving skill would no longer obstructed by antiquated legislation or the monopolistic tendencies of the established public order. Untold thousands of parents, spouses, siblings, children and friends would likely agree: there should be an app for overdoses.

But before I explain why I think there should be an app for overdoses — or at least an alerting system separate from the “public” 911 system (and, yes, full disclosure: Trek Medics has an alerting system that could do this) — I’d like to first explain why I think orthodox 911 systems alone, including your own, will never be able to prevent as many overdoses as it believes it can, and why an emergency alerting system detached from centralized emergency call centers could help immensely in preventing a lot more premature death.

As a paramedic that worked along the U.S.-Mexico border until 2010, my colleagues and I responded to a lot of heroin and painkiller overdoses. Some of them we got to in time, while in others we got there too late — and still many other overdoses we never even heard about. Unlike a lot of the other deaths we witnessed in the course of our work, fatalities resulting from opiate overdoses were almost always preventable, and the number one reason behind every death was time: we simply didn’t get there when we were needed. There are a number of problems that keep paramedics from reversing overdoses in time, many of which centralized 911 systems cannot fix — or even cause themselves.

911 is only good when you call it

First and foremost, in the U.S., Canada and other countries where there’s a unified emergency access number for police, fire and emergency medical services (E.M.S.), asking a drug user who’s witnessing an overdose to dial 911 and send for help is tantamount to calling the police and asking them to arrest you and take you to jail with all the evidence against you packaged up and ready to go for easier booking. No one’s eager to make that call. In the same vein, equipping EMT-Basics, volunteer firefighters and law enforcement officers with naloxone is definitely a good start, and certainly makes for good press, but it’s ultimately a passive approach with limited scope that leaves the life-saving administration of naloxone to largely incidental occasion — i.e., “I happened to trip over him while walking under the highway overpass and noticed he had a needle dangling from his arm.”

Few, if any, life-saving awards have ever been given out to drug addicts

While several U.S. states have passed “Good Samaritan” laws that offer immunities and/or other legal protections to bystanders who report an overdose in progress, it’s quite possible that such legislation, coming from the mouths of lawyers, politicians and police chiefs, translates in the minds of drug abusers into something more akin to, “Good Samaritan today, law-breaking junkie tomorrow.” I haven’t seen any data yet, but I’ve a suspicion that the instances of witnesses invoking Good Samaritan protections are probably pretty low in suburban and rural communities where everyone knows your name.

Opiate abuse is typically an introverted activity

Overdose victims are often found by emergency responders only after considerable trouble and in hard to reach places that are purposely removed from easy public access, making it very inconvenient for crews to bring in their gear and gurney, administer their drugs, and remove the patient. Such behavior is very rational: Nobody wants their spot blown up, and by bringing in the cavalry when maybe all you needed was someone within the community who knew what to do, there’s a strong chance the official entourage will end up scattering the people who will need help later to deeper and darker corners. This is particularly worrisome in the cases when there’s “bad” heroin going around: where there’s a higher risk for users to overdose, you don’t necessarily want to shoo them into the woods.

In the event that a companion opts to call 911 for his/her overdosing friend, it’s often not before considerable efforts have been made to seek alternative home remedies in order to avoid the prospect of having to call 911 — including cold showers, face slaps and banging heads against the floor, to name a few. These are the panicked, yet predictable reactions of an unprepared community that’s literally choosing between life and jail for both, or maybe death for one and likely no jail for the other. This panic, reinforced by a natural aversion to self-incrimination, can be so pronounced that it’s not unheard of for would-be Samaritans to go as far as to drag their overdosed friend to the front lawn or street curb, call 911, and flee the scene. This effectively turns them into fugitives and leaves the task of finding the unresponsive patient to emergency responders equipped with sketchy information taken from a very reluctant 911 caller. Damned if you do, damned if you don’t.

These are just a few of the factors weighing in the heads of drug users who are witness to an overdose. The paralysis of the panic and paranoia — not to mention the adverse effects of the drug itself on the decision-making faculties — inevitably leads to delays in action, which further leads to delays in getting oxygen back to the oxygen-starved brain and heart, and thus increases the chances for both premature death and permanent neurological disability.

And why? Because junkies and addicts deserve what they get? I would leave the right to respond to that assertion to the family and friends of those who’ve lost loved ones prematurely.

Pomp vs. Circumstance

There’s a strong case to be made that bystander-administered naloxone programs could be as effective as orthodox 911 systems in responding to overdoses, administering naloxone, and managing the patient, if not more effective. Such a system would undoubtedly be cheaper and would certainly be better equipped to provide post-overdose care as it could technically even include direct admission to inpatient or outpatient treatment facilities — something most U.S. paramedics are legally forbidden to do. By law, paramedics in the U.S. have basically two options to offer an overdose they just revived: “go to jail with this police officer, or go with us to the hospital (and jail after).”

“Everyday they don’t never come correct” – Flavor Flav

Equipping friends and family and fellow drug users to administer naloxone is also likely a safer approach to the prehospital treatment of overdoses than orthodox 911 systems can offer, and for two reasons:

1. Giving naloxone for a heroin overdose always carries the very real risk of solving the medical emergency while simultaneously creating a behavioral emergency that can be equally, if not more, dangerous to both patients and bystanders. Being pulled from a deep, euphoric sleep to find trusted, familiar and/or non-threatening faces is a lot more manageable from a behavioral perspective than being awoken by a scrum of public safety personnel with diesel engines running and radios chirping. Imagine the circus: a couple of paramedics with weird goggles sticking needles in your arm (and possibly damaging your “good” veins); a handful of firefighters in suspenders and big pants; and two police officers with shiny badges and handcuffs, digging through your wallet. All of this for someone who’s quite literally just been pulled back from the great white light, and who now likely finds themselves in the throes of severe withdrawals. If there was ever a buzz-killer, naloxone administered by the full public safety platoon is it.
2. About those needles: Thank God for nasal naloxone, but the protocols in many E.M.S. systems across the U.S. still require paramedics to start an intravenous line for patients who overdose on opiates. Intravenous drug users are clearly at a higher risk for having infectious blood-borne diseases. Not only does starting an intravenous line on these patients pose risks for the healthcare professionals treating them, but unnecessary needle sticks also put drug users at greater risk for hospital-acquired infections — a very clear sign that we’re over-treating as a society, if there ever was one.

You’ll go to jail for this?

Liability doesn’t really seem too much of a problem either, especially when you consider who the trained responders might include: like public health practitioners, community advocates and the drug users themselves, among others. Let’s be clear: Nobody’s asking the local boy scouts troop to respond to a heroin den. There are certainly more creative and appropriate solutions.

In Baltimore, for example, the foundations for such a response team were detailed in a New York Times article about a program that trains strippers and bouncers in five minutes to carry and administer naloxone. It described these prepared responders as, “a group of health workers trusted and integrated on the streets, empathizing with those plagued by poverty, and meeting the people eye-to-eye to help them see another day.” I suspect people like these would be willing to risk the liability.

Medical Misdirection

Some of the major players in making naloxone accessible to the public at large include the E.M.S. medical directors at the state, county and city levels, under whose license prehospital professionals can legally provide care. These doctors decide what medical interventions can and can’t be performed by E.M.S. professionals and bystanders within their jurisdiction, and many are resistant to making naloxone as easy to buy as a tourniquet. But if the degree of uniformity shared by E.M.S. protocols across the nation is to be any sign, what these medical directors are deciding can and can’t be done isn’t necessarily based on evidence. This lack of evidence is true for many medical interventions performed by E.M.S. professionals in general — it’s hard, if not unethical, to get informed consent for a research study from someone who’s unconscious or believes they’re about to die — and the debate is definitely needed. But there should be little question left about the efficacy of bystander-administered naloxone in reversing opiate overdoses: this stuff saves lives.

Similar to the debates surrounding bystander C.P.R. training in the 60s and 70s, many of these medical directors can’t imagine the public at large capable of performing such a high-risk medical procedure, or even doing it correctly. Well, it’s either that or death, and compared to the damage caused by chest compressions during CPR, naloxone seems little more than a nasal decongestant.

Good Ol’ Uncle Pharma

Of course, all of this talk about Uber for heroin overdoses is probably a bit on the wishful thinking side at this point as the makers of naloxone are currently under investigation for price-gouging. In Massachusetts, it was reported that as soon as the Governor declared opiate overdoses a public health emergency, the prices “skyrocketed.” According to State Attorney General Maury Healey, ““Our office has heard regularly from local law enforcement and public health workers worried about their ability to maintain supplies” — the moral equivalent of jacking up the price of gas as the hurricane evacuation begins.

It’s a shame, really, because if the makers and distributors of naloxone just only took a page from the playbook of the CPR/AED industrial-complex, they’d be able to get naloxone in every first aid kit ever made ever again.

Social Entrepreneurship At Its Purest

There is one last reason why an Uber-style dispatch system run at the community level is not only a good idea, but likely inevitable: These are the times we live in. In a world where everything and anything is becoming available on-demand, and orthodox 911 systems continue to be a victim of their own success, some person will have the compassion, the motivation and the common sense to meet demand where it’s highest, and prevent a lot of senseless death. Since Sept. 11, the United States government has been pumping trillions of dollars into any and every public safety and health agency to prepare for terrorist attacks and active shooters, “even though”, as Nicholas Kristof wrote in the New York Times, “[overdose] kills more people in America than guns or cars and claims more lives than murder or suicide.”

Perhaps we can do better. Maybe there’s an app for it. Or maybe we should just give naloxone to taxi drivers.

Whatever the solution, it’s long overdue.

—————————————

J. Friesen, MPH, EMT-P
Founder / Director
Trek Medics International

Edited June 11, 2015 by Ruffmeister Paramedic

[island emt]

why not an automatic lip stapler for those 400 lb folks who waddle up to the fast food counter and say supersize me ::

or mandatory sterilization to those with IQ's less than 75 ::

or a law requiring folks to have a job with benefits before reproducing ::

See , Even I can come up with hair brained ideas without having an MPH behind my name.

how about putting serious efforts at removing the opiate supply so we didn't have millions of addicts?

gee there's a novel concept

How about getting rid of the afghan supply of black tar at it's source?

Oh wait we wanted to do that , but the Afghan presidents brother was the head of the heroin cartel in charge of distribution and shipping it out of the country, so we couldn't rock that boat.

How about 100% inspection of all trucks and shipping containers coming into our ports of entry instead of random inspections?

[cprted]

I would challenge your assertion that drug users don't call 911 when they or another drug user overdoses. They do. Not as much as they probably should, but they do call. Maybe the police have a slightly different mentality up north of the 49th, but when the police attend OD calls, they're not worried about arresting people. I would say the largest barriers to addicts seeking help from heath care providers is the attitudes of health care providers themselves. The number of times I've had addicts refuse transport because, "they're all assholes in the hospital, they treat me like shit because I'm an addict," is astounding.

Again, maybe this happens more North of the 49th than south, but street narcan kits are quite prevalent up here. It's a little kit with 0.8mg of Naloxone preloaded in a syringe. I'm sure with IN naloxone becoming more common, the street kits will transition to that form over time.

The major problem however is that so few overdoes involve a single toxidrome. Most ODs are polypharm and opiates are but one of the agents on board.

If you want to look at public health initiatives that really do make a difference, read up on Supervised Injection Facilities. There are a number in Europe along with one in Vancouver, Canada and one or two in Sydney, Australia.

Edited June 12, 2015 by cprted

[island emt]

sarcasm alert

just what the world of drug addicts needs. A supervised shooting gallery where they can go & use illegal drugs in safety .

they turned to heroin because the prescription opiates got much harder to obtain after we went through a 5 year span of time where it seemed like every other call involved prescription medication overdoses. Heroin is cheaper and easier to obtain on the street than diverted prescription drugs

I say give them all the blow they can shoot snort or shove up their arse. They will be gone soon enough all on their own.

Their addictions are breeding a whole new adventure in the drug treatment centers who take them off heroin and get them hooked on suboxone that is provided legally by "professionals" who are helping to lighten the states wallet by millions $$$$$$$$$$ yearly.

Now we have a whole new culture of suboxone addicts robbing houses and people to get more illicit drugs on the street.

Edited June 12, 2015 by island emt

[paramedicmike]

Police agencies in the US are increasingly carrying Narcan. The practice is becoming more widespread. I went to the American College of Emergency Physicians conference last fall and there was a guy there who had a Narcan autoinjector designed for layperson use (family, police etc...) that talked you through use of the device. (I'm not endorsing any particular product but this was the device. One of the guys who developed it is a paramedic turned physician. The other is his mechanical engineer brother. I met the doc half of the brothers. Nice guy.)

While I can't speak for other areas places where I have worked and currently work see the police more interesting in keeping people alive than in arresting them.

It's interesting, too. I've heard the same argument about users not going to the hospital because the people there are assholes. What's funny about that is that I think the users think that everyone who's not falling over themselves to help these poor, downtrodden heroin addicts... "Because I have a DISEASE!"... is an asshole. They aren't treated any differently from other patients. But when people are working to take away your high...

(As an aside I did meet one addict who came in after shooting into her hand. She was actually pretty nice. It was a slow morning. I had no other patients. We talked for an hour. She walked me through how she buys. How she prepares the solution. How she decides where she's going to inject. It was pretty fascinating. I got a better drug education from her than I've gotten in years of lectures.)

There was a NYTimes article on supervised drug injection locations last year. I thought the article talked about a place in Washington but it was really about a place across the border in Vancouver, BC.

[triemal04]

I would challenge your assertion that drug users don't call 911 when they or another drug user overdoses. They do. Not as much as they probably should, but they do call. Maybe the police have a slightly different mentality up north of the 49th, but when the police attend OD calls, they're not worried about arresting people. I would say the largest barriers to addicts seeking help from heath care providers is the attitudes of health care providers themselves. The number of times I've had addicts refuse transport because, "they're all assholes in the hospital, they treat me like shit because I'm an addict," is astounding.

Again, maybe this happens more North of the 49th than south, but street narcan kits are quite prevalent up here. It's a little kit with 0.8mg of Naloxone preloaded in a syringe. I'm sure with IN naloxone becoming more common, the street kits will transition to that form over time.

The major problem however is that so few overdoes involve a single toxidrome. Most ODs are polypharm and opiates are but one of the agents on board.

If you want to look at public health initiatives that really do make a difference, read up on Supervised Injection Facilities. There are a number in Europe along with one in Vancouver, Canada and one or two in Sydney, Australia.

Junkies don't call 911 as often as they should, or stick around to help the patient (CPR in someone in respiratory arrest or severe respiratory depression works people) as often as they should...but a lot of times they do. The cops...unless someone there is being a douchebag or something blatantly bad is going on (the 16 year old girl laid out in a roomful of dirtbags...not that that EVER happens... ) or you work in some small place where a heroin OD is such a big bad thing...most cops are not going to waste their time busting someone for a couple bags of heroin. It's a pain and waste of time for them and the vast majority I've seen would rather be doing something better. There's even some states that have passed laws so that if you call 911 for an OD you CAN'T be arrested on drug charges.

[Just Plain Ruff]

Great discussion, I thought it was a thought provoking article but I think we might have stroked Ole Island out with his first response.

But this is good discussion.

[chbare]

First, we need to be able to divorce human hubris and bias from the discussion. For example, I saw earlier comments go on about heroin. What does the data tell us about the types of opioid overdoses that are killing folks? In many cases, the substances involved were not illegally pulled from poppy fields in Afghsnistan, but rather were from prescription opioids. Once we start attaching emotions and using bias to conflate the picture, it is easy to make incorrect conclusions that can further reinforce prior assertions that may not accurately reflect the actual situation.

With that said, I would ask to look at the evidence. What is the impact when naloxone programmes are used? Do they lead to increased abuse and more problems as some may assert? In general, how does education and risk reduction compare to the use of coercion (making drugs illegal and throwing people in prison) when combating the issue of opioid associated death via overdose? There is a base of literature out there that could allow us to make reasonable conclusions.

Regarding this particular article and novel approaches it suggests, I'd ask if it was worth considering the author's thesis based on the current literature. I'm not entirely sure, but would it be worthwhile for somebody to develop a protocol, approach an IRB and gather some data?

[rock_shoes]

sarcasm alert

just what the world of drug addicts needs. A supervised shooting gallery where they can go & use illegal drugs in safety .

they turned to heroin because the prescription opiates got much harder to obtain after we went through a 5 year span of time where it seemed like every other call involved prescription medication overdoses. Heroin is cheaper and easier to obtain on the street than diverted prescription drugs

I say give them all the blow they can shoot snort or shove up their arse. They will be gone soon enough all on their own.

Their addictions are breeding a whole new adventure in the drug treatment centers who take them off heroin and get them hooked on suboxone that is provided legally by "professionals" who are helping to lighten the states wallet by millions $$$$$$$$$$ yearly.

Now we have a whole new culture of suboxone addicts robbing houses and people to get more illicit drugs on the street.

"Supervised shooting galleries" as you refer to them do not really assist anyone in getting off drugs. What safe injection sites do is reduce the amount these people drain out of the public system (remember Canada, and in fact most of the developed world, has some form of publicly funded health care). Safe injection sites reduce 911 responses for overdose, they reduce infection due to the sharing of dirty needles, and for a very small number they provide access to rehab facilities.

From a study in Quebec looking at the cost of caring for septic patients (a frequently occurring malady amongst the IVDU population). "The mean cost for all patients abstracted was $11,474 per episode of care ($1,064/day). The survivors had a mean cost for their treatment of $16,228 per episode of care ($877/day). The total cost per episode was $7,584 per nonsurvivor ($1,724/day). An average cost of $27,481 for survivors after day 28 through 1 year was calculated. The burden of severe sepsis was estimated to be $36.4 to $72.9 million per year, but higher if costs beyond day 28 are included."

http://www.ncbi.nlm.nih.gov/pubmed/12040548

From the CDC regarding the cost of HIV treatment "The most recent published estimate of lifetime HIV treatment costs was $367,134 (in 2009 dollars; $379,668 in 2010 dollars)."

http://www.cdc.gov/hiv/prevention/ongoing/costeffectiveness/

In a country with a publicly funded hospital system the tax paying public is on the hook for Sepsis and HIV treatment cost. In the end I don't support safe injection sites because I think they help people get off the drugs. I support safe injection sites because I'm a responsible tax payer who likes seeing the impact of junkies on the public purse reduced as much as ethically possible.

[island emt]

I will admit to having an issue with the lack of drug interdiction being done by this country.

I will also admit to a personal bias against the the Afghan drug lords err politicians.

My wife's brother was murdered by an Afghan security officer in the direct Employ of Karzi's brother.

Paul was working as a Lepp training the Afghan police forces in drug interdiction and investigation.

He & his team were putting a hurt on the Karzi boys distribution network so an order was put out to whack him & his partner.

We are wasting thousands of lives and spending billions of dollars in support of crooked politicians who are involved in the drug trade.

End of my rant.

RIP Paul Protzenko SSG US Army ,LEPP, Retired Ct State Trooper first class.

October 1964- 9 july 2011

http://oefkia.blogspot.com/2011/07/retired-us-state-trooper-paul-protzenko.html

Edited June 13, 2015 by island emt