Administration and Leadership, Patient Care

One Paramedic’s Perspective on Civilian Naloxone Distribution

The U.S. surgeon general, Dr. Jerome Adams, recently issued the first national public health advisory in 13 years. He wants more civilians to start carrying naloxone “to help combat the nation’s opioid crisis and save lives.”

Since 2010, the number of Americans who die from opioid overdoses annually has more than doubled, and in 2016 there were more than 42,000 deaths. The need for a multifaceted strategy to combat this deadly epidemic is clear.

Among many EMS providers, there’s a great deal of angst directed at civilian naloxone distribution programs, as well as at opioid overdoses in general. If you look at the comments section of social media posts related to these topics, the frustration, anger, and lack of compassion is painfully and publicly obvious.

Some seem to think that an increase in naloxone availability will lead to an increase in the number of overdoses because the drug users will be emboldened and feel like there’s a decreased risk.

Others believe that the public safety response to overdoses—especially for those unfortunate people who overdose multiple times—is a total waste, because the people choose to use drugs. There are also some providers who feel like the naloxone distribution programs aren’t justified because items used to treat other medical emergencies (e.g., rescue inhalers and epi-pens) aren’t distributed in the same fashion.

These arguments are substantively flawed. The suggestion that naloxone distribution will increase drug use because of a perceived decrease in risk assumes that a drug user is acting rationally and making the same sort of risk benefit calculation that an average person would. Addiction, by definition, takes the rational analysis out of the equation.

Myths and Facts

The belief that overdose patients don’t deserve emergency medical care seems contrary to what we do as EMS providers. Many of the illnesses and injuries that we respond to are potentially avoidable or are self-inflicted, yet we don’t see EMTs and paramedics demanding that we stop providing care to the patients suffering from them.

Imagine if we said that, as an industry, we’re not going to care for patients whose COPD was caused by smoking, or those whose eating habits lead to Type 2 diabetes, or those who got injured while driving intoxicated. It’s laughable, and yet that attitude is pervasive as soon as the discussion turns to opioid overdoses.

Finally, there’s the argument that because they aren’t giving away inhalers and epi-pens to the public, then they shouldn’t be giving away naloxone.

Let’s examine the statistics.

According to the American Academy of Allergy Asthma and Immunology, approximately 200 people die from anaphylaxis annually.1 The Asthma and Allergy Foundation of America tells us that in 2015, 3,615 people died from asthma.2

In 2016, more than 42,000 people died from opioid overdoses. In this context, the scale of the public health response to the opioid epidemic makes sense. Every patient who died from a treatable anaphylactic reaction or reversible asthma attack deserved to have access to the medication that could’ve saved their lives—but that isn’t a reason to be against the community use of naloxone.

In the future, maybe the framework that’s developed in response to this crisis can be used to distribute other critical medical supplies.

The Cost of Compassion Fatigue

As medical practitioners, we need to closely examine our prejudices and work to move beyond them. There’s no doubt that many EMS providers suffer from compassion fatigue, which can present legitimate obstacles to doing the job at hand. When responding to increasing numbers of opioid overdoses and deaths, it’s reasonable to experience feelings of frustration, helplessness, and anger.

It’s not reasonable to let those feelings impact the care that’s provided. When you put your uniform on, you’re making a commitment to the community that you serve to deliver care dispassionately and without judgement. If you’re not able to do this, then you shouldn’t be practicing medicine.

Civilian naloxone distribution programs won’t end the opioid epidemic, and they shouldn’t take the place of a comprehensive, evidence-based approach that includes narcotic interdiction, mental health care and addiction recovery services. These distribution programs are, however, part of a quickly implementable harm reduction plan that will help to save lives in the immediate future. EMS should take the lead in these programs as the natural link between the community and the health care system at large.

One example of this is the City of Pittsburgh Bureau of EMS, where a naloxone leave-behind program was started in early 2018. If a patient who overdoses refuses transport to the ED, the responders can leave an intranasal naloxone kit with the patient or other competent adult in the residence. The goal remains the same: to provide transport to the patients in the hope that they’ll be connected to recovery services while in the ED, but if they refuse, the naloxone is available.

Every overdose that’s reversed is a potential opportunity for that patient to get into treatment. As healthcare providers, it’s our duty to try and help our patients, regardless of the nature of their injury or illness—and regardless of how we may feel about their lifestyle or choices.

References

1. Death from Anaphylaxis is a reassuringly unusual outcome. (Dec. 13, 2013.) American Academy of Allergy Asthma and Immunology. Retrieved April 13, 2018, from www.aaaai.org/global/latest-research-summaries/Current-JACI-Research/death-anaphylaxis.

2. Asthma Facts and Figures. (Feb. 2018.) Asthma and Allergy Foundation of America. Retrieved April 13, 2018, from www.aafa.org/page/asthma-facts.aspx.