This past year, the National EMS Advisory Council (NEMSAC) recommended a change to the National Scope of Practice Model, whereby EMTs and EMS first responders would be allowed to administer the opiate antagonist naloxone to patients in cases of suspected overdose.
A predictable Path
Naloxone has been receiving a lot of attention lately, and while EMS leadership considers a change to BLS scope, the drug is already being administered by police officers in many locales. It’s also currently available over the counter in pharmacies in several states, and many EMS systems have already made the leap to BLS naloxone by the intranasal route.
This push to make naloxone more universally accessible is being driven by a resurgence in IV opioids, particularly in certain parts of the country. Tighter controls on prescription painkiller pills have also had the ironic effect of increasing IV narcotics use, thereby resulting in not only more, but also deadlier, overdoses.
Naloxone is an efficacious antidote, and there’s no real downside to using it. As a result, there’s now an entire advocacy movement pushing for its increased availability. Their perspective isn’t so different, perhaps, than the one that led to fire extinguishers in every stairwell and smoke detectors in every room.
Burning Down the House
When your house catches fire, you don’t stand inside and try to figure out why it’s burning down. You get out. Naloxone certainly helps those who overdosed to “get out of the burning house.” By focusing our attention on treating the next acute overdose, however, we may be distracting ourselves from addressing the deeper issues that render such an approach largely futile.
Like stenting a STEMI in the cardiac cath lab but then leaving the patient with uncontrolled hypertension, diabetes, cholesterol and a four-pack-a-day tobacco habit, treating the next acute overdose becomes an endless circle punctuated by episodic death when we can’t get there in time.
A Complex Brew
Narcotics don’t typically appear in a vacuum, but are instead often part of a constellation of substance abuse, psychiatric illness, homelessness, violence and other crime, as well as infectious diseases like hepatitis, tuberculosis and HIV.
Many opiate users cycle through the corrections system for substance abuse charges or intoxication, and for narcotics-related criminal activity. Once incarcerated, they’re then exposed to other high-risk behaviors, as well as to loss of work, income and healthcare benefits.
The final common pathway is interruption of medical and psychiatric treatment and progression of disease upon release, and then re-entry into the system once everything, including the individual, begins to fall apart.
The entire problem is self-perpetuating, as these individuals interact with other members of a subculture that frequents the same hospital EDs, shelters, jails, parks, and abandoned and vacant lots.
Just as you can’t simply put a Band-Aid over a gunshot wound to the chest, we’re not going to make a whole lot of headway if police, correctional facilities, EMS, public health officials, mental health providers and shelters continue to address substance abuse and addiction only from within their individual silos. Instead, the same kind of integrative case management we’re exploring through mobile integrated healthcare might be effectively brought to bear on the complex brew of narcotics use, high-risk behaviors, socioeconomic disparities, and a number of other negative cultural influences and determinants. Innovative approaches to helping patients navigate chronic disease might also be used to help patients navigate chronic cycles of incarceration and release, 9-1-1 EMS transport to the ED, and loss of job, income, home and healthcare.
That also means finding a way to pay for all this. Even though multiple stakeholder groups are already spending extraordinary resources on managing this population, each of these agents has their own individual budgets and internal challenges to manage as well. It’s going to take creative financing and, more importantly, creative and committed leadership to literally move the needle (hopefully away).
The homeless addict with hepatitis C, a rap sheet, and psychiatric or HIV meds they can’t afford or don’t want to take doesn’t belong to a group that community leadership is usually going to focus on or advocate for, even though doing so might provide economic, public health and basic human benefits.
A Different Dose
The problem of opiate abuse is a multifactorial one, and it’s going to take a reality check, as well as a dose of real compassion, to get something done instead of just waiting for the next fix. Find ways to work together and a willingness to step across boundaries into each other’s turfs.
