In 2014, the Centers for Disease Control and Prevention (CDC) reported the noteworthy and sobering fact that the United States recorded the highest number of opioid overdose deaths in the nation’s history, following a steady increase during the previous decade. More than 1.5 times as many people died from overdoses than motor vehicle collisions (MVCs) in 2014; from 2001 to 2014, nearly half a million people died from an overdose. Opioids caused nearly two-thirds of those deaths–meaning 78 people in the U.S. are dying every day from an opioid overdose.1
These are staggering numbers that reflect a cost to individuals, their families and society at large. Unfortunately, the problem doesn’t seem to be getting better, despite efforts to control narcotics, educate the public and expand access to overdose-reversal agents.2
Although the media has recently turned its attention to opioid overdoses, many EMS professionals know this has been a slow-moving disaster for quite some time. Only after it reached extremely critical levels has the opioid epidemic come to the attention of the general public and now even a prominent national political issue.
To better understand the epidemic, how it impacts EMS and what role we play in preventing fatal overdoses, we need to know:
- What opioids are;
- The current state of opioid abuse and how we got here;
- What EMS can offer in the fight against opioid overdoses; and
- What approaches are being used to address the epidemic.
What are Opioids?
Opioids are either natural or synthetic. EMS professionals are probably most familiar with the natural opiate products that come directly from the opium poppy plant (Papaver somniferum).
Opium is the raw product from the poppy plant and is converted through various chemical processes into its other forms. The major active opiates include codeine, morphine and thebaine. Morphine can be chemically altered to make heroin while thebaine is converted to oxycodone and hydrocodone, the major active ingredients in prescription narcotics.
Synthetic opioids being abused include both the old, such as methadone, and the new, including medications such as fentanyl, sufentanil and other designer drugs such as W-18 and U-47700. Synthetic opioids can be up to 10,000 times more powerful than morphine and are extremely dangerous.
In 2014, there were large spikes in overdoses from non-pharmaceutical fentanyl.3 Mixed with heroin, cocaine or both, it’s a deadly, uncontrolled cocktail even for users who know what they’re purchasing. Other dangerous and potent synthetic opioids, such as acetyl fentanyl, U-47700, and carfentanil–100 times stronger than fentanyl-have also begun appearing on the scene.4,5
Trinity EMS uses FirstWatch to track potential opioid-related calls by searching ePCRs for terms such as
“Narcan” or “heroin.” Image courtesy Trinity EMS
How We Got Here
In the not-so-distant past, deaths from opioid overdoses, though still a serious problem, were nowhere near the disaster that exists today. The illicit drug trade couldn’t make enough products to create the current epidemic. In many ways it was the perfect storm that created the opioid crisis we have today.
The epidemic began in the mid-1990s with the introduction of OxyContin (oxycodone) to the market by Purdue Pharmaceuticals. Prior to this, most oral opiates were reserved for people with significant chronic pain, such as cancer patients. However, creators of OxyContin and subsequent opioid analgesics downplayed the possibility of addiction, and the new narcotic was aggressively marketed to physicians to prescribe more widely.
Sales from OxyContin went from $45 million in its first year to nearly $3 billion a decade later.6 With the increase in distribution of legal narcotics came the increase in addiction, overdose and deaths from all opioids. The rapid increase in heroin abuse and addiction is attributed to the ever-increasing numbers of opioid addicts that soon grew a tolerance for oral opioids and began to require more potent and cheaper avenues to fill their addiction.
Despite the recent attention devoted to the opioid epidemic, the number of overdose deaths continues to climb. There were 47,055 deaths from drug overdose in the U.S. in 2014. This rate has doubled since the year 2000. Of the overdose deaths in 2014, nearly two-thirds were due to opioids. From 2013 to 2014 alone, there was a 14% increase in deaths from opioid overdose.1 While the CDC hasn’t yet published data for 2015 and 2016, news reports make it clear that opioid overdoses are still occurring at an alarming rate in cities and towns across the U.S.
Of particular concern is the rapid increase in the death rate from synthetic opioids. From 2013 to 2014, the death rate for synthetic opioid overdose doubled, while the death rate for heroin rose by 26% and prescription narcotics by 9%. In terms of total deaths, however, the natural and semi-synthetic opioids such as oxycodone, hydrocodone and morphine claimed the most lives.1
Treating Overdoses
Opioids act as a central nervous depressant, causing decreased level of consciousness and respiratory depression. Naloxone, a common medication carried by most ALS services for decades, reverses its effects by blocking opioid receptors.
As opioid overdoses have increased, so has interest in increasing access to naloxone. In 2006, even before the rapid rise of opioid abuse in the Northeast U.S., the Commonwealth of Massachusetts granted Boston EMS the ability to trial the use of naloxone at the BLS level. By the end of the trial, there were over 700 administrations by EMTs, and the state authorized BLS providers to use naloxone.7
Today, naloxone (also known under the brand name Narcan) isn’t only used by BLS providers but is commonly issued to police in an effort to get the drug to the overdose victim faster. Most non-EMS programs are utilizing intranasal administration.
Providers are sometimes faced with more complex situations, as occasionally a patient who has already received naloxone doesn’t want ED evaluation. Photo Matthew Strauss
In addition, there’s a trend in making naloxone available to the public with prescription or monitoring. Although a study published in 2015 found that these programs did increase the chances of participants seeking recovery, eliminating the effects of acute overdoses with naloxone has had little impact on reducing the rate of overdose or the rate of death from opioid overdoses over time.8 The popularity of naloxone distribution has also contributed to the rise in cost for treating opiate overdoses. The cost of naloxone, once close to a dollar per dose, has skyrocketed over the past few years as demand has grown, causing members of Congress to question why the price has increased “by 1,000% or more.”9
Widespread naloxone distribution also introduces an additional wrinkle into EMS response when interfacing with bystander programs. Prior to the authorization of layperson and law enforcement naloxone use, EMS providers were in control of the response and early treatment decisions. Providers are now sometimes faced with more complex situations, as occasionally a patient who has already received naloxone doesn’t want ED evaluation. Services are tasked with deciding whether these patients can refuse transport. Although one study found no deaths within 72 hours in patients who received naloxone and refused transport, leaving these patients means a missed opportunity to provide them with the support and addiction services they likely need.10
Information & Education
Although EMS care for overdoses–such as ventilatory support and naloxone–may help save lives, EMS also has the opportunity to help in efforts to slow down the epidemic and perhaps prevent overdoses before they occur.
Although a nationwide problem, many aspects of the rapid rise of opioid abuse vary from community to community. EMS data may provide one key measurement of opioid trends at local, state and national levels and give health officials important clues that can be used to stem the epidemic.
For example, several years ago researchers in Baltimore examined the incidence of EMS naloxone administration and found it was used in 1.1% of calls, approximately 100 times per month. They observed some trends, such as increased use in the summer, weekends and late afternoon.11 This research used data from 2008 and 2009, at the beginning of the rise of opioid addiction across most of the country. The researchers approached the problem of measuring opioid overdoses by considering naloxone administration as a proxy. In most EMS systems, measuring the incidence of EMS naloxone administration is easy, making it a valuable metric for public health officials. However, some overdoses might not require naloxone–and sometimes EMS providers administer naloxone to patients who didn’t use opioids.
Overdose data can be difficult to validate because of the illegality of drug use. Most published data, including from the CDC, comes from hospital records and death certificates. These data sets are always lagging in time (up to months or years) and thus offer limited insight into the current state of the crisis. High-performing EMS systems that place a particular emphasis on data collection and analysis can give almost up-to-the-minute status reports on opioid overdose activity within the community. EMS data offers three specific advantages, making it the very best single source of data for opioid activity within the community:
- EMS data is timely. EMS data can be mined minutes after it’s entered into an electronic patient care report (ePCR). In addition, the computer aided dispatch system can be used as a surveillance tool.
- EMS data is geographically indexed. Unlike hospital or death certificate data, EMS data is geocoded for the location of the incident where the overdose most likely occurred. Although the possibility exists that a patient was moved from where they overdosed, this is the exception rather than the rule. This piece of information is important to understand where pockets of overdoses may be occurring, becoming a surveillance tool for recovery specialists and others.
- Sizable patient population. Patients who require resuscitation from opiate overdose will frequently activate the EMS system. Because of this, the EMS system can be used as a valid surveillance system for opiate overdose activity in the community.
Many EMS systems now look regularly at overdose data, and other healthcare and social services providers, including recovery specialists, social workers and public health workers, can subsequently use and add to these statistics. Partnering with these other components of the healthcare delivery system is essential for EMS to show its value as a community asset and not just an emergency response provider.
In Boston, the number of unintentional opioid overdose deaths has consistently increased over the past several years–from 64 in 2012 to 82 in 2013, 105 in 2014, and 136 in 2015.12
At the same time, Boston EMS saw an increase in responses for what it calls “narcotic-related illness (NRI).” As of late August 2016, Boston EMS had responded to 1,920 NRI incidents, and 1,024 of those patients had been administered naloxone by Boston EMS. The department has assigned a paramedic to track NRIs after receiving automated alerts from the ePCR system when incidents appear to be narcotic related. After reviewing the call, he determines whether or not it’s truly an NRI. He’ll also look to see if patients have had more than one overdose that required EMS response, or other signs that they need additional support. In those cases, Boston EMS will refer patients to its partners in public health and addiction services.
The department also works closely with the Boston mayor’s Office of Recovery Services, created in 2015. Boston EMS’s weekly reports on NRIs are shared with the office and often appear on the mayor’s weekly dashboard to provide all city agencies with information on the state of the local opioid crisis.
Other EMS systems use sophisticated algorithms to detect opioid overdoses in the system with a high degree of certainty almost instantaneously. The Richmond (Va.) Ambulance Authority has shared with local police hotspot maps of overdoses, produced by searching ePCRs for certain terms associated with opioids as well as naloxone administration.
Trinity EMS, in Massachusetts, began using FirstWatch to instantly notify community leaders when overdose patients were seen and provide maps of the crisis in their communities. Not only do EMS officials see the data, but public health, public safety and school system partners also can access the information.
Although naloxone can reverse the immediate effects of an overdose, it doesn’t fix the underlying problem of opioid addiction. Patients who receive naloxone are at high risk of continuing to use opioids and again experience a life-threatening overdose.
Likewise, although EMS can provide near-real-time data about overdoses, this in and of itself won’t reduce overdose or deaths from opioids. In addition, because the problem has become so widespread and pervasive, law enforcement has recognized that communities can’t arrest their way out of this epidemic.
The only true way for people addicted to opioids to no longer be at risk of overdose is for them to stop using. Recovery is a difficult and time-intensive process that’s usually far removed from emergency responders and law enforcement; however, new programs are emerging that show cooperation between these two entities can reduce the population of persons at risk for opiate overdose.
Novel Programs & New Opportunities
As mentioned earlier, more people are dying from opioid overdose than from MVCs. However, when we observe how both of these public health issues are approached in the ED, the treatment and resources are vastly different. For patients of major traumas such as MVCs, we’ve invested vast resources, including entire teams of care professionals, to reduce the rate of death and disability. However, usually patients revived from an overdose are relegated to observation for a period of time and then discharged back into the very environment that got them there in the first place. This isn’t because of a lack of empathy or a desire to do the right things. EDs are overcrowded and busy. If there’s to be any impact in reducing morbidity and mortality from opioid overdoses, systems must be put into place to intervene at appropriate times, such as a near-death overdose.
There are several novel programs that are attempting to bridge the gap between the emergency care community and recovery and addiction specialists, particularly involving patients with a near-death opioid overdose.
In Tom’s River, N.J., the RWJBarnabas Health system has created a novel program that attempts to intervene with opioid overdose patients at the time of overdose. The Barnabas Health Institute for Prevention (IFP) launched its Opioid Overdose Recovery Program in coordination with law enforcement as a two-year pilot in 2015. In this program, recovery specialists are trained and certified as recovery coaches who are immediately deployed to hospital EDs when notified of an opioid overdose patient who was treated with naloxone.
The program offers assistance including immediate access to an inpatient recovery unit or up to eight weeks of long-term follow-up in the community if the patient opts against referral to an inpatient facility. This program is also unique because the recovery coaches are themselves are recovering addicts. With the addition of these coaches, the Barnabas Health IFP program has seen its success rate of getting addicts into recovery rise from 20% of patients to 80%.13 The program relies, however, on the ED to notify the program.
A similar model is also being used in Rhode Island, where the Anchor ED program intervenes with individuals who have presented to the state’s hospital ED with an opioid overdose. Much like in Tom’s River, recovery specialists with Anchor ED are trained and certified. They’re on call 24/7 to respond to the ED and offer recovery services to patients with near-death overdoses reversed with naloxone.14
Both of these programs reported that they haven’t coordinated with EMS. But consider the possibilities: EMS could notify these programs from the scene, much like we do now for trauma, stroke and STEMI. By the time the patient arrives at the hospital, recovery specialists could be en route, ready to discuss treatment possibilities before a patient leaves the hospital against medical advice.
With electronic patient care reporting and the use of real-time notifications, the recovery programs could also potentially be alerted any time an EMS provider submits an ePCR indicating an opioid overdose occurred–preventing the need for busy emergency care providers to remember to contact the program.
Stopping the Epidemic
These programs describe novel approaches to not just treat the symptoms, but to try and cure the disease. Opioid overdose is a complex and widespread problem that won’t be fixed with naloxone, law enforcement or data alone. It will take a multifaceted approach from the entire healthcare community to bring about real change.
EMS already plays a significant role in fighting the epidemic by treating patients suffering from overdoses every day. But the potential for EMS to play a role in the larger fight against the crisis won’t be realized until EMS begins collaborating with its partners in the community as part of a coordinated effort to stop the epidemic.
References
1. Rudd RA, Aleshire N, Zibbell JE, et al. Increase in drug and opiate deaths–United States 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378—1382.
2. Voelker R. New attempt to curb opioid abuse. JAMA. 2016;315(11):1101.
3. CDC health advisory: increases in fentanyl drug confiscations and fentanyl-related overdose fatalities. (Oct. 26, 2015.) U.S. Centers for Disease Control and Prevention. Retrieved Sept. 20, 2016, from https://emergency.cdc.gov/han/han00384.asp.
4. CDC health update: influx of fentanyl-laced counterfeit pills and toxic fentanyl-related compounds further increases risk of fentanyl-related overdose and fatalities. (Aug. 25, 2016.) U.S. Centers for Disease Control and Prevention. Retrieved Sept. 20, 2016, from https://emergency.cdc.gov/han/han00395.asp.
5. Mohr AL, Friscia M, Papsun D, et al. Analysis of novel synthetic opioids U-47700, U-50488 and furanyl fentanyl by LC-MS/MS in postmortem casework. J Anal Toxicol. Sept. 1, 2016. [Epub ahead of print.]
6. Eban K. (Nov. 9, 2011.) OxyContin: Purdue Pharma’s painful medicine. Fortune. Retrieved September 23, 2016, from www.fortune.com/2011/11/09/oxycontin-purdue-pharmas-painful-medicine.
7. Weiner SG, Mitchell PM, Temin ES, et al. Use of intranasal naloxone by basic life support providers. Ann Emerg Med. 2014;64(4):S52.
8. Giglio RE, Li G, DiMaggio CJ. Effectiveness of bystander naloxone administration and overdose education programs: A meta-analysis. Injury Epidemiology. 2015;2:10.
9. Petersen M. (July 17, 2016.) As need grows for painkiller overdose treatment, companies raise prices. Los Angeles Times. Retrieved Sept. 23, 2016, from www.latimes.com/business/la-fi-naloxone-sales-20160707-snap-story.html.
10. Wampler DA, Molina DK, McManus J, et al. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care. 2011;15(3):320—324.
11. Knowlton A, Weir B, Hazzard F, et al. EMS runs for suspected opioid overdose: Implication for surveillance and prevention. Prehosp Emerg Care. 2013;17(3):317—329.
12. Number of confirmed unintentional/undetermined opioid-related overdose deaths by city/town, MA residents January 2012-December 2015. (August 2016.) Massachusetts Department of Health. Retrieved Sept. 20, 2016, from www.mass.gov/eohhs/docs/dph/quality/drugcontrol/county-level-pmp/overdose-deaths-by-city-town-august-2016.pdf.
13. Opioid overdose program. (n.d.) RWJBarnabus Health. Retrieved Oct. 3, 2016, from www.barnabashealth.org/Specialty-Services/Behavioral-Health/The-Institute-for-Prevention/Programs/Opioid-Overdose-Recovery-Program.aspx.
14. Recovery supports for overdose survivors. (2016.) The Providence Center. Retrieved Oct. 3, 2016, from https://providencecenter.org/services/crisis-emergency-care/anchored.
