Overdoses. Addiction. Opioids. Fentanyl. We hear their stories every day across the United States. They’re words seen every day in the ePCRs of EMS providers in every community. When I had my initial education as an EMT and paramedic, beyond the initial discussion of overdose treatment, we received inadequate information regarding patients with substance abuse and addiction disorders.
Unfortunately this fostered misconceptions we have since perpetuated: that this was a problem the patient took on themselves; that they could control their impulses; that tough love was a solution; that we had to let a patient hit rock bottom before they could get the help they needed. That this was an issue somehow only rooted in minority communities or that only affected the underprivileged. We demonized patients: drug addicts, junkies.
We would never say to a patient that they are lung cancer; your physician would never call you a “dislocated shoulder.” Yet for some reason we stamp other sufferers with the disease they have: “You’re a diabetic.” “You’re an epileptic.” “You’re a drug addict.” That addict label stigmatizes, and it can lead people to blame themselves, fostering feelings of hopelessness and failure. This is one factor that can perpetuate a cycle.
The challenges of addiction are not stratified by race or socioeconomic status. The sad reality is tough love doesn’t work. We don’t practice tough love with the lung cancer or COPD patient who can’t quit smoking; we don’t try it with the overweight diabetic patient who struggles with their diet. Tragically, rock bottom for some patients addicted to opioids is death. What we need to do is be compassionate and intervene sooner.
Addiction is a chronic, incurable medical disease. It takes on average eight years for a patient to arrest the disease, and a relapse—which may occur at any time, especially for patients addicted to opioids—can be fatal. We should never be complacent; a patient who has not used opioids in decades is still always in danger of relapse.1
In Search of Solutions
On September 25, 2018 the American Health Lawyers Association (AHLA) hosted a nonpartisan expert panel to facilitate a frank exchange of ideas, perceptions, and an examination of the issues among experts on health law, opioids, criminal justice, treatment, addiction, and emergency response. Their goal was to develop a white paper that would summarize some of the major issues confronting the industry regarding the opioid crisis, frame the problem, and propose solutions.2
The venue was meant to foster constructive discussion among stakeholders. The experts included participants from the U.S. Department of Health and Human Services and Department of Justice; the DEA; health insurance payers; professors and physicians from major academic medical centers; advocacy organizations and trade associations; EMS; state health agencies; and healthcare attorneys. Utilizing the Chatham House Rule—participants could make free use of any information that emerged but could not divulge who made any comment—allowed for the free exchange of viewpoints and fostered a collegial dialogue.2
As the discussion wore on, it was apparent there is not a one-size-fits-all solution to this problem. There are tools we can leverage that hold promise, such as buprenorphine, but it isn’t that simple. As we begin to understand addiction and its consequences, it becomes more complex than anyone can imagine. Consider:
The ability of individuals to acquire opioids through legal and illegal sources;
How we distribute naloxone;
How we pay for distribution of naloxone to the general public;
How we effectively manage pain, both chronic and acute;
What we need to do to educate and work with prescribers;
Who pays for it all;
How we maintain victims’ health insurance and ability to access treatment/detox/rehab services;
How we ensure people with opioid addiction maintain jobs and, more important, insurance;
What the criminal justice system must accomplish to have a system that is fair and does not unjustly penalize those struggling with addiction.
Think about it like this: A minor injury may result in a physician overprescribing pain medication, which for the physician is quick, cheap, and easy. Once a person has become addicted to pain medications, without a continued source, they may resort to buying opioids illegally. If they are arrested for this, they may lose their job and health insurance. Without health insurance they lose the ability to seek treatment. If they receive a custodial sentence, once they’ve served their time, it’s difficult to regain meaningful employment.
This highlights some of the complexity that comes into play when we discuss opioids and addiction. There is an answer, but it will require hard work to address all the points of intersection.
Stories of Tragedy
The AHLA captured the major themes and offered possible solutions, but this was just one step in a process.
On February 22, 2019 the American University Washington College of Law, American University School of Public Affairs, and AHLA held a series of panel discussions and short presentations based in part on the work completed for the white paper. “The Opioid Crisis: Rethinking Policy and Law” provided insight to the challenges of the crisis and offered a glimpse at the solutions being implemented across the United States.
Panel and keynote topics included:
Rethinking access to pain treatment;
Rethinking the role of civil litigation in response to the opioid crisis;
Rethinking access to treatment for substance use disorders;
Rethinking the role of the criminal justice system in the opioid crisis;
Rethinking community prevention for opioid use disorders;
Rethinking harm reduction for people who use opioids;
A keynote address by Sylvia Matthews Burwell, president of American University and former secretary of HHS;
Keynote Address by Mary Taylor, Lt. Governor of OhiA keynote address/discussion from Thomas Farley, MD, MPH, Philadelphia health commissioner.
As an EMS provider invited to provide input to the white paper and panel discussions, I thought back to my own friends, family, and coworkers who struggled with addiction. As each panel unfolded, just about everyone had a personal, deep, and moving description of how opioids had touched the lives of friends and family. Everyone, regardless of background, financial status, or race, shared a story of tragedy. Sitting in the lecture hall at American University, I was overwhelmed by the magnitude of the problem.
When Burwell related the story of Jessie Grubb, there was complete silence. Grubb was a young woman who struggled with heroin addiction whose family met Burwell at a town hall event in 2015. I could hear in her voice how deeply she was affected by the loss of this young girl’s life. Grubb died in 2016 at age 30.
The lessons from the panels were compelling to say the least. As EMS providers we generally aren’t aware of the challenges facing prescribers and patients dealing with chronic, long-term pain or trying to meet a patient’s needs if they are incarcerated. We sit walled off, thinking what we see is unique or that we may not have anything to offer. Nothing is further from the truth. How we treat and manage pain in the prehospital environment can have profound effects on the patients we see. When we are called for patients in pain who are just home from a hospital or surgery center, in many instances we can offer an icepack or fentanyl, but nothing in between. At that point it is the patient’s choice to eschew treatment or go to the ED.
We have tremendous parallels with the emergency department, obviously, but listening to members of law enforcement and the corrections community reconceptualize what needed to be accomplished was surprising. Law enforcement by and large do not want to incarcerate people addicted to opioids. They recognize most do not require incarceration, but instead medical attention.
Chief Carmen Best described how Seattle police are refocusing their mission for those with chronic addiction problems. Instead of incarcerating people, they have embraced an alternative justice model that focuses on providing care, treatment, and solutions. The effort is more akin to social work than law enforcement. I wanted to stand and applaud when she said arrests of those addicted to opioids were not the answer to the problem.
Farley gave an enlightening discussion of the problems he faces. Getting naloxone to the public is a major focus for his department, but his greatest hurdle has been establishing harm-reduction centers (also known as safe injection sites) for opioid users. They have been proven to reduce overdose mortality and morbidity, and when combined with needle-exchange programs reduce infection rates from hepatitis and HIV.3 Community backlash, federal opposition, a lack of understanding of clients’ needs, and fear of rising crime rates (all unfounded) pose substantial barriers to implementation. It was inspiring to hear Farley say he wasn’t giving up without a fight.
A Complicated Process
As the day wound to a close, I was left with conflicting emotions. The problem we face is staggering. As a profession EMS attracts people who seek instant gratification. It’s a hard concept for us when it may take eight years for someone to achieve a measure of success. But I felt uplifted that in spite of what can appear an insurmountable problem, people are working hard and achieving success. Their determination is encouraging.
While naloxone is critically important, it is also important to get patients medically assisted therapy that includes buprenorphine, counseling, and housing and job assistance. While sSome of these issues may appear out of the realm of EMS, but it’s crucial that we be part of the discussions, planning, and care that are essentially to resolving this crisis. Overdose as a consequence of addiction is not a one-and-done scenario; it is a long and difficult road—one that, as responsible healthcare providers, EMS needs to be a part of.
Daniel R. Gerard is EMS coordinator for the city of Oakland, Calif. He is a recognized expert in EMS system delivery and design, EMS/health-service integration, and service delivery models for out-of-hospital care.