The United States is arguably facing the most significant drug crisis in its history. A complex set of circumstances that led to the overprescription of opioid pain-relieving medications is now rapidly expanding by way of illicit street drugs. The opioid epidemic has seen drug overdose become the leading cause of injury-related death in the nation. As it now enters its third decade, it continues to grow and has prompted public health stakeholders to push for an all-hands-on-deck approach that includes EMS.
The expansion of public health programming targeted to opioids continues to be outflanked by the epidemic it seeks to stem. Since the onset of the opioid epidemic in 1999, more than 400,000 people have died from opioid overdose. In 2017 alone there were 47,000 opioid-related deaths1—one every 12 minutes. The year-over-year increase of these numbers makes clear that current efforts have not yet turned the tide.
Three distinct waves have characterized the crisis. The first began with the proliferation of pharmaceutical pain relievers, driven by a sharp uptick in prescription rates starting around the turn of the millennium. A surge of these prescription drugs, such as oxycodone and hydrocodone, washed over the country. It eventually peaked in 2012, with 255 million prescriptions filled that year alone—a number that represents roughly 80 prescriptions for every 100 people in the country.2
In 2010, just as the first wave was cresting, the second wave of heroin use and overdose struck. From 2010–2017, the Centers for Disease Control and Prevention recorded an almost sevenfold increase in heroin-related deaths,3 an unfortunate result of a population rampantly using pain relievers moving on to cheaper, more potent opioids. CDC research has shown prescription opioid users are 40 times more likely to use heroin than the general population and approximately three of four heroin users misused prescribed opioids first.4
As the prescription opioid crisis spilled over into the world of illicit drugs, manufacturers began ramping up production to meet growing demand. Their solution has recently become synthetic opioids, such as fentanyl and carfentanyl, which can be hundreds to thousands of times stronger than heroin by weight. Although the intent of drug-makers and sellers is not to kill their customers, the strength of these synthetic opioids has led to increased accidental overdose deaths. The rise of synthetic opioids now stands as the third wave of the epidemic.
These three waves have each contributed to and expanded a complex public health crisis currently lacking an easy fix. However, EMS stands poised to have a growing impact as public health stakeholders seek a multidisciplinary approach that integrates out-of-hospital providers. This move to incorporate EMS makes sense: EMS practitioners have been on the front lines of opioid treatment since the industry began 50 years ago. Paramedics and EMTs responding to overdose incidents provide respiratory support and opioid-countering medications such as naloxone. Many recognize their proximity to events as a valuable avenue for prevention programming.
Paramedics and EMTs are the first and sometimes only medical providers a victim may see during an overdose event, making them an essential conduit for reactive injury prevention. A reactive EMS prevention program provides tools or information broadly across the workforce so personnel can offer resources to those in need during those critical interactions in and around 9-1-1 incidents. EMS systems also generate timely data that positions them well for proactive injury prevention, where smaller groups of providers can work in the community outside 9-1-1 incidents to stop injury and illness before they occur. The quantitative basis for the prevention program, which is derived from EMS patient care reports, is subsequently bolstered by the qualitative experience of EMS providers who may then steer it.
In 2019 the Colerain Township Fire and EMS Department—located just outside Cincinnati—was nationally recognized with the Nicholas Rosecrans Award for injury and illness prevention. The award was presented to leaders during the 2019 EMS World Expo and celebrated their successful implementation of both reactive and proactive prevention programming in their local battle against opioid use disorder and overdose.
The program was started in 2014 by assistant chief and paramedic Will Mueller and Colerain's then-public safety director, Dan Meloy, after Mueller witnessed another tragic loss of life due to overdose in his community. During Mueller’s session on EMS injury prevention at EMS World Expo—a powerful component of the Rosecrans Award—he told the story of the program’s origin.
“I went on an overdose response for a young woman,” he said. “We found her curled up in the corner of a room with a friend at her side. It struck me that this woman was someone’s daughter or sister. It could have been my daughter. And the worst part was that a friend of the victim was present throughout the whole ordeal and could have activated 9-1-1, potentially saving her life, but was too afraid. I knew we had to do more.”
Since that event Mueller and Colerain Fire and EMS have worked to address the opioid crisis through multifaceted prevention programming. Their initial efforts took a more reactive form and placed educational materials in the hands of frontline EMTs and paramedics for distribution to patients during their routine work. Mueller also worked to drive culture change in the ranks and promote the idea of prevention throughout the department.
From there Colerain Fire and EMS went on to develop significant proactive prevention systems. Mueller advocated a collaborative approach with his local public health officers and police department. His local PD, a proponent of community policing, found the programming to be their next logical step in opioid work, a stance that mirrors national discussions on the redirection of substance abusers from incarceration to more appropriate community services. Mueller’s team also connected with the Addiction Services Council of Cincinnati, which played a critical role in structuring their team.
Colerain’s development resulted in the creation of an Opioid Quick-Response Team (QRT). The QRT consists of a fire-paramedic, a chemical-dependency specialist, and a police officer who work as a unit to reach at-risk individuals identified through historical opioid events. Each Monday the team meets with representatives from public health, local government, and local organizations and reviews regional opioid overdoses from the previous week. They then head out into town, where they attempt to locate the overdose victims, start conversations on their addiction, and then refer them to appropriate resources. Colerain is also now offering a Safe Station Program with around-the-clock resources at each fire station. Residents can contact EMS providers at the stations and receive information and referrals without fear of judgment or legal consequence.
Colerain’s opioid program appears to be having a significant impact. Their Opioid QRT has had a 72% success rate in helping more than 350 individuals enter substance addiction treatment centers around Cincinnati. Together the reactive and proactive components of their prevention programming have driven a 70% reduction in total EMS requests for opioid overdose across Colerain Township. EMS stakeholders say Colerain’s Opioid QRT and Safe Station Program demonstrate the value of EMS-driven prevention programming that operates untethered from the traditional 9-1-1 emergency system.
Opioid prevention programming like Colerain’s stands as an essential demonstration of the promise of EMS-driven prevention—prevention work that can be replicated and scaled across the country. Only time will tell if the prevention movement thoroughly roots in the national EMS landscape and paramedics and EMTs move to accept their role as community leaders in injury and illness prevention.
1. Scholl L, Seth P, Kariisa M, et al. Drug and Opioid-Involved Overdose Deaths—United States, 2013–2017. MMWR, 2019 Jan 4; 67(5,152): 1,419–27.
2. IQVIA Xponent 2006–2017.
3. Hedegaard H, Miniño AM, Warner M. Drug Overdose Deaths in the United States, 1999–2017. National Center for Health Statistics, NCHS Data Brief No. 329, November 2018, www.cdc.gov/nchs/products/databriefs/db329.htm.
4. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes, www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf.
Sidebar: Injury and Illness Prevention in EMS
Communities often struggle to provide high-quality and efficient care through comprehensive medical services, injury and illness prevention, and emergency medical care. Despite the interconnected nature of these areas, they often work in isolation from one another.
In 1996 EMS professionals from across the country laid out a plan for the future of emergency medical services in their EMS Agenda for the Future. A key component in the visionary document was the integration of EMS across the healthcare landscape, particularly with public health organizations. In 2000 EMS and public health leadership gathered in a seminal meeting on EMS prevention.
The initiative lost steam in the wake of the September 11, 2001 attacks, but the idea has been on the rise again in recent years. Paramedics and EMTs have begun to work directly with public health departments and community coalitions to address issues facing their communities—areas such as child drowning and auto safety. Many regions have introduced community paramedicine or mobile integrated healthcare, which can also serve a prevention role.
Recently EMS leaders gathered to renew their plans for the future of the industry. The outcome of their EMS Agenda 2050 project once again pointed to the importance of injury and illness prevention in what they coined people-centered care.
Sidebar: The Nicholas Rosecrans Award
The Nicholas Rosecrans Award is presented annually by the California Paramedic Foundation, EMS World, and RedFlash Group to recognize innovation and excellence in EMS-driven injury and illness prevention. The award is named after a toddler whose drowning in 1996 sparked an EMS-led injury prevention movement in California.
The award has recognized initiatives in many different areas of injury and illness prevention over the last 17 years, from pool drownings and children left in hot cars to EMS provider mental health and community paramedicine. Colerain Township won the award in 2019 for its Opioid QRT program. Each year the winner travels to EMS World Expo, where they are recognized in the keynote address. The winners then lead a session during the three-day conference. Award applications are accepted every year beginning May 1 at CAparamedic.org/nicholas-rosecrans.
John Ehrhart is a critical care flight paramedic and director of the California Paramedic Foundation.