Confronting a Crisis
In downtown Salt Lake City, one of the most prevalent locations for overdose response calls lies within a several-block radius encompassing Rio Grande Street, which is served by the Salt Lake City Fire Department (SLCFD).
SLCFD responds to approximately 35,000 calls for service in the city annually. A large number of these calls lie within in the Rio Grande District. As in geographies nationwide, there has been an increasing frequency of calls responding to opiate overdoses. In locations such as Salt Lake City, novel efforts to decrease opiate overdose deaths are particularly needed.
Recently in the Rio Grande District, two naloxone rescue kits, furnished by SLCFD to community members, proved just how valuable they can be with the proper training. The benefits of having naloxone in the hands of those who are likely to witness an overdose were demonstrated directly in front of city leaders.
Local government officials were touring the area when they came upon an unresponsive individual. When another witness called out for “anyone with a naloxone kit” to respond, two separate bystanders in close proximity immediately responded with SLCFD-labeled naloxone kits. They stepped up and administered naloxone as they had been trained to do by members of SLCFD. The victim was breathing and alert by the time fire department personnel arrived.
Mortality on the Rise
The use of both prescription and illegally manufactured opioids has seen an associated increase in the number of EMS calls, emergency department visits, hospitalizations, and mortality nationwide.1–4 The United States is in the midst of an opioid crisis, with deaths from opioid overdose more than quadrupling from 8,050 in 1999 to 33,091 in 2015.2–4 Estimates for 2016 have placed the number of fatalities related to overdoses at 64,000, or 175 per day.6 Opioid abuse is currently considered one of the greatest threats to public health in the United States, with more than 60% of overdose deaths from pharmaceutical agents attributed to opioids.3
Mortality rates from prescription pain medications and illicit narcotics continue to escalate nationwide, with an impact felt in every element of society. According to CDC data, death rates are continuing to rise, primarily because of opioids, and are escalating as counterfeit fentanyl becomes more prevalent in our communities.6,7 Overdoses are killing more people than guns or car accidents and are doing so at a pace faster than the HIV epidemic at its peak.7 The impact of this crisis is felt greatly by first responders and EMS personnel.
One strategy that’s been implemented nationwide is to increase access to naloxone, an effective opiate antagonist/overdose reversal drug.8–10 First responders and medical personnel have used naloxone in the field for decades to restore breathing in victims of opiate overdose. There are variations in naloxone access laws, but as of 2017 all 50 states had naloxone access laws in place whereby nonmedical laypersons can legally posess naloxone in the event there is an opioid overdose in their presence.11,12
EMS Uniquely Positioned
According to the CDC and its Morbidity and Mortality Weekly Report (MMWR), as of 2014 there were 188 local opioid overdose prevention programs distributing naloxone to laypersons nationwide (a layperson is defined as a nonmedical professional who may come into contact with a person overdosed on an opioid).13 From 1996–2014, these programs reported providing naloxone to 152,283 persons, resulting in 26,463 overdose reversals and lives saved.13 Studies have found that providing naloxone kits does not lead to increased abuse or riskier use of opioids and can actually lead to increased enrollment in drug treatment.8–10
Laypersons can acquire naloxone rescue kits via a variety of mechanisms depending on their locality, with individual state laws dictating availability options.11,12 These methods include purchase at a pharmacy both with or without a prescription, depending on state standing orders, or via direct provision by a community-based entity. Such entities include medical clinics, recovery community sources, health departments, syringe-exchange service providers, emergency departments, and direct access from a harm-reduction entity.
There is wide variation in the ease of access to naloxone rescue kits depending on geography, statute, and local availability. There are also barriers that arise from individual willingness to approach available sources. Unfortunately, many who are at risk of witnessing or experiencing an opiate overdose are not gaining access to naloxone through traditional public health and medical channels such as pharmacies and health departments. Increased naloxone access options are needed.
EMS is uniquely positioned to provide a practical and effective solution, as providers are frequently on scene to reverse overdoses. They can teach others how to administer naloxone if needed in the future. Individuals who have experienced an overdose and those around them have just seen the lifesaving result of naloxone administration and are primed to understand why it’s important to have it on hand. Simply explaining to bystanders how to obtain a rescue kit does not mean it will happen; actually handing it to them on scene will.
The Salt Lake City Initiative
One program aimed at increasing layperson naloxone access via EMS leave-on-scene kits has been implemented in downtown Salt Lake City. SLCFD has partnered with the community-based organization Utah Naloxone to increase awareness of and access to naloxone rescue kits.
Utah has been experiencing continued increases in the rates of opioid overdose and death over the past seven years14 and is currently seventh in the nation in the rate of overdose death.15 This partnership was created with the goal of increasing direct access to naloxone for those at risk of experiencing or witnessing an overdose.
Setting up this collaborative effort required preparatory steps as well as a strategy for rollout. Launching this program in the community required the following steps:
1. Naloxone access laws that allow for furnishing of naloxone rescue kits by first responders (Utah Code Ann. §26-55-101 et seq.);12
2. Legal approval and memoranda of understanding (MOUs) between SLC and the University of Utah arranged and signed;
3. Naloxone community distribution policy put into place by the SLCFD medical chief;
4. Training provided to FD responders on when to consider leaving a naloxone rescue kit on scene (“Who is at risk of witnessing an opiate overdose?”);
5. FD responders given a training platform to educate community members they equip with naloxone kits:
- Overdose recognition,
- Activating 9-1-1,
- Appropriate use of naloxone rescue kit and CPR/rescue breathing,
- Dispelling myths surrounding overdose reversal such as ice bath immersion, rectal ice administration, hitting/punching/slapping the victim, injecting other substances such as methamphetamine, salt water, milk, or cocaine;
6. Naloxone rescue kits provided by Utah Naloxone. Each rescue kit contains:
- Two doses of injectable naloxone in 0.4 mg/1 mL vials,
- Two 3-mL syringes with 22g x 1” needles,
- A brochure on opiate overdose recognition and naloxone use,
- Information on hepatitis C and HIV, including testing locations,
- Information on local recovery resources,
- A “Save a Life” card with essential community resource phone numbers,
- Utah Naloxone contact info,
- A SLCFD label for identification and data tracking.
Salt Lake City Fire Department personnel began dispensing naloxone rescue kits on scene in February 2017. Initially there were nine paramedic engines equipped with the kits, and as of June 2017 all 18 ALS and BLS fire apparatus units were equipped. Kits are also available at SLCFD headquarters, where members of the public can acquire them free with no questions asked.
A total of 505 kits were dispensed to community members by SLCFD personnel within the first nine months of the program, with 18 documented overdose reversals with these kits by bystanders prior to FD arrival. The program is currently being expanded to three other local agencies. A broader community awareness is emerging, evidenced by fire crews being directly approached by community members to access rescue kits even when they’re not responding to an overdose call. Fire department administration is also receiving calls from citizens who would like to be equipped.
Proactive Philosophy Shift
The Utah Naloxone program is making connections within groups that are not always open to interventions from mainstream governmental entities. It is also reaching individuals who are difficult to engage via conventional strategies yet often in need of access to naloxone. It is resulting in lives saved and increasing community-wide awareness. It is providing valuable links to recovery resources and to infectious-disease testing and prevention.
This program is also providing first responders, who are placed squarely in the midst of the opioid crisis, with a proactive position in a realm where frustrations abound about how to combat the rising numbers of overdoses and deaths they see. It is certainly a change in philosophy to have EMS providers furnish a medication for future use on scene, but it is a philosophy shift that has potential for positive outcomes on many levels.
Getting naloxone rescue kits into the hands of those who are likely to experience or witness an opiate overdose is essential in the current environment. This atypical strategy is having an impact, saving lives, and reaching a population that can be difficult to access.
1. O’Donnell JK, Gladden RM, Seth P. Trends in deaths involving heroin and synthetic opioids excluding methadone, and low enforcement drug products reports, by Census Region—United States, 2006–2015. MMWR, 2017; 66(34): 897–903.
2. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR, 2016; 65(50): 1,445–52.
3. Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med, 2015; 372(3): 241–8.
4. Jeffery RM, Dickinson L, Ng ND, et al. Naloxone administration for suspected opioid overdose: An expanded scope of practice by basic life support collegiate based emergency medical services agency. J Am Coll Health, 2017; 65(3): 212–6.
5. Fairbairn N, Coffin PO, Walley AY. Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic. Int J Drug Policy, 2017; 46: 172–9.
6. Ahmad FB, Rossen LM, Spencer MR, et al. Provisional drug overdose death counts. National Center for Health Statistics, https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
7. Katz J. The first count of fentanyl deaths in 2016: Up 540% in three years. New York Times, Sept. 2, 2017, https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html.
8. Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med, 2013; 158: 1–9.
9. Kim D, Irwin KS, Khoshnood K. Expanded access to naloxone: Options for critical response to the epidemic of opioid overdose mortality. Am J Public Health, 2009; 99(3): 402–7.
10. Maxwell S, Bigg D, Stanczykiewicz K, Carlberg-Racich S. Prescribing naloxone to actively injecting heroin users: A program to reduce heroin overdose deaths. J Addict Dis, 2006; 25(3): 89–96.
11. Prescription Drug Abuse Policy System (PDAPS). Naloxone overdose prevention laws, http://pdaps.org/datasets/laws-regulating-administration-of-naloxone-1501695139.
12. Davis C, Change S, Carr D. The Network for Public Health Law. Legal interventions to reduce overdose mortality: Naloxone access and overdose Good Samaritan laws. PHLR, 2015, https://www.networkforphl.org/_asset/qz5pvn/naloxone-_FINAL.pdf.
13. Wheeler E, Jones TS, Gilbert MK, Davidson PJ. Centers for Disease Control and Prevention. Opioid overdose prevention programs providing naloxone to laypersons—United States, 2014. MMWR, 2015 Jun 19; 64(23): 631–5.
14. Fondario A. Prescription drugs in Utah. Fall Substance Abuse Conference; Sept. 24, 2014; St. George, UT; http://ufsac.org/wp-content/uploads/2014/09/Fall-Substance-Abuse-Conference.pdf.
15. Utah Department of Health Violence and Injury Prevention, http://health.utah.gov/vipp/topics/prescription-drug-overdoses/.
Peter R. Sadler, MS, and Sam Plumb, MPA, MPH, are program managers for Utah Naloxone. Michael Fox is chief of the Medical Services Division at the Salt Lake City Fire Department. Jennifer Plumb, MD, MPH, is an associate professor of pediatric emergency medicine at the University of Utah and medical director of Utah Naloxone.