Opioid Epidemic and the Fire Service

The current opioid epidemic has significantly increased the call volume for departments responding to citizens suffering from drug overdoses. Not a shift goes by without a call to assist someone suffering from an overdose.

When I was a street paramedic, we would receive calls from the public to assist individuals overdosing with alcohol, mushrooms, Freon, airplane glue, Benadryl and cough syrup containing dextromethorphan; Percocet, Percodan, Oxycodone, heroin, methadone with patients taking a mix of these drugs in the attempt to suicide or just plain seeking a recreational high. We are faced with individuals overdosing fortunately arriving in time to administer respiratory support, activated charcoal, ipecac, Narcan or other “treatments” to short circuit the effects of a poly drug overdose. 

Today, we are facing an immense challenge from opioid overdoses of unprecedented magnitude, which in many communities has created a medical crisis for Emergency Medical Services (EMS), the fire service cops, and certainly the Emergency Departments.

According to HHS, our nation is in the midst of an unprecedented opioid epidemic. More people died from drug overdoses in 2014 than in any year on record, and the majority of drug overdose deaths (more than six out of ten) involved an opioid. Since 1999, the rate of overdose deaths involving opioids—including prescription opioid pain relievers and heroin—nearly quadrupled, and over 165,000 people have died from prescription opioid overdoses. Prescription pain medication deaths remain high, and in 2014, there was a sharp increase in heroin-involved deaths and an increase in deaths involving synthetic opioids such as fentanyl. Drug overdoses are the leading cause of death among Americans under 50.

In 2015, 52,000 Americans died from drug overdoses, and in 2016 the numbers increased another 19 percent, to approximately 62,000. Drug overdoses are now the leading cause of death among Americans under 50.

2017 figures as of June indicate the problem continues to worsen. Two thirds of the deaths are from opioids. By comparison, in 2010 the figure was 16,000 and in 1999, 4,000. Nearly half of all opioid overdose deaths involve a prescription opioid.

As a provider, this is placing an inordinate stress on the fire service and our EMS providers to respond to this epidemic.

In 2016, Summit County (Ohio) had 312 drug deaths, according to the county medical examiner’s chief investigator — a 46 percent increase from 2015 and more than triple the 99 cases that went through the medical examiner’s office just two years before. There were so many last year, the medical examiner said, that on three separate occasions the county had to request refrigerated trailers to store the bodies because they’d run out of space in the morgue. It’s not unique to Ohio as Coroners’ offices throughout the state are being overwhelmed.

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. Opium is the raw product 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. Mixed with heroin, cocaine or both, it's a deadly, uncontrolled cocktail even for users who know what they're purchasing.

The National Center for Addiction and Substance indicates each year federal, state and local governments spend close to $500 million on addiction and substance abuse, but for every dollar that federal and state governments spend, only 2 cents goes to prevention and treatment and more than 90% of people with a substance problem began smoking, drinking or using other drugs before age 18.

The statistics are equally overpowering as Fire and EMS providers are challenged with providing adequate field treatments using the preferred antidote Narcan. So, we see in our national statistics is that, in spite of an increased use of Narcan by 1st responders including the police, the Center for Disease Control indicates that 91 Americans die every day from overdoses including prescription opioids and heroin

Responding to multiple overdose calls to the same or multiple patients can and has resulted in response fatigue and at times, responders and even elected officials lash out over their social media sites making inappropriate comments related to the current epidemic. Examples are an “Ohio city councilman asks: Is the city legally required to keep dispatching ambulances to rescue drug addicts who repeatedly overdose on opioids?” And some EMS responders have posted on their Facebook’s that “opioid OD’s need to die”. Career suicide for sure.

Just a thought, we are not these people, we are empathetic and care for our patients and will continue to respond despite the frequency of calls to the same person for the same problem.

The feds are pouring millions of dollars in to state sponsored programs addressing this epidemic. How does that money affect the fire departments actually responding the street level effects of this problem? At last report, not much, as that money does not appear to have the “trickle down” effect actually sponsoring the local level responses that Fire and EMS find themselves facing. Mostly the money goes into treatment, education and prevention at the state level.

In many parts of the country regardless of department size, location, economic status or other factors, we are getting slammed with these responses. Local governments have become involved in trying to control their opioid crisis against the manufacturers of prescription level overdoses. Several states such Ohio and cities like Everett WA have filed lawsuits against five drug companies accusing them of abetting the opioid epidemic due to an increase in opioid overdoses in their communities and states.

One potential legal issue may be found in several states whose EMS protocols indicate to administer Narcan (or its derivative Naloxone) and leave the patient at home or where they are found in the care of a “competent adult”. The problem is the overdose drug half-life may exceed the effects of the Narcan and the patient goes into respiration arrest and dies – a lawsuit in the making.

Costs to combat this epidemic are increasing, affecting overall health care costs, EMS and Firefighter training, lives lost, lives saved, public education, responder emotional costs, medication costs and all facets of the human factors associated with our profession and those are not generally measurable. This health care crisis is projected to get worse before it gets better.

Fire and EMS is on the provider end of the chain of treatment. To end this crisis, the real work must be located at the top of the chain – interrupt the distribution and production network, improve the prevention and treatment education, public education and adequate funding for these programs, INCLUDING money for the first responders to manage the effects of this epidemic.

End Notes

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.

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.])

https://www.firechief.com/2017/06/28/why-fire-ems-agencies-should-make-the-opioid-epidemic-their-top-priority/

https://www.centeronaddiction.org/#.WVLf_t4jVrw.email

https://www.hhs.gov/opioids/about-the-epidemic/index.html#.WVLWoEIJXdE.mailto

https://www.cdc.gov/drugoverdose/epidemic/index.html

Facing Addiction in America, U.S. Surgeon General (2016)