Medics on the Front Lines Find Opioid Overdose Antidote a Mixed Blessing

KNOXVILLE

Three decades ago, when Chris Blach began his career as a paramedic, he carried naloxone.

Emergency medical technicians used the drug for patients who weren’t breathing after a narcotic overdose — it can reverse narcotics’ depressive effect on the respiratory system. For a time, they also gave it after strokes, until studies showed it didn’t decrease pressure on the brain. In either case, an ambulance might go weeks without restocking naloxone.

Those days are gone. Now the drug is used solely for suspected narcotic overdoses — and American Medical Response, the ambulance company serving Knox County, averages 40 doses a week.

“We’re purchasing double what we were last year,” said Blach, regional director for AMR.

The drug, lauded for giving a “second chance” to those about to die from narcotics overdoses, is a mixed blessing for those on the front lines.

In September, AMR administered naloxone 51 times in Knox County alone. In January, 173. And not all drug overdoses get naloxone, Blach said; overdose patients who are unconscious but breathing well are simply taken to the hospital. In January, AMR transported 121 overdoses to Knox County hospitals — more than triple the number from January 2016.

Paramedics’ protocol is to give small doses of naloxone incrementally, “just enough to where the respiratory effort is back where it needs to be,” Blach said. More than necessary, too quickly, creates its own issues, including vomiting, which the patient could then aspirate, or a completely awake and now combative patient who’s just been robbed of his high.

“We’ve had a few of our guys smacked or hit, but nobody seriously hurt yet,” said AMR Operations Manager Ken Loftis. But such situations are unpredictable.

More and more, AMR crews arrive on the scene to find naloxone already administered. Not only do laws allow Tennesseans to buy it without a prescription, and protect “good Samaritans,” but other agencies that might arrive first also carry it.

Knoxville Fire Department gave naloxone 17 times in 2013, its first year carrying it. Last year KFD gave it 129 times. In January this year, KFD first responders administered it 35 times, and they were on track for at least that much in February. Knoxville Police Department officers, who began carrying naloxone in September 2015, have given it more than 60 times — seven this January alone.

KFD can give the drug incrementally, but KPD officers carry a nasal injector that automatically gives a premeasured dose, about 1 milligram. Two doses — one in each nostril — is enough to wake most patients.

The problem: Awake, alert drug overdose patients can — and do — refuse to be transported to a hospital.

Then, first responders could find themselves back at the same address, sometimes within 24 hours.

Right now, repeats are a “handful” of patients, Loftis said, but he worries that addicts will grow to see naloxone as a “safety net” in lieu of getting treatment.

“If I know I’ve got a lifeline out there, I’m going to push myself a little farther,” he said.

That’s made carrying naloxone a “hard sell” for some Knox County Sheriff’s Office deputies, said Randy Nichols, special counsel to the sheriff. Law enforcement officials see repeat offenders “saved” by naloxone and then immediately back in the system — some for dealing the drugs they overdosed on.

“That does not sit well with a bunch of people I work with,” Nichols said. “There’s not everybody who wants to” carry naloxone.

The sheriff’s department is hoping a grant will pay for auto-injectors, which deliver a premeasured dose. Name-brand auto-injectors can exceed $4,000 for a two-dose kit.

But a dose of even generic naloxone, which ran around $2 before the opioid epidemic, costs about $40 now.

AMR spends $55,000 a year on the drug. AMR replenishes part of KFD’s supply, though even the smaller percentage that KFD buys is “getting into operating expenses,” said KFD Capt. D.J. Corcoran.

It’s even a bigger drain on manpower, Corcoran said: “If it keeps going the way it’s going, that’s all we’re going to have time to answer. It’s going to start taking away from fires, wrecks, heart attack calls.”

Corcoran said overdose calls now account for more than 25,000 calls a year.

“It’s not just doubling every year, it’s tripling, quadrupling,” he said. The state’s crackdown on pill mills has led to more overdoses on street drugs, and more ways of consuming them: “Smoking, snorting, enemas … you name it.”

On Feb. 22, KFD had to send two crews to a scene to have enough naloxone for four people who had overdosed in a single vehicle. Such “group” OD calls are increasingly common, the agencies confirmed.

Corcoran is worried about losing employees to “burnout.”

“They’re seeing the same type of calls over and over, and there’s no end or no cure in sight,” he said. “They get this helpless feeling.”

The opioid epidemic has added risks. KPD Chief Gary Holliday said officers have to watch at scenes for fentanyl. The painkiller, 50 times more potent than morphine that’s increasingly abused on its own or used to cut other drugs, can be absorbed through the skin.

And though paramedics’ supplies are now “needleless,” drug scenes reintroduce the possibility of needle sticks, Blach said. The CDC estimates 50 percent to 80 percent of IV drug users have hepatitis C.

“I would rather get shot or stabbed than stuck with a needle,” Blach said. “You could develop hepatitis C, hepatitis A, HIV — you never know what that’s going to create down the road. It weighs heavily on you for the rest of your life.”

Karen Pershing, director of the nonprofit Metro Drug Coalition, said naloxone alone can’t be the antidote to the opioid epidemic. Instead, a “save” should provide an opportunity to go straight into treatment — something that rarely happens now.

“We’ve got to figure out how to close this loop,” Pershing said.

http://www.knoxnews.com/story/news/investigations/2017/03/26/paramedics-opioid-crisis-overdose-antidote-mixed-blessing/98544310/