During disaster response, individuals suffering from opioid addiction have both similar and unique needs as compared to those suffering from other types of illness. Emergency responders need the resources to manage opioid-addicted victims of a disaster, and response teams must be appropriately staffed to meet the physical and behavioral health needs of addiction. Response personnel must coordinate closely with local public health officials and other addiction stakeholders to facilitate access to local support services.
On 10 September 2017, Hurricane Irma made landfall on Cudjoe Key, Florida, as a Category 4 storm. Irma continued onto the mainland as a Category 3 hurricane, affecting all of Florida, including the major population centers of Miami and Tampa Bay. The storm (and related incidents) killed 82 people in the state, left millions without power, and caused an estimated $50 billion in damage.
In the wake of Hurricane Irma, Florida residents (along with those from the U.S. Virgin Islands and Puerto Rico who had come to Florida to receive care) began to present at special needs shelters and medical clinics. In general, those seeking shelter came because their homes were without power (with temperatures well into the 90s), or because their homes were severely damaged or destroyed. Not surprisingly, those seeking medical care had very diverse medical needs: some came because they needed treatment and medications for chronic illness (doctor’s offices and pharmacies had not reopened), while others presented with more acute sickness or injuries. Many patients had the added complexity of being in various stages of opioid addiction. Florida, one of the six states to declare a public health emergency in response to opioid addiction, was being hit particularly hard by the epidemic. In 2015, the state experienced 1,417 prescription opioid overdose deaths, second only to Ohio. During the first half of 2016, opioids killed an average of 14 Floridians a day.
The opioid crisis presented new challenges to seasoned emergency response professionals. This article highlights four of those challenges: maintaining access to key pharmaceuticals, inadequate staffing to respond appropriately, increased pressure to coordinate with local service providers, and ongoing legal and ethical deliberations.
Maintaining Access to Key Pharmaceuticals
Medical responders often go into the field with pharmaceutical caches composed to treat the majority of patients they will see, based on experience from previous disasters. However, in the case of Irma, those caches often lacked the specific medicines required to care for individuals suffering from opioid addiction. For example, federal medical responders often did not have access to naloxone, which is used to treat people suffering from an overdose. Although local emergency medical services (EMS) and law enforcement officers increasingly have access to naloxone, supplies vary greatly from state to state, city to city, and even among different ambulance services, making this source unreliable.
Medical responders also did not have access to methadone, which is highly regulated and extremely difficult to stockpile. Although lessons learned from Hurricane Sandy demonstrated a clear need for solutions to dose addicts after a disaster, the take-home doses some methadone clinics supply (for one to three days) are inadequate for a widespread, long-term disaster response. Finally, opioid addicts often have other physical and mental health issues, and they take other medications related to those comorbidities. Disaster relief caches often lack the full range of medicines addicts might need, and substituting drugs that have similar effects as those prescribed is often inappropriate for this cohort.
Considering Staffing for Disaster Medical Teams
Medical responders in Florida believe that shelters and clinics were inadequately staffed in light of the ongoing opioid crisis. The whole community approach to disaster management means that shelters are often staffed with volunteers, who are generally not equipped to identify and deal with the medical and physical health issues (e.g., withdrawal symptoms) suffered by those with opioid addictions. In addition, responders noted a need for more behavioral health specialists certified to counsel and prescribe medication. The mental and physical health impacts of addiction result in complex patients who face more challenges in a stressful disaster environment. This situation is exacerbated when patients go without medications (both for medication-assisted treatment as well as for other chronic physical and mental health issues) for several days before being seen by care providers, and need to be reassessed to ensure that their previous medications and doses are still appropriate. Doctors and nurse practitioners then find themselves making decisions and prescribing medications without the benefit of professional training and experience in chronic addiction. Clinicians also noted that they spent large amounts of time dealing with patients’ behavioral health issues, which limited the number of physical health needs they could address. Response teams that did have behavioral health specialists were able to free up other clinicians to focus on patients without addiction-related issues.
In addition to medical staff, law enforcement missions in shelters and clinics may have to expand if medical caches are updated to include more sought-after pharmaceuticals to treat addition.
Increasing Pressure to Coordinate With Local Service Providers
Since the extended sheltering operations after Hurricane Katrina in 2005, local, state, and federal organizations have placed additional focus on discharge planning. Shelter staff, facility owners, shelter inhabitants, and the community at large benefit when emergency sheltering missions end expeditiously. However, discharge planning is a complex operation that external emergency responders cannot perform on their own. Returning emergency shelter inhabitants to their homes – or to another housing solution – involves a diverse set of stakeholders, including community public health officials, utility companies, shelter facility owners, and the shelter residents themselves. The opioid epidemic adds yet another layer of complexity to discharge planning. Medical responders must maintain close relationships with local public health officials to ensure that they are discharging those suffering from opioid addiction into a community where support services (e.g., methadone clinics, support groups) are open, fully staffed, and adequately supplied.
Providing Legal & Ethical Guidance to Responders
Addressing the needs of opioid addicts during disaster response has put both health professionals and policymakers in legal and ethical grey areas. Many states and localities are grappling with decisions over who can administer naloxone and how to best serve their communities given the strict regulation of methadone. It is also unclear what support state and federal governments can provide to methadone clinics to keep them open, staffed, and adequately supplied during disaster response and recovery.
As communities develop more detailed policies, it will become even more difficult for disaster responders to know the laws and regulations that affect their operating procedures. Laws are in place to protect first responders from liability during emergencies, but responders are still rightly concerned about the legal implications of providing – or not providing – appropriate medication to those in need days after the immediate threat has passed. Many responders deployed for Hurricane Irma also had ethical concerns about the medical care they provided – or could not provide – to addicts and those suffering from overdoses.
Meeting Future Medical Challenges
People involved in disaster management often repeat the mantra, “every disaster is different.” Although new challenges pop up in every disaster, some challenges repeat over time. Given the current state of the opioid epidemic in the United States, medical response personnel will continue to meet challenges in providing appropriate care, and they will continue to encounter difficult legal and ethical situations. With more planning and guidance, medical personnel will be able to better support this population across the country.