Opioids - Overdoses & Antidotes

by Joseph Cahill

According to the Centers for Disease Control and Prevention’s (CDC) website, “Every day in the United States, 105 people die as a result of drug overdose, and another 6,748 are treated in emergency departments (ED) for the misuse or abuse of drugs.” The CDC further states that opioids contributed to 16,651 deaths in 2010 and 420,040 ED visits in 2011. These numbers, of course, do not reflect the unreported number of people in the United States who are addicted to opioids – pain medications that include morphine, oxycodone, and the street heroin. An opioid that is five times more potent than heroin has appeared in the underground market – fentanyl and fentanyl-like drugs.

Overdoses – A Deadly Trend In the past year, health laboratories have been reporting significant increases in overdoses related to acetyl fentanyl. This “mass-fatality” incident is increasing across the country, even among seasoned users. The main response to narcotic overdose of all types is symptomatic support; if the patient is not breathing, the rescuer takes over breathing for the patient and administers the antidote called Narcan (Naloxone). However, getting the antidote to the patient in time to prevent death can sometimes be a challenge.

Over the past few years, emergency medical services have been using Narcan, but its deployment also has been expanding into fire and law enforcement agencies. This method of distribution ensures that the Narcan stays within the control of trained emergency responders who do not have an emotional stake in the patient. These responders tend to follow procedures and, by the nature of their assignments, often encounter users at the times when they are already in distress.

However, many other people also encounter users on a daily basis – including staff such as drug counselors and shelter operators. Public health officials manage most of these programs, which are under an order from that agency’s physician. The use of this or any medication by unlicensed personnel has a host of issues that public health agencies must overcome. Although the Narcan delivery device is noninvasive and relatively easy to use, there is a training component for knowing how to use it.

More importantly, authorized staff must understand the signs that indicate the need for its use, for example, a patient who is: unresponsive to vigorous shaking; has shallow, slow, or absent breathing; and/or is believed to have taken illegal opioids. The program medical director should design this training with input from the medication delivery device’s manufacturer.

Antidotes – Broader Lifesaving Capabilities Although Narcan is available only by prescription, the depth of the overdose problem is such that some states have taken extraordinary action. Rhode Island, for example, has a “blanket prescription” that will allow anyone to purchase the medication at Walgreens. This action in effect bypasses the state and federal prescription medication statutes or, perhaps more accurately, meets the letter but arguably not the intent of those statutes. However, this also allows the family of a user to have the medication on hand in case of an overdose.

A final piece is to provide some degree of protection to those who, in good faith, attempt to save the victim of an overdose. “Good Samaritan” protection takes the assessment of risk out of the decision-making process. Since the immediate risk to the victim of an opioid overdose is that he or she will stop breathing, depriving the brain of life-sustaining oxygen, there is literally no time to waste. Narcan is an essential tool in the survival of overdose patients and, although its distribution is not without challenges, it is certainly a lifesaver.

____________________ Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.