The opioid crisis: Safety implications for EMS

The United States is experiencing an opioid crisis that has clinical and safety implications for EMS and other healthcare responders. The number of deaths from opioid abuse has been increasing since 1999. and iIn 2012, the CDC called opioid abuse an epidemic. 

The surge in use, abuse, and death is staggering. More than 106,000 persons people in the U.S. died from drug-involved overdoses in 2021, including illicit drugs and prescription opioids. The CDC estimates over 1,000,000 million people have died from drug overdoses in the past 25 years. 

• Opioids—mainly synthetic opioids (other than methadone)—are currently the main driver of drug overdose deaths. Nearly 88% of opioid-involved overdose deaths involved synthetic opioids. 
• Opioids were involved in 80,411 overdose deaths in 2021 (75.4% of all drug overdose deaths). 
• Drug overdose deaths involving psychostimulants, such as methamphetamine, are increasing with and without synthetic opioid involvement. 

In 2022, the DEA seized more than 59.6 million fentanyl-laced fake pills and more than 13,000 pounds of Fentanyl powder. 

The CDC defines drug addiction as: “a cluster of behavioral, cognitive, and physiological phenomena that may include a strong desire to take the drug, difficulties in controlling drug use (e.g., continuing drug use despite harmful consequences, giving a higher priority to drug use than other activities and obligations), and possible tolerance or physical dependence.”  

Addiction is clearly a disease process. There’ is ample neuroscientific evidence that addiction lasts beyond acute intoxication. The repeated use of addictive drugs changes motivational and reward circuits in the brain, which can have long-term effects. Naturally, the pre-frontal cortex becomes impaired in decision-making.   

It’s estimated that only one in 10 addicts receive specialized treatment. Given these effects on the brain it is not surprising that the most vulnerable period for becoming addicted is when neuroplasticity is high, and the pre-frontal cortex is not fully developed.  

However, don’t think that drug issues are confined to the young. Elderly people are selling their prescription painkillers. Opiate abuse is popular because in addition to binding to mu receptors, opiates cause a flood of dopamine to be released.  

Dopamine is “happy juice”. It’s involved in everything that feels good. The downside is that the mu receptor binding stops breathing. As natural neurochemistry is altered by abuse, people require new substances to experience desired effects.  

The epidemic is being fought by the widespread use of naloxone. State laws vary, but first responders, law enforcement officers, and drug users themselves are given access to Narcan. It’s becoming available at pharmacies as an over-the-counter medication that does not require a prescription.  

Recently, one state legislature enacted a bill to require music venues to have it available onsite for public use. The legislation also contains an immunity provision. There’s a push to have it available in the same manner automatic external defibrillators (AEDs) and fire extinguishers are in public areas. 

Narcan is a pure opioid antagonist that competes and displaces narcotics at opioid receptor sites. It also causes the release of catecholamines. The release enhances withdrawal symptoms and contributes to the aggressiveness that may be seen with overdose reversal.  

The enhanced potency of substances of abuse may require the administration of multiple doses of naloxone. Intranasal naloxone receives much attention. A mucosal atomizing device is used to administer Narcan 2-4 mg. The effectiveness of intranasal Narcan was estimated at 63%-81% in one study. In another, only 8.8% needed additional antagonist.  

One of the caveats to intranasal Narcan administration is it’s most effective when the person is still breathing, even if minimally. Otherwise, use of additional airway management procedure may be necessary. 

It should be noted that Narcan is not always effective or requires higher doses than normal, as the current trend is to mix or cut the heroin with other drugs including Fentanyl, Cocaine, Xylazine and Tianeptine.  

The lethal dose of fentanyl is estimated at 2 mg. That’s the equivalent of five to seven grains of salt. Fentanyl is 30-50 times more potent than heroin and 100 times more potent than morphine sulfate.  

Heroin goes for about $50,000 per kilogram, while fentanyl is $10,000 per kilogram. Carfentanil is 100 times more potent than fentanyl and 10,000 times that of morphine sulfate.  

The DEA Laboratory has found that, of the fentanyl-laced fake prescription pills analyzed in 2022, 6 out of 10 now contain a potentially lethal dose of fentanyl. This is an increase from 2021 when four out of ten fentanyl-laced fake prescription pills were found to contain a potentially lethal dose. 

Although the description of national events is useful, remember that drug abuse is local. Each community has what the DEA calls a “fentanyl footprint”, which may be applied to the entire drug abuse scenario. Know the substances which are being abused in your area, their names, and the way they are used.   

In addition to users, first responders are at risk. In 2017, The DEA published “Fentanyl: A Briefing Guide for First Responders.” Initially, and out of an abundance of caution, the DEA recommended that all first responders have an individual PPE kit, which includes nitrile gloves, N-95 masks, sturdy eye protection, paper coverall and shoe covers, and naloxone injectors, as there were media reports about police officers having overdosed through casual contact.  

These cases have been disproven and research from the American College of Medical Toxicology indicated there have been no reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids. An updated infographic is available on their website. 

Narcan is not cheap, with an average cost of $60 a dose. In many states, there is also a requirement for EMS providers to leave an additional dose behind, if the person does not wish to go to the hospital. The use of Narcan is so pronounced that it’s impacting the budgets of EMS providers. 

References 

Faul, M, Luric P, et al, “Multiple Naloxone Administrations Among Emergency Medical Service is Increasing”, Prehospital Emergency Care, Published online, May 8, 2017. Accessed May 16, 2017. 

Weiner, SG, Mitchell, PM, et al, “Use of Intranasal Naloxone by Basic Life Support Providers” Prehospital Care, Vol 2, #3, May/June 2017. 

Drug Enforcement Agency, “Safety recommendations for First Responders”, November 19, 2023. 

McLaughlin, Kathleen, “Deadly Chemistry”, Science, 21 March 2017, Vol 355, Issue 6332. 

Humphreys, K, Malenka, RC, et al, Science,23 June 2017, Volume 356, Issue 6344. 

 https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates 

ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders J Med Toxicol. 2017 Dec; 13(4): 347–351.