Your Captain Speaking: After the Naloxone

“Samantha, I don’t feel good about that last overdose call.”

“How so? You nailed the procedure, and even after he told you, in such colorful and vulgar terms, where to ‘stick it’, you were still nice to him.”

Could our procedure for treating opioid overdoses be improved? Is there another way? Many of us have done this type of call many times: Respond to an overdose, revive them with naloxone, they turn mean as hell and tell us to get away. Cycle repeats.

We don’t recall who said it, but it has stayed with me: “It’s abusive to give someone pain medication when they don’t need it. It is equally abusive to not give someone pain medication who does need it.” That was a very smart person.

When we resuscitate an opioid overdose, we often initiate full-on withdrawal symptoms and adverse behaviors. If the patient is a chronic opioid abuser, their symptoms will be profound to say the least. That’s a nice way to say they’ll be very verbal and want to kick our collective butts. The use of naloxone is necessary, no argument there, but its effects put the patient into a bad place. We’re not there to punish the patient by throwing them into withdrawal, so is there something else we can do? Medically? Ethically? How about to keep us from getting verbally or physically abused?

Is it possible to give the patient who has responded to naloxone a drug to ease its adverse effects? There’s a drug you may be hearing about that’s becoming available as a protocol standard: Suboxone is the brand name, buprenorphine the generic.¹ It’s prescribed to reduce opioid cravings and withdrawal symptoms. There are, however, significant legal hurdles that must be overcome for this drug to be used in EMS.

Wait—you’re saying to basically give someone who overdosed on opioids something just like another opioid? Yes, exactly! For many years addiction has been treated with methadone, not just in the USA but worldwide. In many cases it is effective, but in others not at all. It was and still is feared that a patient might just trade one addiction for another. Methadone treatments are long-term and must follow strict rules.

So, does federal legislation allow physicians by inference to develop protocols for EMS to administer buprenorphine? The answer seems to be yes, but restrictions are very tight. According to a DEA rule known as the “three-day rule,” it would allow a physician to administer (but not prescribe) narcotic drugs to a patient for the purpose of relieving acute withdrawal symptoms while arranging for the patient’s referral for treatment, under the following conditions:

• Not more than one day’s medication may be given to a patient at one time;
• Treatment may not be carried out for more than 72 hours;
• The 72-hour period cannot be renewed or extended.²

Pretty strict rules to say the least! How is buprenorphine administered? There are several options, including tablets and a sublingual “film” that stays in the mouth until dissolved, much like we administer Zofran.

This doesn’t mean it will be easy for EMS to train, control, and document. Just like any narcotic on the ambulance, it needs to be very strictly inventoried, administered, and tracked.

Are we saying this is the solution to opioid abuse? Not by any means! It has yet to be seen in a controlled study in the U.S., but it perhaps could raise the compassion level from EMS providers. Perhaps even the patient saved from an overdose will be less hateful toward EMS, have less severe withdrawal symptoms, and, most important, be more accepting that rehabilitation is in order. If those three things could be achieved, that is a step forward.

Perhaps a discussion with your medical director might be in order.

References

1. Facher L. In a nationwide first, New Jersey authorizes paramedics to start addiction treatment at the scene of an overdose. STATnews, 2019 Jun 26; https://www.statnews.com/2019/06/26/new-jersey-paramedics-buprenorphine/.

2. Substance Abuse and Mental Health Services Administration. Special Circumstances for Providing Buprenorphine, https://www.samhsa.gov/medication-assisted-treatment/legislation-regulations-guidelines/special.

Dick Blanchet, BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Mo., and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years.

Samantha Greene has been a paramedic, field training officer, and operations supervisor for Abbott EMS of Illinois for the last 10 years and a lieutenant for the Madison, Ill., Fire Department for the last five.