By John Sullivan
Philadelphia Inquirer (Pennsylvania)
Two months ago, as scores of drug users in the city began dying of heroin overdoses, two city paramedics discovered something alarming. Narcan, a powerful drug that could almost instantly revive a patient, wasn’t working.
In the following weeks, an apparent culprit would be unmasked: Heroin dealers were adding fentanyl to their product, an opioid up to 100 times as powerful. More than 500 people across the country have died of the tainted heroin — a number that is sure to climb.
But as the concerns of the two paramedics made their way up the Fire Department’s bureaucracy, the city did not make key changes in how it treated people dying of a fentanyl overdose — though experts say that simply increasing the dosage of the antidote would counteract the fentanyl.
Fire Department officials say that this year, using the current Narcan dosage guidelines, they used the antidote to treat at least 88 fentanyl-related overdose patients who later died.
To make matters worse, many people suffering from overdoses didn’t receive Narcan because they lived in areas where the number of emergency medical personnel who could administer the drug had been cut.
“We’re losing people every day that don’t need to die,” said Casey Cook, executive director of Prevention Point Philadelphia, a nonprofit that runs the city’s needle-exchange program.
An Inquirer investigation has found that:
City and health officials are at odds over whether current dosages of Narcan are high enough to counteract fentanyl-laced heroin.
The city’s chief paramedic, whom top fire officials referred to as an expert during an interview, did not know that Narcan worked as an antidote to fentanyl.
Because of a shuffling of resources, the neighborhoods hardest hit by heroin-related deaths are not specifically served by paramedic units that can administer the antidote.
Unclear on treatment
Even though the fentanyl-poisoned heroin had been on Philadelphia streets for eight months, Philadelphia rescue officials seemed uncertain last week of the proper emergency treatment.
In interviews, fire paramedic-operations chief Daniel T. Parrish first said he didn’t believe that Narcan had an effect on fentanyl.
A few days later, he changed his mind and said the city needed to increase the dose and would change its protocols. “My feeling is that fentanyl needs a much higher dosage,” said Parrish.
“Unfortunately, some individuals could not be privileged to the change, and we lost some human beings,” he said Thursday. “We will do the best we can to help other individuals [and keep them] from losing their lives.”
Experts who study opioids such as heroin and fentanyl caution that emergency cases are complicated by many unknowns, but that unless a patient is brain-dead when paramedics arrive, Narcan can keep them alive.
“They just need to give more of the drug,” said Charles P. O’Brien, director of the Charles P. O’Brien Center for Studies in Addiction at the University of Pennsylvania Health System. O’Brien has developed medications to treat alcohol, opioid and cocaine dependence.
But C. Crawford Mechem, medical director of EMS, said Philadelphia’s protocol for treating fentanyl-laced heroin overdoses was sufficient, and typical of those in most cities.
“The policy we have in place is perfectly adequate,” said Mechem, who is also an attending physician at the Hospital of the University of Pennsylvania’s emergency room.
The Fire Department’s Parrish said that after his interview with The Inquirer, he discussed the issue with Mechem, and Mechem told him he wanted to review the city’s protocol for using Narcan.
Mechem, who oversees Parrish and makes all medical decisions for EMS, said he did not tell Parrish he would reevaluate the policy. Upon hearing Mechem’s comments, Parrish said he himself must have been mistaken. “I’m in a chain-of-command situation here, and whatever he said is what it is.”
Mechem said paramedics gave 0.4 milligrams of Narcan and continued to administer the drug up to 2 milligrams. After that, they must get permission from a doctor to give more.
When asked whether more Narcan was needed to reverse a fentanyl overdose, Mechem replied: “It may, but there is little literature to support it.”
But at least two paramedics whom the city will not identify became concerned when patients did not respond to Narcan.
In a videotaped interview recorded for a White House-sponsored fentanyl conference in Philadelphia last month, one of the paramedics said he began to suspect bad heroin when he saw users with needles still in their arms. He said he could not revive many of the victims because they were too far gone, but he did manage to save two people.
“The treatment of the two people I did have a chance to save, the big difference with that was the protocol,” he said. He said he was going to administer a few milligrams of Narcan, but because he suspected fentanyl-laced heroin, he asked to use more.
“We had to use, we had to call... contact base command and our doctors to... give a little more Narcan.”
Not just Philadelphia
The spread of fentanyl-laced heroin is a deadly problem that Philadelphia, Chicago, Detroit and other major cities have struggled to deal with. Camden also has seen dozens of deaths. In a large swath of Philadelphia that includes areas where paramedics were removed, fire officials said 137 people had died this year of heroin-related overdoses. An overdose of fentanyl, a powerful painkiller, can kill quickly because it binds to receptors in the brain stem that control breathing, said Bertha Madras, a neurochemistry and psychobiology expert in the White House Office of National Drug Control Policy.
Narcan, which is the brand name of the drug naloxone, is an opioid antagonist that also binds to receptors in the brain. If there are equal numbers of naloxone and fentanyl molecules, naloxone will prevent the fentanyl from binding because it binds more efficiently.
This makes naloxone very effective at reversing the sedation, respiratory depression and low blood pressure that result from an opioid overdose. Some people dying of an overdose will get up and walk away after getting the drug. Further, Narcan is safe, even in large quantities, because it has no effect on people who are not overdosing, experts say.
No Narcan
In Philadelphia, some drug users dying of overdoses didn’t get Narcan.
Before the rash of fentanyl overdoses became apparent, a shortage of paramedics prompted the city to swap them for EMTs, emergency medical technicians. EMTs cannot administer the drug, and the change was made in the very neighborhoods that would be hardest hit by the poisoned drug.
Fire Commissioner Lloyd Ayers said he took the paramedics from places where coverage overlapped and most calls were not medically urgent.
“This is another example of a real crisis we are experiencing in providing our citizens with fast and effective emergency medical services, especially in view of our unprecedented demand,” said City Council President Anna C. Verna, who expressed concerns about the moves when Ayers told City Council about them this summer.
Exactly how many drug users who overdosed went without Narcan is hard to say, but during the fentanyl conference, Capt. Richard Bossert, the EMS official in charge of quality assurance for the city, said that if the paramedics hadn’t been redeployed, the city would have given Narcan to twice as many people.
As of last month, city paramedics had administered Narcan to 630 people this year, compared with 655 patients in all of 2005.
“That number is skewed low,” Bossert told the audience, because EMT units “do not give Narcan.”
Deputy Fire Commissioner Ernest F. Hargett later dismissed Bossert’s remarks as being “off the cuff.”
“I think he was speculating,” said Hargett, adding that the numbers would have been lower.
Ayers said that shuffling of city paramedics was a tough choice, but that ultimately it had had little impact on the quality of service.
“I look at every firefighter and every paramedic and I can tell you the quality of care is the highest that’s available,” said Ayers.
Douglas L. McGee, the past president of the Pennsylvania chapter of the American College of Emergency Physicians, empathizes with Ayers.
“Tainted heroin is not a regular occurrence, so you could redeploy resources only to see the problem go away.”
EMS medical director Mechem said that although it is tragic that so many have died, their deaths are not related to whether they received Narcan or how much. He said they represented a relatively small number of patients compared with what the system handles.
It makes no difference, he said, whether an overdosed patient gets treated by a paramedic or an EMT. He said either they’re too far gone when EMS arrives or an EMT can keep them alive until they reach one of the city’s many hospitals.
“While the ultimate reversal agent for narcotic overdose is naloxone, I don’t think the fact that they can’t administer naloxone is why these people are dying,” said Mechem.
“Ventilating the patient will also keep them alive until they get to the hospital,” he said, adding that respiratory depression is what kills most overdose patients.
Mechem said EMTs use a mask with an inflatable bag attached to drive oxygen into the lungs, a practice commonly referred to as bagging.
Dave Kearney, a Philadelphia paramedic for 11 years, said bagging was not practical.
“Can you imagine trying to hold a mask on someone’s face, squeeze a bag, all while carrying them on a stretcher down several flights of stairs? It doesn’t work,” said Kearney, who is the recording secretary for the local firefighters’ union and a frequent critic of the city’s EMS system.
“Why do that when we can give them a shot?”
Other doctors who have studied fentanyl said that although much depends on the circumstances, bagging is often difficult and can lead to vomiting and aspiration, which can be fatal.
“In theory, there is no doubt that the best treatment is earlier administration of naloxone, because the patient may be near death already and so you want to reverse all the effects,” said Paul M. Paris, a nationally recognized expert on emergency medical care and the chairman of the department of emergency medicine at the University of Pittsburgh School of Medicine.
“It’s not so simple as providing oxygen.”
Paris proposes that Pennsylvania adds naloxone to a list of drugs that EMTs can give patients.
That’s exactly what some states have done. New Mexico passed a law allowing police officers to give it.
In Maine, state EMS medical director Steven E. Diaz said the state allowed EMTs to deliver Narcan after a rash of opiate overdoses three or four years ago.
“This is something we did to save lives, and it worked,” said Diaz, a former paramedic who has written two books on emergency medicine.