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The opiate addiction backlash in EMS

From fentanyl, to heroin, to ketamine, to carfentanil: the drug epidemic didn’t start in the back of an ambulance


Since the early part of the decade, the United States has suffered an epidemic of opioid drug dependency and overdoses. For years now, accidental poisonings have far outpaced car accidents and firearm violence as the leading cause of trauma deaths in this country.

The chronic pain crisis of the late 1990s blossomed in the 2000s into a macabre fruit of opioid dependency and the resurgence of heroin as the drug of choice among addicts. In 2015, heroin alone accounted for more deaths than firearms [1]. Back in the day, the really hardcore drug users took horse tranquilizers, like ketamine. Now, ketamine has emerged as one of the more effective sedative analgesics in the EMS drug box, and the really hardcore addicts are lacing their heroin with elephant tranquilizers, like carfentanil.

I swear, it’s enough to make paramedics and cops pine for the good old days of crack pipes and meth labs.

Shifting attitude toward narcotic analgesics for pain management is the most worrisome. (Photo/U.S. Department of Veterans Affairs)
Shifting attitude toward narcotic analgesics for pain management is the most worrisome. (Photo/U.S. Department of Veterans Affairs)

And now that the general public, legislators and regulators, and medical professionals are coming to grips with the magnitude of the problem, we’re poised for a huge backlash against opioid use.

Newton’s Third Law of Motion states, “For every action, there is an equal and opposite reaction.”

For the sake of our patients, we’d better hope that the coming backlash isn’t ruled by Newtonian physics.

Unfounded fears, proposals in response to opioid crisis

The reality is that the backlash is already here. Public safety officials are succumbing to unfounded hysteria over transdermal exposure to carfentanil, city councilmen are proposing that EMS not be dispatched after a victim’s third overdose, and EMS professionals themselves are openly saying on social media that we should take a Darwinian approach to opiate overdose; keep the naloxone in the box, and just let nature sort it out.

In a profession where a substantial percentage of us feel justified in judging whether a patient is worthy of our care or not, advocating for adequate pain management was already an uphill climb. From paramedics doggedly adhering to outdated dogma that administering pain medication to undifferentiated abdominal pain will mask their symptoms, to others’ fear of getting conned by a drug seeker, EMS has a long history of undertreating pain [2-9]. 

As recently as January, our authority to administer narcotic analgesics in the field was questioned by the DEA. Thankfully, Congress intervened appropriately in that one.

But our shifting attitude toward narcotic analgesics for pain management is the most worrisome. Recently, Fire Chief Kevin Gallagher of the Acushnet (Mass.) Fire Department and Dr. Matthew Bivens announced the addition of IV Tylenol to their pain management protocol. Other proposals included added oral Tylenol and Motrin, and IV Toradol to the Massachusetts state EMS protocols.

All of those steps are good things. It’s great to have options. When the only tool you have in your toolbox is a hammer, every problem tends to get treated like a nail, as was the case of Chief Gallagher’s medics treating things like carpal tunnel syndrome and tendonitis with Fentanyl. With such patients, IV Tylenol or Toradol are more appropriate medications. What is worrisome is the motivation behind it:

"How many of those did we really have to give fentanyl to and expose them to the risk of addiction?" Gallagher asked.  "It's time we start calling fentanyl what it is – synthetic heroin," he said. "If I can keep one person off opioids by this, then it's a good thing."

The source of the opioid epidemic

Right response, wrong motivation, Chief Gallagher. Opioid administration for acute pain management by EMS crews is not what’s causing, or even contributing to, the opioid epidemic. It has been demonstrated in numerous studies that liberalization of EMS pain management protocols does not result in inappropriate administration, nor is it likely to cause increased rates of substance abuse [10].

In administration of opioids to habitual narcotics users with increased tolerance, the typical dose of narcotics in most prehospital pain management protocols is unlikely to produce an appreciable high, nor is it likely to even control breakthrough pain in the chronic pain patient [12].

If we’re going to place blame for the current opioid epidemic, let’s put it where it belongs: The Joint Commission and hospital administrators.

In 1999, The Joint Commission, the accrediting agency for most major hospitals, declared pain “the fifth vital sign,” and began pressuring hospitals to more aggressively assess and treat pain [13]. Hospital administrators, in their quest for ever-higher Press Ganey scores, began pressuring ED physicians to shift their prescribing practices for potent narcotic analgesics. It’s the Burger King motto run amok: “At our hospital, you can have it your way!”

Apparently, The Joint Commission never learned what every EMT student learns in the first few weeks of school; there is a big difference between a symptom and a sign. Symptoms are subjective. Signs, by their very nature, are observable and quantifiable. It is folly to add a subjective complaint like pain to a list of objective physiologic parameters. The consequence of that paradigm shift is but one of a number of ugly healthcare chickens coming home to roost in our current opioid epidemic.

Americans want relief now

The American mentality of “more medicine is better medicine” fosters the belief that we should never feel uncomfortable or even inconvenienced. Americans don’t want to hear, “You have a viral syndrome, go home and hydrate and let your immune system do its job,” nor do they want to hear, “You have a minor muscle strain. Take 800 mg of Motrin as needed, and rest.” They want relief, now.

Couple that reality with the following:

  • Shortage of primary care physicians, leading to more people seeking fragmented and expensive care through the ED
  • Lack of follow-up care
  • The popularity contest that are Press Ganey scores ceaselessly pressuring ED physicians to give patients what they want, instead of what they need
  • More stringent regulation on pain clinics and pain management physicians

You wind up with ED physicians prescribing a sprained ankle a couple of weeks’ worth of potent narcotics and instructions to follow up with their primary care physician.

Only, they have no primary care physician or it takes a month to get an appointment. Taking a week off of work to rest the ankle is a non-starter for the uninsured and under-insured. By the time they do get follow-up care for that ankle, they have exacerbated the problem, and their primary care physician, leery of increased DEA scrutiny of his narcotic prescribing practices, only writes a prescription for NSAIDs, or a less-potent dose of opioids with no authorization for refills. Joe with the bum ankle and the Percocet habit is left little choice but to score heroin now.

We live in a world where ill-conceived government regulations make it easier to score methamphetamine on the street and reverse-engineer it into Sudafed for our colds, than it is to buy OTC Sudafed at the pharmacy.

There is plenty of blame to go around for our opiate addiction, Chief Gallagher, but it wasn’t happening in the back of your ambulances.

References

  1. Washington Post. Heroin deaths surpass gun homicides for the first time, CDC data shows. Available at: www.washingtonpost.com/news/wonk/wp/2016/12/08/heroin-deaths-surpass-gun-homicides-for-the-first-time-cdc-data-show/
  2. McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower extremity fractures receive prehospital analgesia. Prehosp Emerg Care. 2002;6(4):406-410.
  3. Ricard-Hibon A, Leroy N, Magne M, et al. Evaluation of acute pain in prehospital medicine. Ann Fr Anesth Reanim. 1997;16(8):945-9.
  4. Singer AJ, Thode HC Jr. National analgesia prescribing patterns in emergency department patients with burns. J Burn Care Rehabil. 2002;23(6):361-5
  5. Swor R, McEachin CM, Sequin D. Grall KH. Prehospital pain management in children suffering traumatic injury. Prehospital Emergency Care. 2005;9(1):40-43.
  6. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(10):1537-9
  7. Todd KH, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11-16
  8. Vassiliadis J, Hitos K, Hill CT. Factors influencing prehospital and emergency department analgesia administration to patients with femoral neck fractures. Emerg Med (Fremantle).  2002:14(3):261-6
  9. White LJ, Cooper LJ, Chambers RM, Gradisek RE. Prehospital use of analgesia for suspected extremity fractures. Prehosp Emerg Care. 2000;4(3):205-8
  10. Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics. JAMA. 2000;283(13):1710-4.
  11. Pointer JA, Harlan K. Impact of liberalization of protocols for the use of morphine sulfate in an urban EMS system. Prehospital Emergency Care. 2005;9(4):377-381
  12. McCaffery M, Pasero C. Breakthrough pain. Am J Nurs, 2003 Apr; 103(4): 83–4, 86
  13. The Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals, The Official Handbook. Chicago: JCAHO Publication;1998.

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