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How to start an EMS naloxone distribution program

Guilford County EMS partners with the N.C. Harm Reduction Coalition to distribute naloxone to patients who refuse transport after an overdose

By Jim Albright and Tessie Castillo

Guilford County (N.C.) EMS paramedics, when called to the scene of an opioid overdose, will administer naloxone to reverse the overdose. Those same paramedics will also supply any overdose patient who refuses hospital transport with a take-home naloxone kit free of charge.

Guilford County EMS partnered with the North Carolina Harm Reduction Coalition, a nonprofit that distributes overdose rescue kits containing naloxone to community members at risk for an opioid overdose. In the past three years, NCHRC has distributed over 33,000 overdose rescue kits across the state and reports over 4,300 successful reversals using naloxone, including over 900 in Guilford County.

Contents of the naloxone kits distributed by Guilford County EMS. (Photo courtesy Hyun Namkoong)
Contents of the naloxone kits distributed by Guilford County EMS. (Photo courtesy Hyun Namkoong)

But the challenge facing NCHRC has been how to get the kits into the hands of the highest-risk population — people who have already overdosed. Hence, the partnership with Guilford County EMS was born.

5 steps to form a harm reduction partnership
The Guilford County EMS and NCHRC distribution program took about nine months from the time approval for the program was initially sought until the program started. The following steps were completed:

1. Guilford County EMS sought local approval from their medical director, Melanie Belfi, MD, to run a three-month pilot program.

2. Guilford County EMS sought approval from the North Carolina Office of EMS medical director. This was not a necessary step, but support from the state office of EMS was appreciated.

3. Guilford County EMS signed a contract to become "volunteer contractors" for NCHRC when dispensing naloxone kits. NCHRC legally distributes naloxone to lay people through a standing order prescription written by the NCHRC medical director. The standing order authorizes NCHRC staff and contractors to distribute naloxone. Since no one at Guilford County EMS is on NCHRC staff, they had to sign a document to become volunteer contractors in order to distribute naloxone under NCHRC’s standing order and receive the kits.

4. After the contract was signed, Guilford County EMS personnel were trained on how to distribute the overdose rescue kits, when to give them out — when an opioid overdose patient refuses transport to the hospital, and how to train the patient on how to use the overdose rescue kit.

5. NCHRC delivered 100 overdose rescue kits to Guilford County EMS. Two kits were placed in each of the 50 ambulances.

6 EMS top takeaways from the harm reduction partnership
Since the program started on August 11, 2016, Guilford County EMS providers have distributed more than 30 kits to people who refuse hospital transport after an overdose. Here are a five of our top takeaways from starting this program:

1. EMS personnel often have access to patients at highest risks of overdose and can distribute kits effectively post-reversal.

2. EMS personnel who distribute the kits should ideally undergo training to compassionately and effectively engage with people who use drugs. At times conflict may arise between EMS and people refusing hospital transport, but if interactions with EMS are perceived as negative, the program will not be well received by the community.

3. EMS personnel can benefit from additional training on the physiology and psychology of addiction, as well as current and emerging trends in the illicit market.

4. There needs to be buy-in from EMS personnel on the ambulances. The point of any harm reduction and naloxone distribution program is to get naloxone into the hands of as many people as possible who could use it to reverse an opioid overdose. If the EMTs and paramedics don’t buy-in to the concept of naloxone distribution to lay people, then the program will not be effective.

5. Through an EMS program, it is difficult to hear about successful overdose reversals. NCHRC keeps careful track of the number of times their kits are used through a reporting system, which usually means that people who use the kits report back to the person who gave it to them. But people who get naloxone from EMS are not reporting back to EMS, so it is hard to collect data on how many of the kits have been used.

6. Having a community partner such as NCHRC was key to getting the program off the ground because NCHRC provided the kits and the standing order for the program, as well as clear definition of the magnitude of the opioid issues in our community.

For Guilford County EMS, this program is about keeping people alive so they can seek treatment. The medical community was part of issue in creating the opioid addiction problem and we need to be part of the solution. We also must continue to fight the stigma against narcotic use and teach people who are using drugs that EMS is here to help.

Reducing death and disability
In addition to the naloxone distribution program, North Carolina has taken a number of legislative and regulatory steps to reduce death and disability related to growing issue of opioid overdoses. 

North Carolina SB 20, effective since April 9, 2013, extended the 911 Good Samaritan law. Individuals who experience a drug overdose or persons who witness an overdose and seek help for the victim can no longer be prosecuted for possession of small amounts of drugs, paraphernalia or underage alcohol drinking. The purpose of the law is to remove the fear of criminal repercussions for calling 911 to report an overdose and to instead focus efforts on getting help to the victim.

SB 20 also removed civil liabilities from medical care providers who prescribe and bystanders who administer naloxone. SB20 also allows community based organizations to dispense naloxone under the guidance of a medical provider. As a result, EMS providers may encounter people who use opiates and their loved ones carrying overdose reversal kits that may include naloxone vials and 3 cc syringes.

North Carolina SB 154, effective since August 1, 2015, further clarified the Good Samaritan law to include that a person who seeks medical assistance for someone experiencing a drug overdose cannot be considered in violation of a condition of parole, probation or post-release, even if that person was arrested. The victim is also protected. The 911 caller must provide their name to 911 or law enforcement to qualify for the immunity. Pharmacists are now immune from civil or criminal liability for dispensing naloxone to people at risk of an opioid overdose.

North Carolina HB 850, effective since December 1, 2013, passed a safe surrender of needles law, which states that if a person alerts a police officer to the fact a hypodermic needle or other sharp object is on their premises or in their vehicle prior to a search that person cannot be charged or prosecuted with possession of drug paraphernalia for that object. The purpose of this law is to protect police officers from punctures or wounds from sharp objects that could be potentially contaminated with HIV or hepatitis C and to encourage people to be honest about paraphernalia they may have in their possession.

North Carolina HB 712, the Pilot Project/Used Needle Disposal bill, signed into law on October 22nd, 2015 does two things. First, it states that anyone who declares a syringe or sharp object to a law enforcement officer prior to search cannot be charged for possession of the object or for any drug residue inside the object. Second, HB 712 authorizes establishment of pilot programs to collect and safely dispose of used syringes.

An amendment to North Carolina HB 972, signed into law on June 20, 2016, legalized syringe exchange.

North Carolina SB 734, signed into law on June 20, 2016, allows pharmacies to begin making naloxone available without a prescription. North Carolina is the third state to issue a standing prescription order statewide for naloxone.

Tripp Winslow, MD, the North Carolina Office of EMS Medical Director, sought and received permission to move naloxone from the ALS formulary to BLS providers. He then created a first responder category for law enforcement. Guilford County soon followed suit with the largest naloxone implementation in the state with the Guilford County Sheriff’s Office, followed by the High Point Police Department. The Greensboro Police Department will soon be joining the program.

About the authors
Tessie Castillo is the Advocacy and Communications Coordinator for the North Carolina Harm Reduction Coalition.

Jim Albright is the Director of Emergency Services for Guilford County, N.C. He has been involved in prehospital medicine since 1985, and has worked for Guilford County since 1989. He holds a B.A. in economics from UNC-Chapel Hill and a M.S. in accounting from UNC-Greensboro, as well as a NRP. He also serves as the chairman of the North Carolina Association of EMS Administrators and as a board member of the N.C. Chapter of the National Association of EMS Physicians.

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