Should EMS let opioid overdose patients die?
A proposal to withhold treatment from opioid overdose patients shows the epidemic's continuing stress on EMS providers and its strain on municipal budgets
There is no end in sight to the worsening opioid overdose epidemic. Deaths continue to mount, responders are increasingly reporting exposure to carfentanil and fentanyl while attempting to treat patients and the funds to pay for naloxone are dwindling.
For consecutive years, opioid overdoses have killed more people than motor vehicle collisions in the Untied States. Last year, more than 4,100 opioid overdose deaths were documented by Ohio coroners. This year, more than 58,000 Americans are projected to die from an opioid overdose exceeding the number of U.S. soldiers, aviators and sailors killed in the Vietnam War.
A staggering 115 million opioid prescriptions are written annually. A jaw-dropping 50 percent of those prescriptions go to patients with a mental illness who are already at increased risk of abuse and addiction.
EMS, fire and police departments everywhere are reporting increased responses to overdoses and needing to administer multiple doses of naloxone. The epidemic is especially acute in some states, like Ohio and West Virginia, but no community is immune.
As the number of responses and associated costs increase, public safety leaders, elected officials, health care provider groups and field providers are questioning the current response to the epidemic, how to stem the rising death toll, how to manage the spiraling costs and how to reduce future overdose deaths.
There are large systemic causes that need to be solved – inside and outside of the U.S. – before the death rate will decline. Several state attorney generals are suing opioid manufactures for their marketing claims and distribution practices. Clinicians and academics are researching the scope of the opioid overdose epidemic, identifying alternatives for non-narcotic pain management and examining the best approaches for rehab and recovery. Labeling changes and prescribing practices are needed. All of these things will take significant time, collaboration and leadership.
Meanwhile, EMS providers are being pushed and pulled by two opposing philosophies – let 'em die and keep 'em alive until they are ready for rehab.
Should EMS providers let opioid overdose addicts die?
Advocates of the let 'em die approach, including Middletown, Ohio City councilman Dan Picard, believe narcotics overdose is a choice and that administering naloxone to reverse an overdose, especially a second or third time to the same person is coddling and enabling addiction. Without evidence, Picard speculates narcotics abusers are traveling to his community to use drugs because they know they will be treated at no cost by fire and EMS.
Picard has proposed a three strikes and we'll let you die policy for his community. He wants 911 dispatchers to refuse a third response to a patient who has already received two overdose reversals.
Scare tactics and threats of non-response are not unique to Middletown. Last fall, a Pennsylvania EMS agency began asking overdose patients for their preferred funeral home with a "One Breath from Death" card.
Some EMS providers, either through an erosion of compassion from many years of being on the front lines of the opioid overdose epidemic or a misunderstanding of their role as lifesavers, are supportive of the let 'em die approach. Those seemingly calloused caregivers think a get-tough approach is a much-needed reality check to shame or scare an addict into recovery. Their lack of understanding the science of addiction is only equaled by their lack of empathy for the community they have pledged to serve.
Should EMS providers keep opioid addicts alive?
Addiction is a treatable brain disease. Of course opioid addiction, like all medical conditions, requires cooperation from the patient. But rehabilitation, medication-assisted treatment and recovery only works if we can keep the patient alive until they are ready to participate in their own treatment.
Every day, EMS providers assist patients in staying alive to reach definitive care – like transporting a STEMI patient to the cath lab – or while their medication is fine tuned to treat a chronic disease condition – like diabetes, heart failure or hypertension. It's incomprehensible to withhold treatment from one patient cohort – people with addiction – while continuing to treat and manage without hesitation children with asthma, another cohort of patients that is resource intensive for EMS.
We are in the people care business. The let 'em die approach, regardless of the patient's nature of illness or mechanism of injury, is antithetical to our training, professional code of ethics and the values symbolized in the Star of Life.
Not only do we have an obligation to care for patients, regardless of their medical condition, we have a role as life advocates to stand up to misinformed elected officials, to educate our communities about prescription opioids and to refer patients to social services, including community paramedicine programs to aid in their treatment. Create the opportunity for a patient to get sober and share their gratitude for life.
Finally, if you take to Facebook or Twitter to rail against addicts and advocate for their premature death from a treatable disease, you are blinded to the high likelihood that addiction to drugs or alcohol is near to you. Would you be so bold as to stand up in a family reunion, church service or EMS training and declare that your empathy to treat patients does not extend to opioid overdoses?
There are addicts and recovering addicts in our midst – co-workers and supervisors in your agency, nurses and doctors at the hospital, cops and firefighters who co-respond with you – your expressions of empathy, as well as your unconditional willingness to treat them should they overdose, are an important ingredient in keeping them alive until they are ready to start treatment.