Uberdose

911 for people who should call for help, but won’t

Graphic by Sean Jones

To a certain extent, I think we all knew this was coming. For as long as there have been efforts to equip police officers and public transit workers with naloxone — “the overdose antidote” — to reverse opiate overdoses and resuscitate dying patients near instantaneously, it was almost a given that someone was eventually going to pipe up and say, “There should be an Uber for heroin overdoses.”

Well, now it’s happened, and I’m a bit surprised to know that it’s us saying this — and that it’s taken anybody this long to say it at all.

There should be an Uber for heroin overdoses.

For all opiate overdoses, in fact. For any overdose that could be reversed if someone nearby happened to be carrying naloxone (trade name “Narcan”) and got an alert on their phone that said “Somebody’s on the verge of dying around the corner and you can save their life right now.”

There should be an app for that.

It’s not all that far-fetched of an idea, really – especially if you’re a drug addict who’s watched friends die from an overdose, or a parent who’s lost a child.

Like bystander cardiopulmonary resuscitation (CPR) and the automatic external defibrillator (AED) before it, one could argue that it was only going to be a matter of time before common sense prevailed and the possibility of saving someone from a premature death by giving them a basic life-saving skill would no longer obstructed by antiquated legislation or the monopolistic tendencies of the established public order. Untold thousands of parents, spouses, siblings, children and friends would likely agree: there should be an app for overdoses.

But before I explain why I think there should be an app for overdoses — or at least an alerting system separate from the “public” 911 system (and, yes, full disclosure: Trek Medics has an alerting system that could do this) — I’d like to first explain why I think orthodox 911 systems alone, including your own, will never be able to prevent as many overdoses as it believes it can, and why an emergency alerting system detached from centralized emergency call centers could help immensely in preventing a lot more premature death.

As a paramedic that worked along the U.S.-Mexico border until 2010, my colleagues and I responded to a lot of heroin and painkiller overdoses. Some of them we got to in time, while in others we got there too late — and still many other overdoses we never even heard about. Unlike a lot of the other deaths we witnessed in the course of our work, fatalities resulting from opiate overdoses were almost always preventable, and the number one reason behind every death was time: we simply didn’t get there when we were needed. There are a number of problems that keep paramedics from reversing overdoses in time, many of which centralized 911 systems cannot fix — or even cause themselves.

911 is only good when you call it

First and foremost, in the U.S., Canada and other countries where there’s a unified emergency access number for police, fire and emergency medical services (E.M.S.), asking a drug user who’s witnessing an overdose to dial 911 and send for help is tantamount to calling the police and asking them to arrest you and take you to jail with all the evidence against you packaged up and ready to go for easier booking. No one’s eager to make that call. In the same vein, equipping EMT-Basics, volunteer firefighters and law enforcement officers with naloxone is definitely a good start, and certainly makes for good press, but it’s ultimately a passive approach with limited scope that leaves the life-saving administration of naloxone to largely incidental occasion — i.e., “I happened to trip over him while walking under the highway overpass and noticed he had a needle dangling from his arm.”

Few, if any, life-saving awards have ever been given out to drug addicts

While several U.S. states have passed “Good Samaritan” laws that offer immunities and/or other legal protections to bystanders who report an overdose in progress, it’s quite possible that such legislation, coming from the mouths of lawyers, politicians and police chiefs, translates in the minds of drug abusers into something more akin to, “Good Samaritan today, law-breaking junkie tomorrow.” I haven’t seen any data yet, but I’ve a suspicion that the instances of witnesses invoking Good Samaritan protections are probably pretty low in suburban and rural communities where everyone knows your name.

Opiate abuse is typically an introverted activity

Overdose victims are often found by emergency responders only after considerable trouble and in hard to reach places that are purposely removed from easy public access, making it very inconvenient for crews to bring in their gear and gurney, administer their drugs, and remove the patient. Such behavior is very rational: Nobody wants their spot blown up, and by bringing in the cavalry when maybe all you needed was someone within the community who knew what to do, there’s a strong chance the official entourage will end up scattering the people who will need help later to deeper and darker corners. This is particularly worrisome in the cases when there’s “bad” heroin going around: where there’s a higher risk for users to overdose, you don’t necessarily want to shoo them into the woods.

In the event that a companion opts to call 911 for his/her overdosing friend, it’s often not before considerable efforts have been made to seek alternative home remedies in order to avoid the prospect of having to call 911 — including cold showers, face slaps and banging heads against the floor, to name a few. These are the panicked, yet predictable reactions of an unprepared community that’s literally choosing between life and jail for both, or maybe death for one and likely no jail for the other. This panic, reinforced by a natural aversion to self-incrimination, can be so pronounced that it’s not unheard of for would-be Samaritans to go as far as to drag their overdosed friend to the front lawn or street curb, call 911, and flee the scene. This effectively turns them into fugitives and leaves the task of finding the unresponsive patient to emergency responders equipped with sketchy information taken from a very reluctant 911 caller. Damned if you do, damned if you don’t.

These are just a few of the factors weighing in the heads of drug users who are witness to an overdose. The paralysis of the panic and paranoia — not to mention the adverse effects of the drug itself on the decision-making faculties — inevitably leads to delays in action, which further leads to delays in getting oxygen back to the oxygen-starved brain and heart, and thus increases the chances for both premature death and permanent neurological disability.

And why? Because junkies and addicts deserve what they get? I would leave the right to respond to that assertion to the family and friends of those who’ve lost loved ones prematurely.

Pomp vs. Circumstance

There’s a strong case to be made that bystander-administered naloxone programs could be as effective as orthodox 911 systems in responding to overdoses, administering naloxone, and managing the patient, if not more effective. Such a system would undoubtedly be cheaper and would certainly be better equipped to provide post-overdose care as it could technically even include direct admission to inpatient or outpatient treatment facilities — something most U.S. paramedics are legally forbidden to do. By law, paramedics in the U.S. have basically two options to offer an overdose they just revived: “go to jail with this police officer, or go with us to the hospital (and jail after).”

“Everyday they don’t never come correct” – Flavor Flav

Equipping friends and family and fellow drug users to administer naloxone is also likely a safer approach to the prehospital treatment of overdoses than orthodox 911 systems can offer, and for two reasons:

  1. Giving naloxone for a heroin overdose always carries the very real risk of solving the medical emergency while simultaneously creating a behavioral emergency that can be equally, if not more, dangerous to both patients and bystanders. Being pulled from a deep, euphoric sleep to find trusted, familiar and/or non-threatening faces is a lot more manageable from a behavioral perspective than being awoken by a scrum of public safety personnel with diesel engines running and radios chirping. Imagine the circus: a couple of paramedics with weird goggles sticking needles in your arm (and possibly damaging your “good” veins); a handful of firefighters in suspenders and big pants; and two police officers with shiny badges and handcuffs, digging through your wallet. All of this for someone who’s quite literally just been pulled back from the great white light, and who now likely finds themselves in the throes of severe withdrawals. If there was ever a buzz-killer, naloxone administered by the full public safety platoon is it.
  2. About those needles: Thank God for nasal naloxone, but the protocols in many E.M.S. systems across the U.S. still require paramedics to start an intravenous line for patients who overdose on opiates. Intravenous drug users are clearly at a higher risk for having infectious blood-borne diseases. Not only does starting an intravenous line on these patients pose risks for the healthcare professionals treating them, but unnecessary needle sticks also put drug users at greater risk for hospital-acquired infections — a very clear sign that we’re over-treating as a society, if there ever was one.

You’ll go to jail for this?

Liability doesn’t really seem too much of a problem either, especially when you consider who the trained responders might include: like public health practitioners, community advocates and the drug users themselves, among others. Let’s be clear: Nobody’s asking the local boy scouts troop to respond to a heroin den. There are certainly more creative and appropriate solutions.

In Baltimore, for example, the foundations for such a response team were detailed in a New York Times article about a program that trains strippers and bouncers in five minutes to carry and administer naloxone. It described these prepared responders as, “a group of health workers trusted and integrated on the streets, empathizing with those plagued by poverty, and meeting the people eye-to-eye to help them see another day.” I suspect people like these would be willing to risk the liability.

Medical Misdirection

Some of the major players in making naloxone accessible to the public at large include the E.M.S. medical directors at the state, county and city levels, under whose license prehospital professionals can legally provide care. These doctors decide what medical interventions can and can’t be performed by E.M.S. professionals and bystanders within their jurisdiction, and many are resistant to making naloxone as easy to buy as a tourniquet. But if the degree of uniformity shared by E.M.S. protocols across the nation is to be any sign, what these medical directors are deciding can and can’t be done isn’t necessarily based on evidence. This lack of evidence is true for many medical interventions performed by E.M.S. professionals in general — it’s hard, if not unethical, to get informed consent for a research study from someone who’s unconscious or believes they’re about to die — and the debate is definitely needed. But there should be little question left about the efficacy of bystander-administered naloxone in reversing opiate overdoses: this stuff saves lives.

Similar to the debates surrounding bystander C.P.R. training in the 60s and 70s, many of these medical directors can’t imagine the public at large capable of performing such a high-risk medical procedure, or even doing it correctly. Well, it’s either that or death, and compared to the damage caused by chest compressions during CPR, naloxone seems little more than a nasal decongestant.

Good Ol’ Uncle Pharma

Of course, all of this talk about Uber for heroin overdoses is probably a bit on the wishful thinking side at this point as the makers of naloxone are currently under investigation for price-gouging. In Massachusetts, it was reported that as soon as the Governor declared opiate overdoses a public health emergency, the prices “skyrocketed.” According to State Attorney General Maury Healey, ““Our office has heard regularly from local law enforcement and public health workers worried about their ability to maintain supplies” — the moral equivalent of jacking up the price of gas as the hurricane evacuation begins.

It’s a shame, really, because if the makers and distributors of naloxone just only took a page from the playbook of the CPR/AED industrial-complex, they’d be able to get naloxone in every first aid kit ever made ever again.

Social Entrepreneurship At Its Purest

There is one last reason why an Uber-style dispatch system run at the community level is not only a good idea, but likely inevitable: These are the times we live in. In a world where everything and anything is becoming available on-demand, and orthodox 911 systems continue to be a victim of their own success, some person will have the compassion, the motivation and the common sense to meet demand where it’s highest, and prevent a lot of senseless death. Since Sept. 11, the United States government has been pumping trillions of dollars into any and every public safety and health agency to prepare for terrorist attacks and active shooters, “even though”, as Nicholas Kristof wrote in the New York Times, “[overdose] kills more people in America than guns or cars and claims more lives than murder or suicide.”

Perhaps we can do better. Maybe there’s an app for it. Or maybe we should just give naloxone to taxi drivers.

Whatever the solution, it’s long overdue.

J. Friesen, MPH, EMT-P
Founder / Director
Trek Medics International

Showing 5 comments
  • Dominic Haazen
    Reply

    Many thanks for sharing this. I am a bit torn by this suggestion. In 1990 I saw first-hand what Narcan could do. This was before I joined the British Columbia Ambulance Service (BCAS) and I was “riding 3rd”. I was then responsible for financing the BCAS so wanted to see what challenges the Service faced. The patient was picked up in a boat in the Coal Harbor Marina in Vancouver and was soaking wet since his friend had put him in the shower. The crew responding was an EMA2 (intermediate EMT crew, and Narcan was administered in the ER at St. Paul’s Hospital.
     
    Soon after taking over BCAS, I convinced the Medical Committee to introduce Narcan as a protocol for intermediate EMTs (it was already in the ALS “toolkit”). We called it “the Lazarus drug” …
     
    Both the first time and after I joined the Service, I also saw first-hand the violent reaction of the patient, who’s high had been unceremoniously interrupted. It had nothing to do with EMS and fire and police standing around (the first time was in a hospital), but solely due to “tripus interuptus”. I can’t imagine a different reaction if it happened to be a friend or stranger that administered Narcan. So one of my main concerns would be the safety of the person administering the drug. Who will pay if a “good Samaritan” is beat up by someone they try to help?
     
    My second concern is that ongoing monitoring is needed once Narcan is administered since it can wear off before the narcotic is out of the patient’s system. This is why our protocol called for immediate transport to hospital and continuous monitoring until the crew got there. Aside from the potential adverse health implications for the patient, who would be liable if the patient relapses and then dies?
     
    Finally, unless an IV is needed for other medications following the administration of Narcan (which is often the case), I can’t think of a reason why an EMS service could not use the nasal spray. It would just need to be built into the protocol. Of course, there may be a problem (and a higher chance of needle sticks) if the crew needs to insert an IV following the administration of Narcan, while the patient is combative …
     
    So while I am not opposed to this idea, I don’t think it is as simple as distributing an app, or even using an Epi-pen for that matter. Thanks again for sending this and encouraging the debate.

     
    Dominic S. Haazen
    Lead Health Policy Specialist
    World Bank
    Former Executive Director of the British Columbia Ambulance Service

  • Leaston hill
    Reply

    Bravo!!!!! I think letting drug users or friend family of drug users should be allowed to carry and purchase naltrexone to save the overdosing persons life. As a drug addict myself i would buy one to keep in my purse and id be willing to wear a medical id stating in case of emergency i have it on me to save my life. I have done drugs for years to take away the misery of my life but that doesnt mean im trying to kill myself. Also ive heard for years that my family doesnt want to find me dead one day. So i think they would be willing to learn how to administer it too. I remember on an episode of mtv true life about heroin addiction that one state actually let family members get a prescription for naltrexone to administer to addicts. Food for thought from an addict

  • SA
    Reply
  • R.N. (FF/EMT-P)
    Reply

    This seems great on the surface, but I can’t help thinking that it will be more of a reason for addicts to use heroin and other opiates in even larger doses, especially if you know you’re buddy can “save” you. The very real fear of Overdosing and dying or watching a friend OD has turned many an addict to rehab. “Narcan for everyone” seems like the best form of enabling if you ask me. We need to be more concerned with, and spend more resources on, treating the addictive behaviors and mental states of addicts before they get into these OD situations.

  • Read More
    Reply

    There medical inaccuracies presented here are surprising for someone with medical training.

    Uncle Pharma’s brother Uncle ED died due to lack of medical care. His buddies presumed he must have had a heroin OD but in fact he was suffering from hypoglycemia. Or hyperglycemia/DKA. Or a stroke. Or any condition that might be mistaken, particularly by a layperson- as a “overdose”.

    When a true overdose doesn’t respond to naloxone because it’s a poly pharmacy OD that includes non-opioids, EMTs or paramedics have medical training and can support airway and breathing.
    And for the behavioral emergency after receiving naloxone- persons with medical training can handle that better than laypersons.
    And for the medical problem like myocardial ischemia that may result from opioid withdrawal- again, EMS is better equipped to deal with it.
    Naloxone for laypersons is intended to get an easy to use antidote closer to the patient, but not to replace the EMS system.

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