When emergency responders find an overdose victim, not breathing, with the needle still in their arm, the last thing they think about is getting them clean.
Treatment usually ends once a patient is stable and in the hospital's emergency department, said Kim Woodward, Orange County's Emergency Management Services operations manager.
That's because emergency departments don't have the resources to help patients once they've addressed the immediate health issue, whether it's an addict or someone with mental illness, said Joseph Grover, EMS medical director and a member of UNC's Department of Emergency Medicine faculty.
“Traditionally, our main role in the emergency department has only been to triage," Grover said. "We triage those patients who need emergency admission to a psychiatric institution. For those who do not, we are pretty much left to discharge them and hope for the best that they are going to end up with the right resource.”
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Two new Orange County EMS programs starting this summer will offer people help before they even go the emergency room.
The state's inadequate mental and behavioral services have sent patients to emergency rooms for years, officials said. The problem was noted in a 2013 N.C. Department of Health and Human Services report that showed emergency rooms saw 17,000 more visits for mental health issues in 2012 than in 2010.
The opioid epidemic has magnified the stress, officials said. North Carolina is among 10 states — and the only one in the Southeast — with significant increases in opioid-related emergency room visits from July 2016 to September 2017, according to the U.S. Centers for Disease Control and Prevention.
A February 2018 state report shows the number of visits for opioid overdoses spiked last year to 5,746 from an average of 4,000 in the three prior years. There were 437 emergency department visits in January 2018 compared with 385 in January 2017.
In Orange County, EMS crews have taken over 135 patients with behavioral emergencies and multiple patients who overdosed on opioids to the hospital this year, Grover said. However, emergency rooms lack the resources to help those patients, leaving them faced with a long wait for a psychiatric consultation or to be admitted, he said.
In August, Orange County EMS crews will have another option: taking patients directly to the Freedom House Recovery Center in Chapel Hill for an evaluation and potentially treatment and support.
Deciding where to take a patient will follow a strict protocol, beginning with a paramedic's evaluation. Patients must meet specific standards, including being over 18, having no major health issues requiring immediate attention, and having no intentional overdose history, or suicidal or homicidal ideas.
If the patient agrees and an EMS supervisor signs off, the patient would be taken to Freedom House. The center has space for multiple clients to get short-term evaluations, Grover said.
It's a different way of patient care that requires a fair amount of training for EMS responders and Freedom House professionals, he said.
Orange County EMS crews also are thinking differently about how to help addicts get clean.
Starting July 1, they will give clean needles, naloxone, and information about treatment options to overdose patients who refuse help and their friends and families.
EMS crews across the state use naloxone about 45 times a day to reverse opioid overdoses, Grover said. Last year, they used naloxone 16,037 times — an 89 percent increase since 2011 — to revive patients who overdosed.
But that doesn't tell the full story.
“If a patient has normal respirations and is awake, even though they overdosed on an opiate, they would never receive naloxone," Grover said. "These numbers really do undervalue the total number of overdoses of opiates in our community and nationwide.”
The problem prompted North Carolina last year to launch its Opioid Action Plan aimed at stopping the spread of bloodborne diseases, like HIV and hepatitis; reducing the oversupply of prescription opioids and drug abuse; and boosting public awareness and services.
While Orange County has less of a problem, Woodward said, naloxone use has increased since 2013, when EMS responders reversed 34 overdoses. In 2017, they used naloxone 80 times, and so far this year, they have used it 32 times, she said. Local law enforcement has saved another 33 patients who overdosed since 2015, she said.
Not every patient makes it.
State data shows 15 Orange County residents died from heroin overdoses between 2010 and 2017, and another 10 died in the last two years — the most so far — after overdosing on fentanyl and fentanyl-like drugs.
Harder to help
While Orange County EMS responders have carried naloxone for 30 years, powerful, synthetic opioids like fentanyl are making it harder to revive patients and get them breathing again, Woodward said.
Still, some addicts refuse to get help, and officials have said others flirt with death to get as high as they can, because they trust that a friend with naloxone will bring them back.
Unintended consequences aside, Woodward said it's a good thing that naloxone is available now to anyone without a prescription.
“In the last two months, we had residents give [patients] naloxone prior to law enforcement, [and it still] required law enforcement’s naloxone, the residents’ naloxone and EMS naloxone to get a response from these patients,” she said.
The state's first fire- and EMS-based needle-exchange program was launched late last year in Havelock. There also are over two dozen groups and health departments with needle-exchange programs, including the Orange, Durham and Wake county health departments.
Needle exchanges also are the right thing to do, Woodward said. It makes the job safer for responders who recover drug needles, she said, and prevents blood-borne diseases that are booming again because of the opioid crisis.
"The next reason — and this is coming from the [nonprofit] Harm Reduction Coalition — is that in communities who engage in needle-exchange programs, the people that are addicted to the opioids are five times more likely to reach out for rehab resources," Woodward said. "It's not an enabling process. It's really a doorway to building trust in that community."