Death Prevention: A Community Responsibility
Photos by Nigel Brunsdon
INTRODUCTION
In 2018, a total of 67,367 drug overdose deaths were recorded in the United States (CDC). Simultaneously, most people here have at least heard of Naloxone, if not seen it, been trained on it, or even used it. With these facts and years’ experience in emergency services behind him, Jason Friesen set out to build a bridge between Naloxone carriers and people experiencing overdoses. In doing so, his work saves lives through a strong network of people who are ready and willing to serve their communities. In the following Q&A, Friesen explores different sides of the issue, and outlines how his organization Trek Medics International has risen to the occasion in response.
Could you talk about safe injection work and the different problems that are happening/different programs in response?
Absolutely. I’m a paramedic by training. I have worked for years in San Diego right along the border. In my time working the border, we responded to a lot of overdoses. This was before there was an “opioid epidemic.” One thing that was evident was that people were waiting way too long to call 911 to report an overdose. It was because they were afraid of prosecution, guilt by association if you will. So people were waiting way too long and it was a shame, because we had naloxone on the ambulance.
As things got worse in this country, it became evident that they needed some kind of protections so people weren’t afraid to call 911. They passed a bunch of what are called Good Samaritan Laws-- amnesty, so to speak. It was intended to tell the public “If you witness an overdose and call 911, we won’t arrest you.” For many people, that was great. For some states like New York, these protections had teeth and people felt very comfortable calling 911. In other states, people just did not take it seriously. They would think “Yeah. I am a good Samaritan today, but I am a junkie tomorrow, right?” Then on top of that, local governments started distributing naloxone through public health departments and through harm reduction organizations primarily, but in many ways they were getting naloxone onto the streets so that lay persons had it.
That was great, but there was a problem with that too. You could go to a naloxone training program and they would teach you how to use Naloxone and how to identify signs and symptoms of an opioid overdose. They’d give it to you and you’d walk out the door and that was the end of it. The problem was, well, what if I’m out and I witness an overdose and I don’t have my naloxone? Who can I call for help? The answer was inevitably 911, and if you’re in one of these states where Good Samaritan was not taken very seriously, the response would be “No, I don’t want to call 911, who else can I call?” There wasn’t much of an answer to that.
The answer was “PLEASE CALL 911.” I was thinking to myself, “well I just went to a class where there are 25 other people. I know they’ve all got naloxone and they are all in the area-- how do I call them?” There was no formal, reliable, established way to call for naloxone when you needed it. So, that’s where we thought there could be a real opportunity for us to get involved. My organization built this little dispatching software called Beacon; it sends out alerts by text message or by mobile app to responders in the community who have some kind of training and can be alerted to get on scene quickly. We wrote a blog post called “UberDose: Uber for Overdoses.” Forgive the name of it, but that was kind of the spirit. This was back in 2014 or so, and as someone pointed out, the reception was a lot of standing ovations as people slowly backed away. “Great idea, go get ‘em and let us know how it goes.” We didn’t get anywhere with it, until finally we got some real funding for it and we were able to start going out and not only asking organizations if they’d be interested in doing this program but offering to help them fund it too.
One of the first programs we launched was in rural Puerto Rico, where there wasn’t a question of whether or not to call 911-- if you call 911 and the ambulance is 45 min away, that’s not going to work for an overdose. That’s not going to save any lives, so we were working with a group of volunteer firefighters and EMTs and Search and Rescue teams: community responders. They had naloxone, so we worked with them to set this program up. That was a rural program, so volume was pretty low. There was not a high incidence of opioid overdose.
The second program we started was in Hartford, CT. It is in a community called Frog Hollow, which is predominantly African American and POC. We partnered with an organization called the Greater Hartford Harm Reduction Coalition. They had 15 street outreach workers on the streets every day, working with people with opioid use disorder. They’re giving out clean syringes, fentanyl testing strips, safe sex kits, and literature, and offering social services (ex: Narcotics Anonymous meetings). They’re running the full gamut of harm reduction interventions. We said to them, “What do you think about this program?” They said, “This sounds like a no-brainer!”
So, we got the program going. We trained their 15 street outreach workers how to receive alerts and respond to them, and we worked with the office manager and some other office staff to be dispatchers. As it turns out, the office manager’s father and uncle were both firefighters, so she grew up with the radio scanner running in the background all her life. She knew what it was to listen to the radio scanner, and that’s the way the program works. They started a new program called “Don’t run, call 911,” and they respond to overdoses in two ways: one, they listen to the radio scanner and when they hear Hartford fire department go out for an overdose, they’ll send an alert through our Beacon software to their street outreach workers. Their average response time was less than five minutes to get on the scene. The second way is that, because again there are people who don’t want to call 911, they say, “call us, when you call us we will dispatch our responders. Then, we’re also going to call 911, because 911 is the established authority and the most guaranteed way to get help when you need it.” They do not want to circumvent 911. They’re not trying to undermine 911, they’re trying to augment it. They do not want to be on the hook if they send an alert and nobody shows up. So, when someone calls them to report an overdose, they dispatch their responders while they also call 911 on behalf of the caller. That way, they get one of the street outreach workers on scene, 911 shows up, and in many cases it is very helpful and reassuring for the victim and the witness because the street outreach workers are familiar faces. These are people that they know and have a relationship with, whereas when police and fire or EMS show up, there’s often not a relationship there. Those may not be familiar faces, and in some cases they may not even be seen on both sides of the equation as friendly faces. In turn, this is how GHHRC augments the 911 system.
There is another big value add as well. If you look at it from a 911 perspective, after the overdose has been reversed, police, fire, and EMS have 3 options: take the patient to the hospital, take them to jail, or put them back out on the street. None of those options are doing anything to address the chronic issue of opioid use disorder, whereas when you have the street outreach workers who are part of a harm reduction organization, they can offer things that legally the ambulance cannot do, such as referrals to support services, mental health and substance abuse counseling. By law, EMS can only transport patients to an emergency department. I know there are pilot programs that are trying to change that, but generally speaking the law of the land is that 911 services can only transport patients to the emergency department.
When I was a paramedic, we often thought, “What this person really needs is not available. We cannot offer it to them. The best we can do is take them to the hospital and hope that the hospital has some kind of program to intervene and get them the assistance they need to stop this cycle of overdose and resuscitation.” The more times someone overdoses, the more damage that does to their brain -- assuming we get there in time to save them. No oxygen means that your brain cells are dying, so we want to stop that, but as a paramedic you just don’t have those options. Having the harm reduction organization involved is really expanding this response. So far, we’ve been doing this program where overdoses are reported and responders are dispatched to the scene. If they get there before EMS, they reverse the overdose. If they get there after EMS, then they’re a value-add. They are a resource that EMS can’t offer. What we are trying to do now is expand it.
Because of COVID, state and even federal agencies have dropped or loosened regulations on telehealth visits across the country. Because of this, we’re trying to set up programs where after the overdose has been reversed, the street outreach worker would be able to set up an on scene telehealth visit with the doctor who could then prescribe them medication-assisted treatment (MAT) like methadone, suboxone, buprenorphine. That would close the loop, so to speak. We have prevented death. Now, we want to prevent that from happening again so it’s not just a cycle of overdose, resuscitation, overdose, resuscitation. I’m very optimistic that by summer, or at the latest by the end of this year, we will have programs in place where they’re not only carrying naloxone, but they are setting up telehealth visits with doctors who can provide methadone and medicated assisted treatment.
Chicago Recovery Alliance naloxone preparation for distribution
Let’s talk about numbers! What is the percent of cases you receive that go to hospital or not, and why do you think that is?
I can only answer for my personal experience on that. When I was on the ambulance, I think at least 50% of the overdoses that we resuscitated signed an AMA and said they did not want to go to the hospital. That’s because you give somebody naloxone, you effectively send them into withdrawals and they get dopesick. The only thing they’re thinking about right now is fending off the dope sick. So, they’re looking to go back and get high again. That’s not gonna happen in the emergency department.
Legally, they are A&O (alert and oriented) x4. Because they can answer those questions, they’re alert and oriented times three, then taking them to the hospital would be kidnapping. The conversation becomes “Okay, just sign the AMA here and we will let you go. There’s nothing else we can do about it.” Once they are A&O x3, they don’t need to go to the hospital. Oftentimes, you’re bringing people into the emergency department who are taking up beds and who did not need to be there. We knew what the problem was: they have an addiction and addictions aren’t necessarily going to be resolved or cured in the emergency department, so they are kinda just taking up space in a certain sense. As a result, we had a very large number/proportion of overdoses who would sign the AMA and go back on their own.
I was on the ambulance 2005-2010. This was already true back before fentanyl. Now, with fentanyl, it’s an even bigger concern of what’s going on out there. We need more resilience in the community to handle these types of overdoses because waiting until 911 gets called is not working. I was reading an article about somewhere in a tiny town in West Virginia (and this was a couple years ago), population 25,000 or something. They had something like 26 overdoses in 24 hours. If you think about a community of ~25,000 people, they might have one ambulance. They probably don’t have a hospital, so that means the ambulances will have to travel some distance to transport patients. If you have more than one overdose per hour, you are overwhelming the local overdose response system, not even counting any of the other day-to-day emergencies that might be happening. Strengthening the resilience of the community to detect and respond to overdoses as an augment or an extension of the formal 911 system is absolutely essential these days.
When tax revenues go down, as they are due to COVID, the first place they cut the budget is first responders: police, fire, and EMS. Fentanyl is making things worse, and budgets are forcing staff reductions. The police don’t have substance abuse and mental health training. They don’t have addiction counseling training, nor should they. They are law enforcement. They’re not social workers. What these people need are social workers; they need people with specialized skills. These programs we’ve got going on now, we hope are seeds that will sprout and grow and really begin to strengthen the capacity of the communities across the country to deal with the opioid problem. With Fentanyl, the problem is not going away any time soon.
One of our partners is Mark Jenkins, the executive director of the Greater Hartford Harm Reduction Coalition. I asked him the question, “Fentanyl is everywhere. What’s the solution?” He said, “More Heroin!,” with the point being that because fentanyl is so deadly, it’s so strong, so potent, and from a drug dealer’s perspective it’s good business. The history of drug prohibition in the US is very simple: you outlaw one drug, they make something more potent and stronger. It’s this arms race. You can outlaw fentanyl all you want, but the FDA can’t keep up with the rate at which they’re changing the molecular structure of these synthetic psychoactive substances. It’s just impossible, so I think that’s why we are seeing what we saw in Portland, OR this past election. The war on drugs has pretty much been a failure, things are only getting worse, we’re spending more and more money, not getting any results, and what do we do? Do you just keep upping the ante? Synthetic chemical manufacturers are going to outwit you every time. Let’s strengthen the community and stop overwhelming our limited formal responders with all sorts of things.
I remember the summer in the immediate days following the George Floyd murder, there were two police chiefs (I believe one was from Dallas and the other was from Chicago) and they were saying the same exact thing. They said, “you have overwhelmed the police with responsibility. If there is homelessness, call the police. If there is drug abuse, call the police. If there is domestic abuse, call the police. If there’s a mental health crisis, call the police. That’s not what we do, but that’s what we’re expected to do and we’re overwhelmed.” I think that’s exactly right; police officers are not social workers, and there are lots of people in the community with training and experience who can handle these situations very well. However, the way the structure is set up, they are not going to be included the way they are needed. In this program, we are talking about medical emergencies. We’re not stepping out of our bounds here. We’re staying in our lane.
If you can give laypeople naloxone, then you should also be able to send them alerts when they’re needed. It has to be not one, but both. Otherwise, it’s just incidental. When you distribute naloxone without alerting people who have it when they are needed is basically saying, “If you happen to see an overdose, hopefully you have your naloxone with you.” That’s not a public health strategy. That’s a public health hope. By linking the two, we can give you naloxone and send you messages when you are needed. We aren’t talking about signing up boys scouts. We’re talking about signing up people with lived experience, who are familiar with the community they are serving. They’re comfortable in this environment; they have no problem being involved. We aren’t saying, “let’s just sign up any old person who wants to help.” We’re targeting the people who know what they’re doing. In Hartford and the other programs we have in Birmingham and in Indianapolis is, these people are already responding to overdoses. But they’re doing it in this uncoordinated, informal, ad hoc way where they are sending messages like, “Somebody’s overdosing, do you have naloxone? Oh no, you don’t?” It is a free for all! Our approach is to say, “Let’s formalize that, let’s bring some coordination and systemization to that and make sure that you’re not on a wild goose chase every time you need naloxone.”
Chicago Recovery Alliance safer smoking kit preparation for distribution
From a Public Health standpoint, could you talk about what background/education you think people need re: recognizing OD’s, etc, (apart from actually having the naloxone)?
It’s almost like all of the pieces are there, we just need to bring them together. You have public health departments all across the country doing naloxone training and distribution, which is phenomenal, and harm reduction organizations. The group we are working with in Indiana is called Overdose Lifeline. We were supposed to have started the program with them in mid 2020, but then they got a big grant from the state to be the naloxone training and distribution organization for the state of Indiana (which is a really good reason to delay a program). So they’re doing all of this naloxone training, the curriculum exists, and it is proven to work. You also have the formal 911 system, and everybody has mobile phones. We have all of these pieces. How do we bring them together and make it a coherent, formal strategy?
The way I see it, naloxone is so effective, you could eradicate fatal opioid overdoses. They do not have to happen. Of course, the one catch is the unwitnessed overdose. With technology, we’re not far away from resolving this. There’s a group in British Columbia called BRAVE. They are researching how to detect overdoses when no one is looking, when people are using alone. In my mind, that’s the missing link here to have a comprehensive strategy to eradicate fatal opioid overdose, but it’s totally possible. These people do not have to die. A lack of on-demand access to naloxone and centralized communications are getting in the way of things, so in my mind if all the pieces are there, it’s just a matter of bringing them together (and we’re working on this with our partners), putting together a tool kit-- a do it yourself toolkit for communities to set up their own opioid overdose response networks. We’re going to put out our first edition of that later in this year, but for me it’s all there. All the pieces are there, we just need to put them together. In my mind, what’s keeping them from being together is stigma. There’s still just so much stigma against persons with opioid use disorder. I was just reading an article in the Wall Street Journal two days ago that was talking about how bad the opioid problem is among construction workers. They estimate that one in five construction workers are addicted to opioids. This is not your under-the-highway-overpass, dark corner problem. These are the people going out and building America. So, let’s get over this stigma! Fentanyl is out there and only making it worse. I think that if you look, everything is there to move ahead. Stigma is just still getting in the way.
For More Information
Please reach out to Jason if you are interested in partnering, think your organization could benefit, or if you’d like to learn more about setting up this program in your community.
Jason Friesen
Email: jfriesen@trekmedics.org
Website: https://www.trekmedics.org/
