The United States is in the midst of an epidemic of addiction to opioids and fentanyl. On 18 September 2018, DomPrep hosted a roundtable discussion at MedStar NRH Rehabilitation Network in Washington, DC, to discuss this threat. The three-hour conversation led by Craig DeAtley, PA-C, emergency manager for MedStar System, examined the extent of the problem, including the harmful risks to operational responders – people who are in physical contact with people as part of their daily work – from fentanyl/opioid exposure. Key discussion points summarized in this article included: impacts on public safety, data collection, best practices, personnel protection, and whole community collaboration.
According to the Centers for Disease Control and Prevention, overdose deaths in the United States totaled more than 72,000 in 2017, with almost 30,000 of these deaths being attributed to fentanyl and fentanyl analogs (synthetic opioids). This statistic is almost 10,000 more deaths than in 2016 and more than three times higher than in 2002. Despite the significant number of deaths, the impact of the opioid crisis is far greater in volume than confirmed data reflect. The data sometimes differ between jurisdictions because the primary and secondary causes of death are recorded differently – for example, a responder may describe the cause in the narrative portion of a patient care report rather than using a more traceable drop down menu. Other discrepancies between jurisdictions may occur because of difficulty in navigating the data-sharing process.
In addition to fatalities, there are even larger numbers of nonfatal overdoses each year. With a crisis that is stigmatized, the “court of public opinion” judges government agencies based on these statistics and numbers of deaths. This then leads to policies being created more to calm public concern than solve the problem.
Knowing what data to collect and how to use that data constructively is necessary but challenging. One significant barrier for policymakers in obtaining a complete picture of the crisis is the reporting within disciplinary siloes. Each agency has its own objectives and agendas, so these internal priorities drive decisions about which data are gathered. For example, effectiveness of law enforcement is often ranked based on homicides and violent crime rates. This draws the focus in the law enforcement arena away from drug-related deaths, with limited resources available for nonviolent drug offenses. In addition, the opioid crisis has had a different impact on rural versus urban environments as well.
To create a dashboard, Maryland government collects three levels of data – real-time data, impact indicators, and research data. However, the process is not simple. Each agency has a responsibility to their agency’s perspective, but the totality of data and solutions cannot be found within any single agency. To better identify and interpret data, multidiscipline perspectives and discussions are required to solve complex problems.
Organizations such as the Police Executive Research Forum (PERF) also provide strong national leadership, necessary public debate, as well as valuable research and policy development for critical issues and concerns related to law enforcement. However, law enforcement topics certainly go well beyond the scope of law enforcement agencies.
Multidiscipline discussions like the DomPrep roundtable expose gaps that otherwise may go unrecognized when only addressed within disciplinary or jurisdictional siloes. The opioid crisis is just one example. At the federal level, one participant stated that government facilities experience minimal narcotic-related problems. As a result, those tasked with protecting those facilities may not consider opioids a significant threat within their daily operations. However, their counterparts at the local level have different firsthand experiences. Federal agencies see a snapshot of the problem, but do not see the daily overdoses at the street level. For example, SWAT teams and canine officers who enter scenes are at greater risk for exposure to dangerous substances, so education about such risks is particularly important for them.
From a laboratory perspective, only a portion of the drugs being confiscated are actually tested, but forensics are looking to expand surveillance on drugs beyond those that have prosecutions associated with them. However, testing can take up to 45 days depending on the priority of each test. With drugs such as synthetic cannabinoids (K2/Spice) competing with other testing concerns, comprehensive and field testing by trained responders is not generally yet available.
From an emergency department (ED) perspective, prescription drug monitoring programs help ensure that prescribed drugs are available to ED personnel. The “gold standard” in emergency care keeps prescriptions to three days or less to minimize abuse and shift the culture away from opioid overuse. In some Washington, DC, hospitals, high-risk patients (those who have overdosed in the past) are offered a naloxone-dispensing program and a video of how to use it. However, many hospitals across the country do not have funding for such programs.
Homeless and transient populations present exposure threats that law enforcement officers may not consider when focusing on dangers associated with criminal violent activity. Despite interagency discussion groups being formed, more action is needed following these discussions. Talking about policy and analysis is great, but to fix the problem, individual people must be considered – for example, where they are located, where they are getting their sources, and which conditions are prevalent. Discussions need to be turned into actionable data, with widespread multi-disciplinary efforts being sustained in order to have a significant impact.
Data simply for the sake of data does not solve the crisis. The federal government has a National Response Framework, but does not adequately coordinate federal efforts. A key problem is operational coordination, knowing where funding and resources are. For example, when the federal government simply shuts down a drug-dispensing facility without considering the consequences, thousands of patients receiving medication are suddenly affected. In such cases, the solution is often to simply spend more money. However, there needs to be clear coordinated plans and operations.
To develop best practices, jurisdictions must understand how to interpret the data collected and consider data that may be missing. Pertinent data must identify the different elements of the problem, addressing the front end of dealing and using as well as the back end of treatment and recovery. Roundtable participants described different ways in which the following four jurisdictions manage the opioid crisis within their areas.
In Massachusetts, agencies focus on the opioid dealers rather than the end users. One program employs station lock boxes for residents to dispose their medications safely. Another program involves street interdiction of suspected abusers to get them into programs and work with hospitals to follow up with those released. The programs resulted in dramatic reductions in repeat offenders.
In Maryland, opioid prescriptions are down because of programs to minimize over-prescribing. State agencies offer workshops, which are similar to TedTalks, through Project Purple. These workshops are collaborative with operational personnel around the state. In addition, county correctional facilities have treatment programs to help integrate incarcerated people back into society.
In Washington, DC, some hospitals are implementing a pilot program with two phases: (1) a screening, prevention, and referral program; and (2) enrollment in clinics and programs. One concern that is currently being addressed, though, is the need for more facilities and resources to handle the expected volume of referrals and enrollments. DC shelters, which used to have a low tolerance for drugs within their walls, have needed to shift to address inevitable concerns as the opioid crisis expanded. Shelters now are equipped with naloxone kits.
Seattle, Washington, is planning to implement a controversial plan for “supervised injection sites,” where drug users can inject illicit drugs under the watch of nurses equipped with naloxone. The argument for such spaces is to allow people to take drugs in a safer more hygienic area than on the streets. The argument against such spaces is that it will only enable users and exacerbate the problem. Whether this becomes a best practice or a practice that compounds the problem is yet to be seen.
Various steps are being taken to protect personnel in law enforcement and beyond. However, some protection efforts may hinder investigations. For example, to prosecute many cases, testing must be performed in the field, which offers less protection to officers than testing in laboratories equipped with additional safeguards. Some agencies are re-ranking their protocols, having their officers not touch substances at all before sending them to laboratories, but others still handle testing them in the field. Agencies are working on determining how to handle probable cause without field-testing methods. To ensure safety, some agencies train their officers to the hazmat operations level and issue personal protective equipment (PPE) such as goggles, gloves, and masks. However, protective security officers who are contracted may have different protective measures when they are responsible for their own PPE.
For all responders, education is needed for learning how to react and handle situations. The law enforcement environment is dynamic, so personnel in an active scenario may not have the time to put on the proper PPE before engaging with potential threats. Despite a recent spike in carfentanyl and the current emerging problem of K2, some law enforcement chiefs do not think providing their officers with naloxone is necessary. However, others see the benefits of such distribution for officer safety reasons and because officers are often the first on scene before emergency medical units. For example, Virginia’s Revive! program addresses the public safety issue and factors for law enforcement using the antidote.
Naloxone & Burden on Responders
The use of naloxone to address the opioid crisis is still evolving. Some EMS agencies have reduced the use of naloxone by titrating to maintain adequate respirations, but not necessarily to wake up patients. However, without being able to provide statistics depicting who would have died without naloxone administration, it may be difficult for agencies to justify keeping the opiate antidote in stock. Some people question whether agencies are actually doing something or are keeping it on hand more for show. The Commonwealth of Virginia, though, attributes naloxone as a key variable in saving more than 26,000 lives.
Even with reductions in some areas, numerous calls for overdoses – including repeat calls to the same patients – has negative mental health effects on responders, which can lead to “compassion fatigue.” When burnout occurs, responders may lose some quality control or may treat patients based on assumptions. In addition, the psychological wear and tear could lead to response personnel abusing drugs encountered during operations – for example, EMS medications and law enforcement confiscations. It is critical to recognize the potential problem to put a system in place to combat drug and alcohol use of responders who are heading toward trouble, which in turn could lead to increases in workplace violence. Treatment after a crisis should not be optional, as counseling saves lives following traumatic stress. However, keep in mind that simply treating symptoms does not address the disease.
The Value of Working Across Disciplines
The opioid crisis is too large for any one agency or organization to tackle alone, especially considering that fire, EMS, law enforcement, and other service-based professions are declining. Although politics and funding are common obstacles, the need to take action is high. The stigma of this topic is also high, so buy-in is needed from investors and educators. Messaging must also be consistent to avoid confusion, especially for vulnerable populations such as children.
Even many suggestions for addressing the crisis do not address the underlying problem – for example, the concept of supervised injection sites remains controversial. In other cases, some people simply do not want help and treatment. Needle exchange programs have reduced hepatitis cases, but do not address the problem. Those inflicted with drug addiction may not feel comfortable having frank discussions with law enforcement officers, but breakthroughs could be made with health personnel under HIPPA guideline protections.
Open communication is key. In some jurisdictions, law enforcement is shifting to programs that help in ways other than arrest, which in turn build trust in law enforcement agencies. By identifying obstacles and implementing best practices, communities can better address networked problems, such as the opioid crisis. Lessons learned from other networked issues could also be applied.
There is a significant need to break down the disciplinary walls because there are too many different communities affected. Without national direction and leadership, service levels vary from community to community. For example, some jails and correctional facilities offer addiction and recovery services during incarceration, whereas others have made no advancement in this effort. With no single agency oversight, more challenges and vulnerabilities are created. For example, the same government agencies that say they want to help those affected by addiction refuse to hire these people. Thus, they remain stigmatized. The disease of addiction leads to criminal records, which lead to the inability to obtain jobs. The problem is self-perpetuating.
In addition to breaking down disciplinary walls, hierarchical walls need to be understood. Historically, the local role is to design and execute, the state role is to manage, and the federal role is to support. Unrealistic expectations that contradict these roles are catalysts for failure.
Media outlets plays another big role in the stigma surrounding drug addiction. Reports focus more on situations rather than circumstances. They have to be integral partners to report accurately on the problems as well as the successes. Also, police departments should communicate with media to promote community-policing suggestions and collectively address problems. The “us versus them” approach is counterproductive.
Legislators and emergency managers are well positioned, yet not necessarily motivated, to drive situational awareness. Legislators could introduce global programs such as drug awareness in schools K-12. In fact, the U.S. Department of Health and Human Services developed a “5-Point Strategy To Combat the Opioid Crisis” and the Senate just passed the “Opioid Crisis Response Act of 2018” with high expectations. Emergency managers could serve as coordinators and facilitators, albeit some have argued that they should not be involved.
Hospitals and other receiving facilities balance many complex decisions. Most addiction issues have a primary need for behavioral health. However, behavioral health units in hospitals have limited beds and staff. In-patient rehabilitation facilities are plagued with long waitlists. Other empty hospital beds often do not have the psychiatric and behavioral services required to assist these types of patients. In addition, there is a growing need for psychiatry and behavioral health professions, but the supply is not meeting the demand.
The nation cannot afford to ignore this problem. When people come together to examine data in a meaningful way, a solution(s) can be found. The opioid crisis needs to be a high priority for a number of professions (not just one) and requires funding to support commonly agreed upon solutions. With more than 100,000 American fatalities from drug abuse over the past few years, the problem is even bigger than many people realize. To address the problem, data needs to be connected with actionable solutions.
The 14 subject matter experts at the September 18 roundtable discussion leave DomPrep readers with the following recommendations (in no particular order):
- Be more inclusive in community problem-solving discussions. Invite members from all the categories listed in Figure 1.
- Consider a spending shift. Rather than spending significant amounts of money on the cure, start investing in prevention.
- Recognize demographic changes. Problems that were traditionally found in urban settings have shifted to rural and suburban spaces.
- Mitigate responder addictions. Agencies need to inventory and monitor EMS control medications and ensure that all LE confiscations are being reported.
- Address circumstances without glorifying them. Increase awareness of the problem by being transparent and staying focused on moving toward a solution.
- Coordinate between correctional institutions and addiction centers. Through education and addiction counseling, programs can be created to reduce recidivism.
- Define community service boards’ role in solving the opioid crisis. Community stakeholders need to recognize and invest their time and resources into it.
- Establish more out-patient services and treatment programs. Treatment and rehabilitation services reduce the need for more costly in-patient care.
- Create opioid intervention teams. Actions should be taken when warning signs appear, before a person is in crisis.
- Examine data from both police and EMS 911 calls. Research and studies could help identify vulnerable populations that would benefit from targeted efforts.
- Recruit recovering addicts or addicts who have not yet recovered into the planning response.
- Include champions of the cause, such as celebrities, to inspire the program and publicly promote it.
- Structure the mental and behavioral health role. Clinics, personnel, and funding are all required to support these services.
|Network of Communities Affected by the Opioid Crisis|
|Faith-based community||Emergency medical services||Fire/rescue services|
|Public health agencies||Media outlets||Legislators|
|Facilitators||Department of corrections||Private sector|
|Businesses||Emergency managers||Addiction centers|
|Pharmaceutical companies||Schools||Behavioral services|
|Local law enforcement agencies||State law enforcement agencies||Federal law enforcement agencies|
The opioid crisis is a slow-rolling disaster that has been building for years. As one roundtable participant said, “The only difference between a public health emergency and a disaster is time.” The time to act is overdue, but it is not too late to reverse course. Lives depend on integrated, networked action by all community stakeholders. The recommendations shared by subject matter experts during the September roundtable discussion will help focus community resources and efforts on mitigating the opioid crisis rather than simply responding to it.
DomPrep would like to thank FLIR for sponsoring the 18 September 2018 roundtable discussion in Washington, DC, and MedStar NRH Rehabilitation Network for hosting the event. A special thanks also goes to Craig DeAtley, PA-C, and to all those who participated in the discussion, upon which this white paper is based. The following disciplines participated at the roundtable: hospital emergency room, fire and EMS, homeless services, local and federal law enforcement, forensic sciences, governors office Department of Homeland Security, emergency management, and the private sector. The participants who contributed to this important discussion include but are not limited to the following:
Craig DeAtley, PA-C, Emergency Manager, MedStar System
Myra Derbyshire, Project Coordinator, Opioid Operational Command Center (OOCC)
Jessica Milke, Science & Technology Manager, FLIR Detection Inc.
Sue Snider, Director of Consulting Services, G&H International Services, Inc., and former Executive Director, Northern Virginia Hospital Alliance
Clay Stamp, Executive Director, Opioid Operational Command Center (OOCC), Senior Emergency Management Advisor to the Governor, Chair of the Governor's Emergency Management Advisory Council
Lauren Wiesner, MD, Director of Emergency Preparedness, Attending Emergency Physician, MedStar Washington Hospital Center