Driving an Ambulance in the Age of Narcan
hazlitt.net
hazlitt.net
Regarding the EMTs yelling, could they have been trying to clear people away, to be confident the scene safe for themselves (one of the first steps I've heard some first responders have), or to get access to the patient? Or maybe the opioid epidemic is wearing heavily on them, though they keep doing their job?
(I looked into EMT-B training a while ago, and it's a really difficult, scary, and severely underpaid job. I probably couldn't do that job for very long, emotionally, even if I could afford it financially. Ironically, the compensation for being an EMT, helping people, seems unfortunately backwards, by societal value, with a lot of software jobs I'm considering right now.)
An example: in Georgia, just picking a random county, teachers make around 20,000~60,000$ a year, leaning more toward the lower end. It seems that importance to society and salary are negatively correlated...
You can look them up here: http://open.georgia.gov/openga/salaryTravel/list
Also, a somewhat-related video I watched recently (a fantastic channel, by the way:) https://youtube.com/watch?v=VOAaFyv_shY
It toils be interesting to see if these problems were related. Eg invest heavily in education and teachers, and would the demands on EMTs fall?
They can somehow hire enough even at this salaries, and appear to think that's enough. Quality of education is hard to measure, and it takes very long to measure, much longer than a typical election term.
See also:
- Truckers
- Farmers (though some do pretty well) and farmhands
- Janitors
- Babysitters
- Teaching assistants
- Receptionists
There are two drugs I carried that had an instand life saving effect: Narcan and D50 (50% dextrose solution). Somebody with low blood sugar will often present with a radically altered level of response, if they are even conscious. Start an IV, push D50 and within seconds, they sit up and talk to you as if nothing is out of the ordinary. Be advised, it is relatively short lived and the patient needs to consume some complex carbohydrates or protien to sustain their blood sugar levels.
Yes, it is terribly under paid, but there is great job security. I worked tech/research most of my adult life, but market and government priority changes made it really tough to work toward a retirement. It seems every few years, either the project was cancelled, or the line was shut down.
As an EMT/firefighter, my minimum week was 56 hours (by federal law due to the standard 33% duty cycle of a 24 hour, 7 day week) and sometimes nearly double that. Unfortunately, only the firstw 40 hours, (at just above minimuim wage) applied toward retirement benefits where I worked.
On what is so hard with putting the cell phone on speaker and setting it down next to the downed person? Your are still on the line but have your hands free?
Aside from that: thanks for helping a fellow human and congratulations on keeping it together under high pressure.
is because it creates adequate air exchange to keep somebody alive until Narcan is administered.
I had forgotten to ask if there is any legality or cover-your-ass issues there, say if they infect the person or the Narcan ends up being something else that kills the person. I imagine they probably thought this person is going to die and decided to do it anyway.
In my town, an ambulance was involved in a traffic collision. The ambulance was not moving, and was still found to be at fault. Go figure.
Aside: It took me far too long to figure out that “paracetamol” is called “acetaminophen” in the USA. You would think that at least the generic names would be universal.
Their over the counter paracetamol are usually 1000mg per tablet whereas ours are limited to 500mg per tablet.
In an average dose, thy only take one, whereas we take two.
To make up for it, it’s very difficult to buy painkillers in the UK in quantities of more than about 8, while Costco sells jars of literally hundreds of tablets.
This is a useful suicide prevention measure and we've seen deaths by suicide from paracetamol reducing a bit as a result.
IV Morphine wasn't touching it. Then she came in. An older lady and told me it was going to be alright. She pulled a syringe up and I was blubbering in pain, crying and explaining to her I would do anything to make the pain stop and how I
I quit talking. I quit crying. I was comfortable. Happy. Content. The world was fine.
It was Dilaudid.
When I was released it occurred to me that this is how people feel when using the drugs.
The best explanation I've ever heard is from a reddit comment:
Are you still doing well?
I must say thank you to you for authoring something that spoke to me logically and perfectly encapsulated the feeling I had.
I shared it with my teenage daughter and will share it with my other children when they become older teenagers.
You have made an impact.
https://www.reddit.com/r/IAmA/comments/wnj2d/iama_heroin_add...
I have had them 3 times since. The last time was after the opioid crisis hit and I was petrified I wouldn't be able to find relief. The local hospital no longer provides anything more than morphine in the ER; you have to be admitted. I was admitted and no issues getting the shot.
tl;dr: kidney stones suck. When we say that they hurt more than $terribad_injury, that is not hyperbole.
I am lucky to have a personality type that can easily externalize addiction. Basically for me it is like flipping a switch, or confining the feelings to certain contexts.
Even so, I can easily see how people do get addicted beyond their control, so I would never say it is 'easy' to 'just stop'.
Edit: a nurse friend came to visit after surgery and said: "oh, they gave you the good stuff." I still wasn't impressed.
His take was less sympathetic (paraphrasing): "i thought i would be helping society, not endlessly cleaning up after its recurring mess-making."
I know a few people in first response fields (eg, fire, emergency med, police) and this is a common view, albeit not often leading them to quit their jobs.
Since there is seemingly no political will to prevent and mitigate drug epidemics, the issue rolls downhill to emergency workers.
Coworkers were the hardest part, not just that they were jaded, but they actively viewed coworkers that did not ascribe to their jaded worldview as the enemy.
It’s fast and potent, but only lasts a few minutes. For a really bad OD, you might go through several doses.
Where I am Narcan is $50+ per dose, a small price to save a life but kinda crazy when you meet the same patients again and again.
IV push is the best, though SQ and IM are pretty good. IM and SQ are slow acting. You have to slowly bring the patient up. The important thing is to titrate dosage to rate and depth of breathing and slowly bring the patient up. If you push a large dose and suddenly rip the patient out of their warm, fuzzy cloud, into a world of hurt, they will often come up swinging.
You can breathe for a patient with artificial respiration for as long as needed, there is no rush to slam the Narcan in quickly. In fact, the protocols I ran under said nothing about bringing an OD patient back to consciousness, only to ensure adequate air exchange.
Also, talk to the patient with soothing, caring tones. Even though they are not responding, they can still hear you, increasingly so as the Narcan takes effect.
I never had a patient swing at me after administering Narcan once learning technique from a master that had administered literally gallons of the stuff over his career.
Some of the more jaded EMTs will purposely slam an OD patient with Narcan to punish them for using. This is just wrong.
Now I could see it not working as well if they aren’t breathing since it will likely be distributed over a smaller surface area.
Preventing ODs is easy if you have a pure product of an exact known strength and an accurate scale, but these conditions aren't often true in the real world.
Addicts often dont do it since the test dosage is wasted and its extra injection. It becomes especially problematic when money is tight and you buy individual bubbles. But that is the inherent risk you take with street drugs and the care and effort you have to invest to not OD. Its like never sharing anything that goes into your veins. Neither an OD nor catching HIV or Hep-C are cases of just bad luck, they are the result of being reckless and skipping an important and necessary step.
As unfortunate as it is, but normally people who OD are those that no longer care if they do. There are freak exceptions of course, like tainted or mixed up batches where even a allergy test can kill you, but those arent happening regularly to individual users.
People are just risking it, and its a very human thing to do. You can see the same behavior with the failure to use protection during sex. People should know better, but some people still risk it and are then faced with the unfortunate consequences.
edit: Dont get me wrong this isnt about victim blaming, but not promoting the myth that these things are just out of peoples control like the weather. You can be a heroin addict without catching HIV or Hep-C and with a reasonable level of care you are not going to end up needing Narcan regularly. You already fucked up by becoming an addict, there is no reason to also OD or catch something. Telling people that these are just inherent side effects to being an addict just makes it easier on people to excuse themselves for forgoing basic safety precautions. ODing regularly is not something normal, even for an addict. Its the result of being reckless.
You can talk about what people should do all you want, it doesn’t change anything.
My main point is that, as a health problem, drug addiction doesn’t look that much different from a lot of other health problems. Personal choices greatly influence your chances of acquiring it, your ability to beat it, and your odds of dying from it. This applies to many other medical conditions as well, but attitudes toward addicts are vastly different.
And if you are an adult chances are you know better and those arent unfortunate sideffects either. Its precautions you have to take or risk the consequences. If you get a sunburn you are not a poor victim of the sun but an idiot who skipped the necessary step of using sunscreen. As a result you are risking skin cancer. If you dont brush your teeth you get caries. It is similarly absurd to say that caries are the unfortunate sideeffects of eating. They are the reaction to your behavior of not brushing your teeth as you should. Wearing your belt in a car isnt optional either just because you have airbags. The human race, and with them you, know of what precautions you have to take to avoid certain fates. The higher the risk, the less optional they become. You might spend a day in the sun without sunscreen, the increased risk of skincancer might however be minimal if its not a regular occurrence. The risk of sharing a needle or the same watercup during cooking however is just to grave for being stupid.
Your point seems to be, that people make mistakes. I agree, but they dont have to make mistakes where they know better. There is a difference between an "ups" mistake and just a stupidly destructive choice. Unless there is a severe lack of information they chose to do something stupid for little to none benefit. Thats no mistake, thats action and reaction where you decided to no longer care for the reaction. It is people making the unfortunate decision to go from seeing themselves as addicts to seeing themselves as junkies where the tomorrow doesnt matter anymore. Sure, you can argue that there are clean people with a similar disregard for their future. Just pick people who actually live after the motto "live fast and die young". Or who are eating or drinking themselves to death. They however are making a problematic choice too.
>My main point is that, as a health problem, drug addiction doesn’t look that much different from a lot of other health problems.
I kind of agree. However different to being an addict, being a junkie is a separate kind of problem stemming from deeply destructive choices you make consciously or unconsciously. You can become an addict, there arent however good reasons and rarely good excuses for becoming a junkie. I think a vastly different approach has to be taken to help addicts then ro help people who see themselves as junkies. If you are ODing regularly, changes are you should be treated as a suicide risk who lost your will of self preservation. I dont disagree that there are other people who dont use illegal drugs where the same applies, but thats why we as a society run mental health emergency wards. Differently put, if you are ODing regularly or no longer care that you share syringes you are having a second much more dangerous problem next to your deeply unhealthy habit of injecting unknown illegal drugcocktails to escape whatever. You are having a death wish.
But is it more expensive than what we're currently doing?
(USA viewpoint)
A person who eats poorly and doesn’t exercise can easily rack up millions of dollars in treatments for heart attacks and strokes. Yet they don’t seem to get anything like the same derision. Why?
I'll point out that people rescued from the brink of death are usually grateful for it, whereas these poor individuals, as noted in the article, often take a swing at their rescuers. I think that pretty much answers the question of whether they cost more than they contribute.
> A person who eats poorly and doesn’t exercise can easily rack up millions of dollars in treatments for heart attacks and strokes. Yet they don’t seem to get anything like the same derision. Why?
What makes you think people don't? Have you never observed someone or even yourself doing something unhealthy and thought glumly "Yep, eating/drinking this is going to put him/her/me one step closer to death by a lifestyle disease. Foolish of him/her/me."
What makes me think people don’t? The fact that you begrudge $50 to save an addict’s life, while your theoretical reaction to someone eating themselves to death is “foolish of him” seems to back that up pretty strongly.
To be frank, and I say this having addicted family members, sometimes it’s rather hard to care about a junkie.
I’m not exactly in the “fuck ‘em” camp, as a society we should have a better answer than leaving them a nuisance, but the idea that we should give up at a certain point is scarcely exotic.
Even if it's not as effective, maybe better than nothing. Until professionals arrive.
Separately: the title should be as written in the article: "magic eraser juice".
All speaking super generally, I guess.
In that situation, no matter how fulfilled you might be most of the time, you're at a super vulnerable low point. You feel damaged, like your resiliency is compromised.
Then you take drugs, prescribed or not, while at that low point. Many substances can pattern compulsive, addictive behavior after just weeks of use.
Now you're regularly under the influence of substances that actively oppose your returning to a fulfilled, resilient lifestyle. Not only do you have to recover from what happened to you, you have to do so while also ceasing use of chemicals that tend to pattern "just do this instead of expending effort on other things" behavior.
True, many people do bounce back. And there are many cases where drugs' side effects are worth it.
But the compounding effect is real, and handwaving it away with "happy, healthy people don't abuse drugs" is missing the point. What if someone takes those drugs during a moment when they're not happy or healthy?
Relatedly, there's a feedback effect here. You know what makes it really, really likely that you'll have an unfulfilled, hard life and feel like you're on the outside of society? Being around people who feel that way, which, as you point out, can often be heavy drug users. Now you have questionable behavior modelling (often starting young) as well as an emotionally unhealthy environment that makes it likely that you won't be resilient to the addictiveness of anything you try.
This applies equally to transgenerational drug abuse and to people who just live in/around communities with lots of drug abuse. If you spend a lot of time in a household/group/community like that, you're more likely to abuse drugs as well* .
This is part of the reason that radical decriminalization programs are great ideas: they focus on improving quality of life and everyday function of drug users with the goal of both reducing immediate likelihood of overdose etc., and of reducing the ingress rate--the number of new users of a given drug.
* This should not be taken as an assertion that drug abuse is the only, or even the primary, reason that people in many communities/groups/households are marginalized and feel unfulfilled, just that it is a single factor with a negative feedback cycle that can be broken.
Edits: grammar, clarified the idea of transient unhappiness.
You lump in cocaine as though all schedule 1 drugs are equal. You are having two different conversations. One of them is complicated (why are LSD, peyote, and marijuana classified with opioids? why are they enforced and punished so unevenly along race and class lines?)
Opioids are critical medical tools for pain management. The solution is to have doctors decide when it is necessary and to have pharmacists manage its distribution. Why this works is that doctors and pharmacists will be delicensed and possibly go to jail for this, and they generally have a highly asymmetric amount to lose from doing so.
Opioids are unlike any other drug. Look at national death statistics. Read this article. If they weren't so necessary for critical pain management and hospice care they'd be completely illegal.
Heroin is dangerous because of cuts like fentanyl and various contaminants, not because you just inherently die randomly after using it.
One could use heroin your whole life with no ill effects. In that way, it's comparable to coffee.
Addicts simply need cheap access to legal heroin to stop using. Only after that's taken care of can they start getting their life back on track and to be about something other than drugs.
Heroin and especially heroin addiction is extremely dangerous, many people die. However, it doesn't have the deteriorating affects that you describe. Heroin users that don't die and are able to get over their addiction have few long term health affects. It's not at all like smoking or alcohol.
It eats you from the inside because everything else in life fall away in importance of being high, and if manage to get clean you are essential on a tightrope the rest of your life and the temptation haunts you all the time. It ruins your ability to feel truly happy or fulfilled by anything besides heroin. You are a day or two away from the morgue the rest of your life.
The addiction cycle usually ends in a place where Hep, sepsis, and HIV are comorbidities. But the long term health effect is the addiction and brain structural changes. Just because it's mental health doesn't mean it's any less real than lung cancer or cirrhosis.
Users are currently resorting to crime to acquire their heroin because it's illegal, not because heroin inherently makes you evil.
That's not quite right. Heroin users definitely resort to crime to fund their addiction. They are not "evil" for being addicted, but they do become desperate. And if you're desperate, you're more likely to do "evil" things.
Most do not immediately resort to crime. Imagine you were addicted to some expensive substance. You'd likely try hard to keep whatever job you had to fund the addiction, then if that fails you'd pressure family to fund it. If family stops paying, then you'd sell whatever property you had. When that's over you may turn to illegal "jobs" such as prostitution or dealing drugs yourself. Only finally, as a last desperate resort, would you try to steal or commit other crimes.
Addiction is not "evil", but it results in desperation. When one is starving for bread, they're more likely push the boundaries of their morality to eat, maybe steal, and in extreme cases maybe worse. Desperation can make people do evil things.
If heroin was not illegal, and therefore not extremely expensive, users would not have to resort to crime to afford it.
Now imagine heroin was legalized and/or freely available: noone would bother to commit crimes, and would be able to start living a regular life since they don't have a single reason to exist anymore. One of their basic needs are taken care of.
It's amazing how quickly we've forgotten prohibition. When you make something illegal that there is a demand for, an illegal market pops up.
If heroin was legal, it's does not necessarily follow that it would be much less expensive. In states that have legalized marijuana, the price is roughly the same (and often more) than black markets.
> it's hard to afford daily heroin with a regular job without resorting to crime.
Regular jobs typically pay more than petty crime. The reason that heroin addicts resort to crime is not because their regular job doesn't pay enough, it's because they can't hold a regular job because they're addicted to heroin.
> Now imagine heroin was legalized and/or freely available: noone would bother to commit crimes, and would be able to start living a regular life
I'm not sure that many heroin addicts (legal or otherwise) can live a regular life.
> If heroin was legal, it's does not necessarily follow that it would be much less expensive. In states that have legalized marijuana, the price is roughly the same (and often more) than black markets.
Heroin is extremely cheap to manufacture, and it's of course also not patented anymore. There's no point to discussing this, really.
> Regular jobs typically pay more than petty crime. The reason that heroin addicts resort to crime is not because their regular job doesn't pay enough, it's because they can't hold a regular job because they're addicted to heroin.
This is partly true. It's a large topic. A heroin habit will take a lot of time, since you're doing a lot of waiting around for dealers. But it depends on the job, though. These days, Americans are very close to losing everything in the time of one or two paychecks. Add a heroin habit of hundreds of dollars a day on top of that, and you need something else.
> I'm not sure that many heroin addicts (legal or otherwise) can live a regular life.
I think far more people are using heroin and keeping a regular life than you realize.
All the ways heroin can kill you are direct consequences of its prohibition.
Most people die from heroin by overdosing (taking too much). Very often, this is a result of mixing heroin with other drugs and pushing the limits of what a human body can tolerate. If it were legalized and regulated, maybe some accidental overdosing could be prevented, but there would be plenty of deaths.
Heroin is pretty different from other drugs because it's pretty easy to die from it. It's nearly impossible to die from smoking marijuana. Even alcohol is safer if you're not driving a vehicle: you're far more likely to pass out before you get alcohol poisoning.
Heroin is significantly more dangerous. A slightly higher dose or a new formulation can easily kill you.
There's 2 groups of heroin overdoses.
1) Varying amounts of cut like fentanyl. Due to heroin being illegal, users have no way of knowing whether their drugs are pure, so it's hard to gauge the dose. The exact same dose can kill you if there's a little too much fentanyl.
2) Taking the same amount after e.g. rehab or tolerance break. Due to the way heroin tolerance works, after a while of not using it, your body will reset the tolerance. So you come out of rehab and of course you want to do heroin again, and many unfortunately start right at their old (extremely high) dosage.
Legalization would obviously help no. 1, but I also think it would prevent deaths due to no. 2, since users would not have to go through rehab until they're actually ready for it. When the system forces you to stop, most users will just immediately start again when they have the possibility.
First, you're assuming that legalizing heroin would result in a high quality pure product. Considering that heroin addicts are desparate for heroin, it's pretty likely that they would go to cheaper black market sources with the same quality problems we have today.
Second, legalizing heroin would dramatically normalize it, very likely resulting in many more people becoming addicted to it. Even if the danger of the drug decreased, it would almost certainly be offset by the large increase in new addicts.
In terms of saving lives, I don't see how legalizing heroin can help.
> First, you're assuming that legalizing heroin would result in a high quality pure product. Considering that heroin addicts are desparate for heroin, it's pretty likely that they would go to cheaper black market sources with the same quality problems we have today.
I don't feel like this is a genuine argument on your part. If it was available in an affordable, high-quality manner, very few people would continue to use dirty, cut and illegal versions.
I think legalizing it is a good start, but an ideal scenario are heroin treatment clinics like we see in Switzerland or Denmark. They are 100% free and obviously use pure drugs.
> Second, legalizing heroin would dramatically normalize it, very likely resulting in many more people becoming addicted to it. Even if the danger of the drug decreased, it would almost certainly be offset by the large increase in new addicts.
I don't think that everyone would start using heroin after it was legalized. Most people are still extremely afraid of it due to e.g. media characterisations. Even so, as I've already postulated, I don't think there's any inherent danger in using it, so it's really a moot point to be honest.
This was probably the main cause of overdose deaths before fentanyl came along. In one study 45% of the deceased also had a blood alcohol level, and 30% were on Benzodiazepines (one Swedish study had benzos present in 55% of fatal overdoses).
https://sci-hub.se/10.1080/09595239996743
>The majority of cases involved heroin in combination with other drugs: alcohol (40%), benzodiazepines (30%)and antidepressants (9%). In only a third of cases was morphine the sole drug detected.
https://sci-hub.se/10.1046/j.1360-0443.1996.911217652.x
>Fatalities involving only heroin appear to form a minority of overdose occasions, the presence of other drugs (primarily central nervous system depressants such as alcohol and benzodiazepines) being commonly detected at autopsy.
From what I’ve heard, most addicts prefer heroin to fentanyl, even though it’s less potent on a weight basis.
It's less risky then fentanyl most of the time.
Brompton cocktail: https://en.wikipedia.org/wiki/Brompton_cocktail#Variants
>Some specifications for variants of Brompton cocktail call for methadone, hydromorphone, diamorphine (heroin), or other strong opioids in the place of morphine.
Like others are saying, other powerful opioids are used instead.
A GP could also prescribe it no problems. Indeed there are a small number of people that get it prescribed if other drug treatments have failed.
Always follow the money.
So if following the money is the answer, why doesn't this happen?
Pain is a complex phenomena.
This has caused a lot of problems with pain treatment. We used to think heroin was okay, then we realised it was addictive. So we moved to other opioids thinking they weren't as addictive, but they are all about as addictive as morphine and diamorphine. We started reducing the quantities of the opioids and adding other meds like paracetamol / acetaminophen. This led to fucking stupid meds like coproxamol -- a mix of dextropropoxyphene (an opioid) and paracetamol. This opioid is very toxic, and it was killing many people in the UK until the licencing changed. And then we tried other meds like NSAIDs and etc. Some of them sort of work for some pain, some are very good for a specific type of pain. But they all have side effects.
We split pain up in different ways. We talk about chronic (long term) pain or acute pain. We talk about medically unexplained pain, and the implication is that the other pain has a medical explanation.
The public have three incorrect beliefs about pain treatment.
1) Opioids are effective
2) Pain is either real or imagined, and imagined pain isn't real pain.
3) The aim of pain treatment is always to eliminate all pain and anything less is a failure.
Turns out none of these are true.
Opioids are a good choice for a limited number of patients. It's really important that people get all the opioids they need at end of life, for example. Or that people going through surgery have them available if needed. But for long term pain they're a bad choice. The person in pain ends up taking very high doses of opioids, with all the side-effects that causes, and they're still in pain. We can see their function - the stuff they do every day - is much reduced. We also see some conspiracy-theory style thinking here - "morphine is dirt cheap and this non-opioid you've got me on is really expensive, because you're in the pocket of big pharma".
We know that patients reject psychological treatment for their pain. They'll say "but my pain is real, it's not all in my head". But many pain patients experience benefit from psychological treatment. (Imagine a purely physical disease like t1 diabetes. Even these patients will get benefit from a psychological treatment. Clearly I don't mean that mindfullness will control blood sugars, but the 3 questions "can you do your bloods every day?", "can you take your insulin at the right dose and right time every day?" and "can you adjust your diet and lifestyle?" -- these are all firmly psychology).
Sadly, lots of people in pain will not experience relief from that pain even if we give them high dose opioids. So pain treatment should be looking at function. The aim should be to allow someone to live their life even if they still have pain.
For one example of this see "Sean's Story" https://www.england.nhs.uk/south/2019/06/25/seans-story/
There's also a visit to a pain-management clinic in a section of this radio programme: https://www.bbc.co.uk/programmes/b04wv052
I'm very glad that I never got into opioids. I've used them for pain relief, but never really liked the other effects. Just lucky, I guess.
The addict will look like they will be OK after getting the Narcan, but the opioids are still in their system. The Narcan will wear off any they could get an OD from the drugs in their system.
>> He stares at his hands for what seems like a long time.
>> “No,” he says finally. “I don’t think there’s anything that would help. It’s a hell of an addiction.”
It's a travesty that iboga[0] isn't widely available (or even known).