Angling for Trouble? Catch and Release for Heroin Overdose.

Ok, I’ll make this quick, as it’s half time during the Bledisloe Cup, and nothing is more important than seeing Straya get beaten (again).  Therefore, no references – but I’ll follow up with some data once another study has been published (in the pipeline)

 

I’ve commented on the Melbourne experience of treat and release from an EMS viewpoint a number of times, but 140 characters is not conducive to explaining the situation…

During the late 90s, Australia had a catastrophic glut of heroin on the streets. Stories abound of dealers selling “Starter Kits” outside high schools, and the death toll from heroin overdose far outstripped the road toll. One of our major newspapers published the daily heroin death toll on their front page every day.

Most of the heroin trade (and therefore use) was conducted in a relatively small geographic area, centered on the CBD and inner North and Western suburbs (such as Footscray, where I work)

As a result, ambulance crews in those areas were exposed to a ridiculous number of heroin overdoses every day, with each crew sometimes hitting double figures in a 10 hour shift. Due to this workload, guidelines were introduced that allowed the treatment with IM narcan in order to wake the patient up completely (as opposed to titrating to respiratory effort). I’m sure you can also imagine the impact it would have on the 3 or 4 hospitals in the areas if they received another dozen or so patients each, all requiring airway and ventilation management every day, on top of normal caseload (plus whatever walk-in/drop-off ODs presented as well)

It should be noted that heroin in Australia is typically very pure, with most adulterants being mere bulking agents like lactose to increase yield for the seller. This is obviously not the case everywhere, with fentanyl and fentanyl analogues becoming an increasing issue in some parts of the world.

So for the last 20+ years we have successfully treated and released uncomplicated heroin overdoses in the community, with excellent safety, and we continue to do so for the most part.

So what actually do after identifying the heroin overdose is: ventilate well (+/- airway adjuncts), for as long as it takes for SpO2 to normalise, CO2 to normalise, and heart rate to normalise. Whilst doing so, we assess for any other issues (other drugs, injuries, prolonged downtime etc), and then administer 1.6-2mg of IM naloxone. The patient then wakes up, thanks us, we offer transport to hospital, and further narcan if this is refused*. If they do refuse (and most do) we do our best to make sure they are safe and have someone to keep an eye on them, and offer them more narcan.

Where I find (and I can only speak for myself here) a complicated overdose (polypharmacy or a prolonged downtime) or post heroin arrest, I will typically not administer naloxone, but instead provide supportive care (intubation, ventilation and so on) and transport for further assessment and management. I do this rather than have an agitated, vomiting, hypoxic brain injured patient thrashing around in the back of an ambulance after a dose of naloxone that could never be expected to work anyway. No-one dies of naloxopenia…

We have a great deal of experience, and some upcoming data to demonstrate that in our context, this is safe and effective. One of our University researchers has been doing some research matching coroner data with ambulance data (not just heroin specific either) and it appears that by and large we have been doing the right thing in Melbourne.

And that is the final note: all of the above is specific only to our context in Melbourne where we have very pure heroin (pharmacologically speaking) and a history of catastrophic amounts of it being available. In the case of deciding to intubate, we have paramedics with a minimum of 6 years training and education (post-graduate), and a proven track record at intubation (97-100% success, with >90% first pass, and excellent procedural/patient safety) making these decisions and providing that level of care.

Even so, with falling rates of heroin OD, there is discussion around altering our approach to include more transport with titration of naloxone to effect, as is common in other services. There are potential benefits to transporting to hospital (like access to counselling, testing for bloodborne infections and so on), and if our system is better able to handle it (which it previously wasn’t) it is likely a good idea.

Our approach may not work for you: it depends on your local situation. I have no issue with different approaches being used, as EMS is not homogenous around the world. However I have typically heard nothing but disbelief and disgust from other medics at our approach, so I am very pleased to see some discussion around this topic.

For anyone with an interest in the drug and alcohol scene in Australia, Turning Point (http://www.turningpoint.org.au… is the foremost agency conducting research in this area. When the data is published on our safety with treat and release, I will post on Ambofoam.wordpress.com, and let you know on Twitter.

 

* I have to point out, the classic image of the heroin overdose patient coming up violent, swinging punches, vomiting and so on, is something that I have never seen in nearly 18 years on the streets.  When we take our time to ventilate and oxygenate, don’t be dicks and cut clothes off, and generally treat the patient like a human being, they tend to be very grateful and placid when IM naloxone is given.  The same is not true for IV naloxone, particularly large doses.

Take your time, treat them well and you will save a life.  Literally save a life, these patients WILL DIE if we don’t treat them, yet 20 minutes to after arriving to find a blue, apnoeic patient, we can be shaking hands and wishing a grateful patient well.  To me that is pretty damn cool!