Why fire, EMS agencies should make the opioid epidemic their top priority

Sarah Calams, Associate Editor

A new report claims that opioid overdoses could kill nearly 500,000 Americans in the next decade. According to the Centers for Disease Control and Prevention, 91 Americans die every day from an opioid overdose.

However, the epidemic, which has been at the forefront of national news headlines, is not a new issue.

In their presentation at the International Association of Fire Chief's Fire-Rescue International conference in July, Fire Chief John Butler and Medical Director Matthew Levy will discuss the opioid epidemic. Their seminar, "The opioid epidemic: Considerations for the fire rescue agencies," will be held July 26; the early registration discount is available until July 7.

Chief Butler and Dr. Levy, both with Howard County (Md.) Department of Fire and Rescue Services, will review the magnitude of the epidemic and discuss the challenges it presents to the fire service.

Chief Butler, who has been with the department since 1993, was appointed as chief in January 2015. He's the first chief to hold every rank within the department. Before joining the fire service, he served in Panama and the Persian Gulf War as a U.S. Marine.

Dr. Levy – the medical director of the department – is also an associate professor of emergency medicine at the Johns Hopkins University School of Medicine. His career in EMS and disaster response spans more than 25 years.

The opioid epidemic, Dr. Levy says, is a complex situation and one that the fire service is on the front lines of.

Challenges of the opioid epidemic

While urban inner city environments have been dealing with the opioid problem for decades, the evolution and expansion of the problem – at a rate that we're now seeing – is alarming and problematic for responders.

"Agencies are running more and more of these calls – in some cases at a disturbingly alarming rate," Dr. Levy said. "As these calls increase, we have to also be prepared for the increased need."

And with the surge in overdose calls, Dr. Levy says, comes responder-specific operational challenges.

"The elephant in the room is that these are very emotional, frustrating and challenging calls for our responders," he said. "And especially when we're responding several times to the same individual."

There's also a concern for increased risk to responders.

"It's important that providers understand the risk, but the risk can be contained with good universal precautions – like wearing gloves and masks."

Another challenge, Dr. Levy says, is determining what synthetic opioid a patient has overdosed on.

"It's not possible to launch a full-on hazmat response for every single overdose and no one is advocating for that," he said. "But you have to have a response plan in place."

And perhaps the biggest – and most overlooked challenge – is the human factor.

"Our responders are running these calls with such frequency now that we have to still be cognizant of the fact that we can't allow complacency to occur," Dr. Levy said. "If it's your fourth overdose call in a shift, it can become just another overdose call. But we have to keep our guard up and maintain our situational awareness."

Responders must also be able to deal with the cumulative and emotional stress of responding to the calls.

"There's an emotional burden to these calls – and sometimes there's a potential for that burden to be manifested as anger. That's a very dangerous thing to have happen. You lose your objectivity when that happens."

According to Dr. Levy, opioids have claimed more lives in Howard County than firearms, violence or motor vehicle trauma combined last year.

"That's a pretty powerful statement," he said. "By sheer numbers, this opioid challenge is going to – or has already or likely will – affect fire service members on a personal level.

"No longer is this someone else's problem. No longer is this a disease that affects other people."

Combating the epidemic

The responsibility for finding a solution to the opioid problem does not exclusively lie with emergency services.

"A solution to a problem like this only comes through an interdisciplinary approach," Dr. Levy said. "It's not a fire-centric problem, but we are a huge stakeholder in this problem because we are running these calls."

Dr. Levy says his department has seen a substantial increase in overdose calls within the past two years – especially when it comes to overdose fatalities. As a way to track the calls for data-related purposes, the department added a question into its electronic patient care report.

"We added, 'Do you suspect the call you're on is related to a heroin or opioid-related overdose?' The first thing we had to do was understand how prevalent it was. Asking that question was a really good start," he noted.

Dr. Levy says the department also went to other stakeholders in the county to find out how the problem was affecting other agencies.

"That became the catalyst for an interagency sharing agreement and for the creation of a dashboard that we now have to help us understand what the problem looks like for our community as a whole."

And by having this 360-degree perspective, Dr. Levy says it allowed the department to understand and define the problem.

"We are looking at any and all possible intervention solutions that we can provide at the fire service level to help," he said. "Ideas that we're looking at include a community paramedicine-type intervention, partnering with our health department to have peer support recovery people to come out to the scene of the calls to help provide patients with resources, and we're looking at opportunities to get these people into fast-track recovery programs."

Currently, the health department's CPR program is training people on not only how to perform CPR but also how to give naloxone to overdose patients. Additionally, working with the health department, HCDFRS is assessing the potential impact of intermittently placing naloxone with the county's public access defibrillators throughout the county.

"The truth is – there is no simple solution to this problem," Dr. Levy said. "And that's perhaps the most important thing to remember. You can't get frustrated. Everyone knows naloxone isn't going to solve the opioid crisis, but it is going to save the life at the moment of the overdose. The key is to get that person resources and into recovery."

The fire service, Dr. Levy says, can capitalize on the goodwill and trust of the community to help build and get patients into fast-track recovery programs.

The adoption of such programs will include both early and late adopters. What drives a department to make the opioid epidemic a priority, according to Dr. Levy, is a local decision.

Making the epidemic a priority

In the fire service, there are many things that compete for a fire chief and department leaders' time and public safety needs.

"I encourage department leaders to have a healthy respect for just how significant the penetrance of this problem is," Dr. Levy said. "If it hasn’t hit your community yet, then it will."

Where the leadership opportunity occurs, Dr. Levy says, is to recognize that there are other agencies that are already dealing with the issue. Additionally, there are best practices that are already ready to go that chiefs can use to begin implementing within their own jurisdiction.

"Where the leadership failure would be is to just deny the problem. And it may not be a problem right now, but it will be a problem later on. This is an epidemic that is not going away any time soon. It's going to get worse before it gets better. This is going to be part of the landscape that defines emergency response."

If a fire department doesn't have the capacity to partner with other agencies, then it could, according to Dr. Levy, do something as simple as keep several copies of resources on hand to leave with a patient on scene.

"At a house fire when a family is displaced, we don't leave them on the side of the road. We call the Red Cross or the Salvation Army. After a fire, we do overhaul … after a rescue, we're monitoring for secondary collapses. What our responders need to remember is that after the initial resuscitation in these patients, the 'overhaul' is linking that person to recovery."

Responders, Dr. Levy says, may feel like they're responding to overdose calls day in and day out.

"I beg them for their patience and continued professionalism. Don't become complacent, it's easy to become frustrated, but we are laying the foreground now for some very complex interventions and solutions."

And there may be political, fiscal and internal operation roadblocks when adopting interventions and solutions to the opioid epidemic.

However, they can be overcome and navigated by understanding the magnitude of the problem locally. Also, having a system in place to measure and quantify how the epidemic is affecting your jurisdiction and being open and transparent with updates to your frontline responders about what's being done to combat the epidemic will pay off in dividends.

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