The opioid epidemic requires American ingenuity, not Big Government
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The United States is experiencing an epidemic of preventable deaths from opioid abuse: With drug overdose deaths quadrupling in number since 1999, and over 15,000 deaths involving prescription opioids in 2015 alone, this crisis is affecting families of all social status, and demanding new and innovative solutions to combat it from all angles.

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In order to defeat this epidemic, we must be willing, as a nation, to fully utilize life-saving treatments that can prevent overdoses and give victims a second chance at life and to overcome their battle with addiction. But in order to do this, we must first recognize the tools and resources that are there to help, as well as the barriers to their implementation.

 

Resources have been provided through a range of federal government awards to explore potential harm reduction strategies and prevent needless deaths. Most recently, the21st Century Cures Act, signed into law in December 2016, allocates $1 billion to create an account for states that are disproportionately affected by the opioid crisis to:

    • improve state prescription drug monitoring programs;
    • implement and evaluate prevention activities;
    • train healthcare practitioners on best practices for prescribing opioids and pain management, recognizing potential cases of substance abuse, referral of patients to treatment programs, and overdose prevention;
    • supporting access to health are services to treat substance use disorders; and
    • other public health-related activities, as the state determines appropriate, related to addressing the opioid abuse crisis within the state.

Prior to that, in July of 2016, the Comprehensive Addiction and Recovery Act became law, which addressed aspects across the full continuum of care. Of particular note is the improvement of access to rapid overdose treatment by increasing the availability of naloxone (the primary opioid overdose reversal medication) to the general public through federally qualified health centers, to create standing orders for pharmacists to dispense, and to make training materials available to the public.

Furthermore, the Affordable Care Act has created access to addiction therapies and services to many previously un-insured. It has also created incentives for states to develop innovative models that have better and more efficient outcomes.

Yet with these steps forward, we are also poised to take a few steps back:

While there is uncertainty inherent to the change in any administration, for those battling the opioid epidemics at home, the struggle is real and ongoing. This challenge comes with an opportunity for states to approach the opioid epidemic with the full ingenuity our nation has to offer.

American society has long been a pioneer in the global reversal of sudden medical death. Whether the Heimlich maneuver, CPR, the EpiPen or ambulance systems in general, America has led the world in innovative and scalable interventions to reduce premature death and disability from preventable emergency conditions at the community level. And now with naloxone available in a simple nasal spray, opioid overdoses should be as preventable as restaurant chokings or diabetic comas. 

Yet two major obstacles still remain to drastically reduce preventable opioid overdoses.

First is the ability to recognize an overdose. Owing originally to a deluge of opiate prescriptions, and followed by the cheap heroin that replaced it when doctors started cracking down, overdoses are no longer an “under the overpass” type activity. Today, drug overdoses cause more deaths than car accidents or shootings, yet public awareness campaigns to educate all ages about opioid overdoses are still far from reaching the levels that public service announcements for seatbelts and drunk driving achieved. But if we can teach six-year olds how to call 911 and the general public to perform CPR, we should certainly be able to teach others to recognize shallow breathing and pinpoint pupils.

However, this is where we run into our second obstacle: Witnesses to an overdose must be willing to call for help. There are many people across the country who are unwilling, unable or are otherwise disincentivized to call 911. When official paramedics and police remain the sole gatekeepers to naloxone, lives are unnecessarily lost. But even when we acknowledge this problem and seek to empower community-based solutions, lawyers and bureaucrats are quick to scare off the public with the implications of liability.

In late 2016, we conducted nearly 50 informal phones interviews with public health and safety leaders in 16 states actively involved with training and distributing naloxone to the general public to learn more about this paradox. We did so by asking about their communications systems, and specifically, how bystanders can call to find help when they don’t have their naloxone but need it. In the course of our interviews, we found:

    • All of the interviewees stated that the most reliable way to access naloxone in life-threatening, time-dependent cases was by calling 911;
    • All but one of them readily acknowledged that calling 911 was also a major barrier to access for persons witnessing an overdose;
    • Of those who were directly involved in naloxone training and distribution, none said they had an established communications protocol to alert trainees when naloxone was needed in life-threatening, time-dependent cases; and
    • A few reported giving out their own personal phone numbers to known opioid users in case of an overdose. 

Given the proliferation of crowd-sourced and on-demand mobile phone technologies, and following the lead of the FDA’s funding for innovative technological solutions to prevent overdoses, we also asked if they thought that a neighborhood crime watch-type alerting system would be feasible and all agreed on principal. While a few said they would be willing to implement the program now if funding were available, the majority said they would consider such a program but would need to know that obstacles could be addressed. Principle among these were concerns about safety and the appropriateness of the technology, but above all, the greatest reservation was potential liability for layperson-administered naloxone. 

The irony here is that these same potential areas of liability exist for CPR, if not even more so: The risks between giving naloxone to a person who has not overdosed on opioids versus doing CPR on a person who still has pulses are incomparable. The survival outcomes are equally incomparable: If opiates are the sole cause of the patient’s condition, naloxone, if administered quickly, will reverse the overdose, while only a small percent of sudden cardiac arrest victims undergoing CPR survive.

Like emergency medical care, America is pioneering the crowd-sourced world of on-demand services. Whether in a rural community that’s outside of the orbit of resources for major urban areas, or in a big city that’s afraid of losing federal government support, those serious about stopping overdoses need to do little more than take a page from the same community pioneers who brought us CPR and the Heimlich maneuver, and find strength in numbers.

Rather than place barriers out of fear of liability and political optics, our officials and our medical community should work together to further this kind of innovation in a way that rewards the saving of lives.

 

Jason Friesen, MPH, EMT-P (@quixotech) is founder of Trek Medics International, a nonprofit organization dedicated to improving emergency medical systems, and co-founder of Quixote, an emergency communications technology service.

Jeff Schlegelmilch, MPH, MBA (@jeffschlegel) is a senior adviser for Trek Medics International. He is the deputy director of the National Center for Disaster Preparedness at Columbia University’s Earth Institute and has over a decade of experience in developing programs for community resilience and public health preparedness.


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