Prior columns have discussed the critical state of the opioid crisis and the EMS use of Naloxone and other harmful reduction strategies. Unfortunately, the opioid crisis is getting worse. This column will focus on the origins of the opioid crisis and something called Medication Assisted Treatment. Medication Assisted Treatment (MAT) is the only evidence based way for people with an opioid use disorder to stay off drugs on a long term basis. EMS should know about MAT since many of their patients might be on MAT. Locally, there also might be ways that local EMS can help their patients get access to MAT.
Opioid overdoses are the leading cause of death for people who are less than 50 years old. In North Carolina five people die every day from opioid overdoses. In the past there was a huge push for physicians to treat patients’ pain and no one realized how additive prescription narcotics could be. As a result, physicians often prescribed large amounts of narcotics to their patients This caused may people to become addicted to narcotics.
Figure 1 is a graph showing the chance of a person getting addicted to narcotics based on how many days they initially took prescribed narcotics. According to the graph, if a person takes 10 days of physician prescribed narcotics, they have almost a 20 percent chance of being addicted to opioids one year later. As they became addicted to these medications the chemistry of their brain actually changed somewhat so that it became extremely difficult for these patients to stop taking the drug. Over time, many people could not afford prescription narcotics or their physicians stopped prescribing them. These patients then began buying cheaper illegal drugs. Initially, this mainly consisted of heroin with the even more dangerous Fentanyl making an appearance later on. The second graph (Figure 2) titled “3 Waves of the Rise of Opioid Deaths” gives an illustration of this progression.
Many do not understand why people keep using opioids. One reason is that people with opioid use disorder experience severe withdrawal symptoms when they stop using opioids. In addition, they will have cravings that than can persist for long after their use has stopped. Withdrawal can cause elevated heart rate, sweating, severe anxiety, dilated pupils, diarrhea and vomiting. It is described as a horrible experience. People going through withdrawal have said that they feel as if they were walking through the desert dying of thirst and needing a drink of water. The feeling and urges that people describe when undergoing withdrawal or when they are craving the drug are extremely powerful.
There are different approaches to helping people with opioid use disorders. One approach involves abstinence with no long term medication assistance. The other approach involves the use of medications to help a patient maintain abstinence.
Abstinence might involve giving people medications to help people through their withdrawal and then having them pursue abstinence without any medication to control cravings. Abstinence has a success rate of only seven to 13 percent. This method has been and is still widely used even though long-term success rates are very low. This is the case even when combined with counseling. One reason that abstinence may not work is that people still continue to have cravings which persist.
There are medications that can be used to help people with opioid use disorder. One of these medications is called Naltrexone. It is basically a long acting injectable naloxone that will stick around in the body for about a month. Naltrexone can also be given every day in pill form. It blocks the effects of opioids so that if a person uses a drug like heroine while on the Naltrexone the person will not be affected by the heroine. Before a person can use Naltrexone, they must first go through withdrawal. This can be very difficult to go through so many people choose not to use this medication. Long term success rates for patients using Naltrexone are around 35 percent.
Another medication that has been around a very long time is Methadone. It is a long acting opioid. It can be used to help a patient through withdrawal and it can serve as a long-term maintenance therapy to alleviate cravings. Success rates for patients on Methadone are 45 to 53 percent. Methadone does have some side effects and it is possible to overdose on Methadone. There are also some logistical constraints associated with getting Methadone administered; although, it is an effective drug.
Buprenorphine has not been around as long as Methadone. Buprenorphine can also be used to lessen withdrawal symptoms and prevent cravings. Its long-term success rates are between 46 to 54 percent. There are fewer logistical constraints to receiving Buprenorphine, it has fewer interactions with other drugs, and it is difficult to overdose on. It is also only a partial agonist at the opioid receptor. This means that although it occupies and binds tightly to the opioid receptor it does not give as strong of an effect on the body as do other opioids. This is why it is unlikely for patients to overdose on Buprenorphine.
Even if EMS agencies are not helping patients get into MAT programs all EMS provides should be aware of what treatments are available for opioid use disorder. One EMS agency in Florida actually helps patients get started on MAT in the field. There are also other EMS agencies in North Carolina who are looking at helping patients get started on MAT.
EMS needs to take the lead in addressing the opioid epidemic whether it’s by administering naloxone, encouraging harm reduction strategies or by encouraging people to enter MAT. EMS providers live and work in their communities so they often have more insight into what is happening than anyone else. EMS providers must be leaders who help stop this epidemic and save our communities.