Pubdate: Sun, 20 Aug 2006
Source: Philadelphia Inquirer, The (PA)
Copyright: 2006 Philadelphia Newspapers Inc
Contact:  http://www.philly.com/mld/inquirer/
Details: http://www.mapinc.org/media/340
Author: John Sullivan,  Inquirer Staff Writer
Bookmark: http://www.mapinc.org/heroin.htm (Heroin)
Bookmark: http://www.mapinc.org/rehab.htm (Treatment)

CITY STAND ON HEROIN ANTIDOTE RISKS LIVES

The drug combats overdoses, but experts say the proper dose isn't 
being given. And the antidote isn't readily available to all patients.

Two months ago, as scores of drug users in the city began dying of 
heroin overdoses, two city paramedics discovered something alarming. 
Narcan, a powerful drug that could almost instantly revive a patient, 
wasn't working.

In the following weeks, an apparent culprit would be unmasked: Heroin 
dealers were adding fentanyl to their product, an opioid up to 100 
times as powerful. More than 500 people across the country have died 
of the tainted heroin - a number that is sure to climb.

But as the concerns of the two paramedics made their way up the Fire 
Department's bureaucracy, the city did not make key changes in how it 
treated people dying of a fentanyl overdose - though experts say that 
simply increasing the dosage of the antidote would counteract the fentanyl.

Fire Department officials say that this year, using the current 
Narcan dosage guidelines, they used the antidote to treat at least 88 
fentanyl-related overdose patients who later died.

To make matters worse, many people suffering from overdoses didn't 
receive Narcan because they lived in areas where the number of 
emergency medical personnel who could administer the drug had been cut.

"We're losing people every day that don't need to die," said Casey 
Cook, executive director of Prevention Point Philadelphia, a 
nonprofit that runs the city's needle-exchange program.

An Inquirer investigation has found that:

City and health officials are at odds over whether current dosages of 
Narcan are high enough to counteract fentanyl-laced heroin.

The city's chief paramedic, whom top fire officials referred to as an 
expert during an interview, did not know that Narcan worked as an 
antidote to fentanyl.

Because of a shuffling of resources, the neighborhoods hardest hit by 
heroin-related deaths are not specifically served by paramedic units 
that can administer the antidote.

Unclear On Treatment

Even though the fentanyl-poisoned heroin had been on Philadelphia 
streets for eight months, Philadelphia rescue officials seemed 
uncertain last week of the proper emergency treatment.

In interviews, fire paramedic-operations chief Daniel T. Parrish 
first said he didn't believe that Narcan had an effect on fentanyl.

A few days later, he changed his mind and said the city needed to 
increase the dose and would change its protocols. "My feeling is that 
fentanyl needs a much higher dosage," said Parrish.

"Unfortunately, some individuals could not be privileged to the 
change, and we lost some human beings," he said Thursday. "We will do 
the best we can to help other individuals [and keep them] from losing 
their lives."

Experts who study opioids such as heroin and fentanyl caution that 
emergency cases are complicated by many unknowns, but that unless a 
patient is brain-dead when paramedics arrive, Narcan can keep them alive.

"They just need to give more of the drug," said Charles P. O'Brien, 
director of the Charles P. O'Brien Center for Studies in Addiction at 
the University of Pennsylvania Health System. O'Brien has developed 
medications to treat alcohol, opioid and cocaine dependence.

But C. Crawford Mechem, medical director of EMS, said Philadelphia's 
protocol for treating fentanyl-laced heroin overdoses was sufficient, 
and typical of those in most cities.

"The policy we have in place is perfectly adequate," said Mechem, who 
is also an attending physician at the Hospital of the University of 
Pennsylvania's emergency room.

The Fire Department's Parrish said that after his interview with The 
Inquirer, he discussed the issue with Mechem, and Mechem told him he 
wanted to review the city's protocol for using Narcan.

Mechem, who oversees Parrish and makes all medical decisions for EMS, 
said he did not tell Parrish he would reevaluate the policy. Upon 
hearing Mechem's comments, Parrish said he himself must have been 
mistaken. "I'm in a chain-of-command situation here, and whatever he 
said is what it is."

Mechem said paramedics gave 0.4 milligrams of Narcan and continued to 
administer the drug up to 2 milligrams. After that, they must get 
permission from a doctor to give more.

When asked whether more Narcan was needed to reverse a fentanyl 
overdose, Mechem replied: "It may, but there is little literature to 
support it."

But at least two paramedics whom the city will not identify became 
concerned when patients did not respond to Narcan.

In a videotaped interview recorded for a White House-sponsored 
fentanyl conference in Philadelphia last month, one of the paramedics 
said he began to suspect bad heroin when he saw users with needles 
still in their arms. He said he could not revive many of the victims 
because they were too far gone, but he did manage to save two people.

"The treatment of the two people I did have a chance to save, the big 
difference with that was the protocol," he said. He said he was going 
to administer a few milligrams of Narcan, but because he suspected 
fentanyl-laced heroin, he asked to use more.

"We had to use, we had to call... contact base command and our 
doctors to... give a little more Narcan."

Not Just Philadelphia

The spread of fentanyl-laced heroin is a deadly problem that 
Philadelphia, Chicago, Detroit and other major cities have struggled 
to deal with. Camden also has seen dozens of deaths. In a large swath 
of Philadelphia that includes areas where paramedics were removed, 
fire officials said 137 people had died this year of heroin-related 
overdoses. An overdose of fentanyl, a powerful painkiller, can kill 
quickly because it binds to receptors in the brain stem that control 
breathing, said Bertha Madras, a neurochemistry and psychobiology 
expert in the White House Office of National Drug Control Policy.

Narcan, which is the brand name of the drug naloxone, is an opioid 
antagonist that also binds to receptors in the brain. If there are 
equal numbers of naloxone and fentanyl molecules, naloxone will 
prevent the fentanyl from binding because it binds more efficiently.

This makes naloxone very effective at reversing the sedation, 
respiratory depression and low blood pressure that result from an 
opioid overdose. Some people dying of an overdose will get up and 
walk away after getting the drug. Further, Narcan is safe, even in 
large quantities, because it has no effect on people who are not 
overdosing, experts say.

No Narcan

In Philadelphia, some drug users dying of overdoses didn't get Narcan.

Before the rash of fentanyl overdoses became apparent, a shortage of 
paramedics prompted the city to swap them for EMTs, emergency medical 
technicians. EMTs cannot administer the drug, and the change was made 
in the very neighborhoods that would be hardest hit by the poisoned drug.

Fire Commissioner Lloyd Ayers said he took the paramedics from places 
where coverage overlapped and most calls were not medically urgent.

"This is another example of a real crisis we are experiencing in 
providing our citizens with fast and effective emergency medical 
services, especially in view of our unprecedented demand," said City 
Council President Anna C. Verna, who expressed concerns about the 
moves when Ayers told City Council about them this summer.

Exactly how many drug users who overdosed went without Narcan is hard 
to say, but during the fentanyl conference, Capt. Richard Bossert, 
the EMS official in charge of quality assurance for the city, said 
that if the paramedics hadn't been redeployed, the city would have 
given Narcan to twice as many people.

As of last month, city paramedics had administered Narcan to 630 
people this year, compared with 655 patients in all of 2005.

"That number is skewed low," Bossert told the audience, because EMT 
units "do not give Narcan."

Deputy Fire Commissioner Ernest F. Hargett later dismissed Bossert's 
remarks as being "off the cuff."

"I think he was speculating," said Hargett, adding that the numbers 
would have been lower.

Ayers said that shuffling of city paramedics was a tough choice, but 
that ultimately it had had little impact on the quality of service.

"I look at every firefighter and every paramedic and I can tell you 
the quality of care is the highest that's available," said Ayers.

Douglas L. McGee, the past president of the Pennsylvania chapter of 
the American College of Emergency Physicians, empathizes with Ayers.

"Tainted heroin is not a regular occurrence, so you could redeploy 
resources only to see the problem go away."

EMS medical director Mechem said that although it is tragic that so 
many have died, their deaths are not related to whether they received 
Narcan or how much. He said they represented a relatively small 
number of patients compared with what the system handles.

It makes no difference, he said, whether an overdosed patient gets 
treated by a paramedic or an EMT. He said either they're too far gone 
when EMS arrives or an EMT can keep them alive until they reach one 
of the city's many hospitals.

"While the ultimate reversal agent for narcotic overdose is naloxone, 
I don't think the fact that they can't administer naloxone is why 
these people are dying," said Mechem.

"Ventilating the patient will also keep them alive until they get to 
the hospital," he said, adding that respiratory depression is what 
kills most overdose patients.

Mechem said EMTs use a mask with an inflatable bag attached to drive 
oxygen into the lungs, a practice commonly referred to as bagging.

Dave Kearney, a Philadelphia paramedic for 11 years, said bagging was 
not practical.

"Can you imagine trying to hold a mask on someone's face, squeeze a 
bag, all while carrying them on a stretcher down several flights of 
stairs? It doesn't work," said Kearney, who is the recording 
secretary for the local firefighters' union and a frequent critic of 
the city's EMS system.

"Why do that when we can give them a shot?"

Other doctors who have studied fentanyl said that although much 
depends on the circumstances, bagging is often difficult and can lead 
to vomiting and aspiration, which can be fatal.

"In theory, there is no doubt that the best treatment is earlier 
administration of naloxone, because the patient may be near death 
already and so you want to reverse all the effects," said Paul M. 
Paris, a nationally recognized expert on emergency medical care and 
the chairman of the department of emergency medicine at the 
University of Pittsburgh School of Medicine.

"It's not so simple as providing oxygen."

Paris proposes that Pennsylvania adds naloxone to a list of drugs 
that EMTs can give patients.

That's exactly what some states have done. New Mexico passed a law 
allowing police officers to give it.

In Maine, state EMS medical director Steven E. Diaz said the state 
allowed EMTs to deliver Narcan after a rash of opiate overdoses three 
or four years ago.

"This is something we did to save lives, and it worked," said Diaz, a 
former paramedic who has written two books on emergency medicine.
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MAP posted-by: Beth Wehrman