By A.M. Sheehan
PARIS — On Thursday, Jan. 14, some 30 to 40 members of law enforcement gathered to train to administer naloxone, commonly referred to as Narcan, in the case of opiate/opioid overdose.
The training was in part an initiative of the Western Maine Drug Addiction Task Force and the Paris Police Department, according to Paris Police Interim Chief Jeff Lange who arranged the session.
Paramedic Krista Comis, PACE employee and member of the task force, provided the training, along with PACE EMS personnel.
Member of the Oxford County Sheriff’s Office, Paris Police, Bridgton Police, Dixfield Police and on-duty Paris Fire Department members took part.
The task force is a community-based coalition dedicated to reducing the demand of heroin in Western Maine through the use of education, recovery, prevention, intervention and treatment, according to Lange, along with legislation, legal resources and proactive law enforcement.
Officers, deputies and fire personnel saw a 40-minute presentation that outlined what to look for to identify an overdose, the ease with which they can administer Narcan, reassurance that Narcan can not harm a patient and the suggestion that each department develop its own protocol for overdose response and Narcan administration.
Following the presentation, trainees broke into smaller groups to get hands-on experience in assembling and administering the drug.
What is Narcan?
Naloxone, or brand name Narcan, is an opioid antagonist. Specifically, naloxone is used in opiate/opioid overdoses to counteract life-threatening depression of the central nervous system and respiratory system, allowing an overdose victim to breathe normally. Naloxone is a nonscheduled (nonaddictive), noncontrolled prescription medication, according to the American Society of Health System Pharmacists.
Opiate/opioid molecules attach to certain brain receptor sites causing the feeling of euphoria, killing pain and making the user feel calm and relaxed. However, too much or prolonged use can also make it impossible to breathe.
Naloxone fits the receptor sites better than opiates do. Naloxone will throw any opiate off of the opiate receptor sites and will stay attached to these opiate receptor sites. This reverses the effects of the opiates.
Naloxone effects only last about a half hour and may have to be readminstered. Naloxone will not counteract other drug overdoses, only opiate/opioid.
Because naloxone reverses the effects of the opiate/opioid, those addicted will experience symptoms of withdrawal.
These can include restlessness, agitation, nausea, vomiting, a fast heart rate, pain and sweating. Consequently, very small doses are given and repeated if needed. Further, Comis warned, the sudden withdrawal may also cause the patient to become violent. She suggested this reaction might be less physical than psychological.
“You’ve taken away their high … they just spent a lot of money on that high,” she said.
Narcan pathways include intranasal (through the nose), intramuscular (in the arm) and intravenous (through an IV directly into a vein). Law enforcement are only allowed to treat with the nasal application. They will carry a naloxone kit that includes two doses of naloxone and a nasal atomizer.
Indications that naloxone is needed include decreased or ceased respirations (breaths), lack of response when shaken, poor breathing, snoring deeply/gurgling sounds, possible bluish color to skin, nails or lips, and small pupils. Other indicators include signs of injection of drugs (track marks), drug bottles and/or bystanders who report drug use.
Naloxone only works on opiates/opioids. These might include heroin, buprenorphine (Suboxone), butorphanol (Stadol), codeine, fentanyl (duragesic patch), hydrocodone (Vicodin), hydromorphone (Dilaudid), meperidine (Demerol), morphine, nalbuphine (Nubain), oxycodone (Oxycotin/Percocet/Percodan), oxymorphone, pentazocrine (Talwin), paregoric, and propoxyphene (Darvon).
Opiates are natural derivatives and opioids are man-made chemicals.
The treatment is not complicated. The naloxone comes in a small vial that is inserted into one end of the atomizer. The cap is removed and the atomizer cap is attached. The atomizer is then inserted into a nostril and half the medication is sprayed.
Because the nose has numerous small blood vessels the medicine is quickly absorbed into the bloodstream and the effect of the antidote is almost instantaneous. If, after a minute, breathing is still not adequate, a second does is given, usually in the other nostril.
The antidote will usually last approximately a half hour, providing enough time for more advanced medical treatment via EMS or hospital staff.
In Maine heroin overdoses increased four fold from 2011 to 2012, according to the Journal of Emergency Medical Services.
The Maine Department of Health and Human Services Office of Substance Abuse July 2015 report Substance Abuse Trends in Maine State Epidemiological Profile 2015 notes MDEA drug offense arrests for heroin increased from 40 in 2010 to 216 in 2015.
Interestingly, Parm-narcotic (controlled substances such as oxycodone) arrests decreased from 327 in 2010 to 163 in 2015. However, more recent figures claim 265 arrests by Maine drug agents for heroin-related crimes alone, which is a 200 percent increase from 2012.
Overdose EMS responses for drug/medication went from 2,189 in 2011 to 2,947 in 2014.
According to recent media reports, the 2015 figures aren’t finalized but it is estimated opiate/opioid overdose deaths range between 230 and 250 in 2015 across the state.
In 2014, naloxone was administered to 829 patients statewide, the DHHS report states, by EMS responders. The number of deaths caused by pharmaceuticals and/or illicit drugs went from 167 in 2010 to 208 in 2014.
The biggest jump was illicit [drugs] which went from 17 to 75 during that period. Fentanyl, oxycodone and heroin/morphine have seen a 20-, 20- and 27-percent rise respectively.
In 2014, the DHHS report states, most drug overdose deaths involved an opiate or opioid – 69 percent.
In Oxford County, according to Lange, law enforcement dealt with 38 opiate/opioid overdoses in 2015. This does not include, he explained, those dealt with by EMS or hospitals only.
“Paris had five; the Sheriff’s Office, 12; Rumford, 10; Mexico, two, and Fryeburg may have had seven – they aren’t on Spillman (dispatch system),” noted Lange, so he can’t verify Fryeburg’s number.
According to the White House Office of National Drug Control Policy, the number of overdose deaths involving prescription drugs alone, increased 21 percent from 2006 to 2010. The number of overdose deaths involving heroin increased 45 percent.
The Centers for Disease Control in Atlanta state 120 Americans a day lose their lives to drug overdoses. At high risk are veterans, residents of rural and tribal areas, the elderly, recently released inmates and people who recently completed drug treatment or detox programs.
A cop’s job?
Law enforcement and naloxone began years ago. In 2010 the Quincy (Mass.) Police Department pioneered an overdose reversal program that has since been used as a national model.
The U.S. Attorney General’s Expert Panel on Law Enforcement and Naloxone noted that “delaying first aid [Narcan] by mere minutes can translate into a difference between life and death or permanent brain damage.”
Every law enforcement agency in Oxford County was invited to the free training, said Lange. Only four of the eight came. Reasons for and against were similar and represent the national discourse among law enforcement on whether the administration of naloxone is law enforcement’s responsibility or should be.
Some reasons not to take part and not to have departments equipped with naloxone – on both a local and national level – include being in the business of enforcing the law; having EMS response times so good that they arrive at a call before or with law enforcement; the “difficulty” of maintaining naloxone (naloxone needs to be stored between 59 and 86 degrees Fahrenheit); the “shelf life” of naloxone (between 18 and 24 months) and putting law enforcement in a dangerous position (patient may become violent), not enough incidents; where does it stop (police becoming medics) and liability issues.
Countering those reasons are equally compelling reasons to take part including the difference a few minutes can make between life and death, longer response time for EMS (rural areas) and cops should save lives when they can.
Oxford County Sheriff Wayne Gallant had about 30 staff at the training, according to Lange.
“I plan to have the entire department trained, more at a later date,” said Gallant – both patrol and corrections. “There is a chance we will never use [Narcan] and a chance we will save a life.
“The program will begin as soon as we finish writing a department policy regarding its use. I am working on that now. My goal is to have Narcan on board within days and not weeks.”
It’s the latter Gallant is focusing on.
“No one deserves to die,” he continued. People who drive OUI … and crash into someone … we still take them out of the car and save their life.
“I look at it [addiction] as a disease and if we have to save someone three times … then we do.”
Gallant noted there were nine drug-related deaths in Oxford County in 2015.
He tells of one experience where Narcan saved lives.
“We had two separate people in an arrest in Rumford. One collapsed in the cruiser and one in an apartment. Narcan brought them back.”
Dixfield Police Chief Jeffrey Howe agrees.
“It is important because our response may be before rescue and minutes really do matter,” he said. “If we can save a life … it’s important.”
Howe noted that MedCare – the ambulance service that covers Dixfield, has quick response times but that Dixfield is at the outer limits of the MedCare coverage area [leading to potential longer response times].
“Part of law enforcement is saving lives,” he said.
“We’re in the business of saving lives,” concurs Bridgton Police Chief Richard Stillman, “so anything we can do to enhance that is important.”
He added police officers are in the business of keeping the peace and protecting people.
“We are guardians of the entire community and protection is the most important part,” Stillman said.
Stillman said his department is part of a newly formed coalition to combat drug abuse, and they are still in the process of determining the stats for overdoses in the Bridgton area. He noted United Ambulance response times are outstanding and that most often, they [EMS] would be the ones to initiate the use of Narcan.
“But if they’re out and Naples has to come … .”
Naples response time would be longer and his officers being able to administer Narcan could save a life, he explained. “We have AEDs (automated external defibrillator) in the cruiser for the same reason.”
“If they aren’t there [EMS] I don’t want an officer or the public in a situation where we can’t help.”
Stillman says his department’s protocol or policy will be very brief: “If you come upon a person you suspect is an OD event, do Narcan.”
Lange’s reasoning is similar. He further hopes that his officers can work with the district attorney to get addicts into a diversion program (instead of arresting them).
“We will encourage them to get treatment,” he said.
Comis supports law enforcement having Narcan.
“We [EMS] could be on calls and police could be quicker [responding] than we are. PACE covers a large area and [police being able to administer Narcan] lessens the potential of lives not being saved, gives more chances of a life being saved … getting someone breathing is a life saved,” she said.
She reminds people that every overdose is not necessarily an addict.
“What about the first time users who don’t realize there’s a drug out there [who have] and accidental overdose the first time out?” she asked.
However, this is one of the many concerns expressed about having Narcan so readily available – even to family and friends of addicts.
Many see this as an invitation to take drugs without concern because someone will be there with the antidote.
Gov. Paul LePage expressed similar concerns when he refused to sign a bill enabling naloxone to be prescribed by health care professionals (to patients) and be carried by emergency responders.
LePage cited concerns that it would raise Medicaid costs and provide “a false sense of security that abusers are somehow safe from overdose if they have a prescription nearby.”
“Offering temporary relief without medical treatment or oversight will not combat drug use,” he said.
And he’s not wrong but no one is suggesting Narcan is the panacea of drug addiction.
Oxford Police Chief Jon Tibbetts, who did not take part in the training, said, “We don’t do Narcan, rescue does it.”
“Our rescue (Oxford Fire and Rescue) is usually there at the same time [as police] or beats us.”
It is one less thing his guys have to worry about, he said.
“I am not a big fan of police officers giving out Narcan – on the one hand it is great to save a life but on the other hand … what risks are we taking?” Tibbetts cites putting officers at risk having to restrain a violent patient and the fact officers only have handcuffs as restraints. “Rescue has softer forms of restraint.”
“We are there, we respond to all rescue calls and can assist … if I didn’t have my own rescue that responds so quickly, I would probably have my guys trained in it,” Tibbetts added.
Rumford Police Chief Stacy Carter said that with both MedCare and Rumford Fire personnel carrying Narcan, he sees no reason for his officers to do so.
“We are so close to our [fire and rescue] service that we can get it administered in a timely fashion,” he said.
Norway Police Chief Rob Federico said his department has, on more than one occasion, been a deterrent in a patient or bystanders admitting to an overdose.
“There was one time when PACE responders asked us to leave so they could find out what the patient had taken,” he said.
Further, he said, they have had no overdoses in Norway, so far, that have been reported to the police.
He said he agreed that some departments, with longer EMS response times, should carry Narcan, but that PACE response times were as good if not better that police’ times.
“It’s a very hard decision to make,” Federico said, “and I would reconsider if incidents rise.”
He also noted concerns about liability and handling and maintaining Narcan.
However, Stillman said there is no liability for law enforcement.
“Police officers have certain immunities if we are trying to help someone and we can’t be sued,” he said.
Maine enacted a statute authorizing law enforcement and fire personnel to carry and administer Narcan if properly trained.
Mexico Police Chief Roy Hodsdon said his officers will assist MedCare but will not administer Narcan.
“MedCare is right here and we respond with them,” he said. “We will assist them and can help them restrain [a combative patient] but they can do the patient [medical care].”
Hodsdon said he was at a call where Narcan was administered and the patient got violent and spit blood in his face after which he had to go through a series of blood tests. He notes response time differences between the police and MedCare “are a matter of seconds.”
Stephen McCausland, spokesman for the Maine State Police, said Maine State Troopers do not carry Narcan.
“It isn’t issued to them,” he said. He cited the issues with maintaining proper storage temperatures to keep Narcan viable. “It would sit in the cruisers.”
The U.S. AG’s panel recommended in 2014 that law enforcement be able to provide Narcan “where law enforcement may come in contact with opioid overdose victims at least two to four minutes before emergency medical personnel.”
It further noted that treating overdose events first and foremost as medical emergencies can foster a culture of trust with the public enabling improved community relations, cross-sector information sharing and better intelligence-gathering capabilities. Additional outreach such as referral to treatment or prevention programs may also be appropriate.
According to the Trust for America’s Health June 2015 report, law enforcement agencies in 34 states and the District of Columbia currently have Narcan programs.
The departments starting the Narcan program have received funding through various grants, including one through the state Attorney General’s office and one through the federal Department of Justice.
Narcan costs approximately $25 per dose and $3 to $5 for the atomizer.