For years, paramedics in Camden have revived certain residents from heroin overdoses over and over again using naloxone, or Narcan, only to have these individuals rush off to get another fix of illegal drugs to calm the anxiety, muscle cramps and vomiting that accompany withdrawal.
But emergency responders in New Jersey now have a new tool at their disposal, a medicine that starts to reduce the painful withdrawal symptoms — often likened to a severe intestinal flu — moments after a patient pops it in their mouth. Health officials hope this approach will free drug users from the daily grind of their addiction long enough to consider connecting with a treatment program and pursuing long-term recovery.
Last week, state Department of Health Commissioner Dr. Shereef Elnahal made New Jersey the first state to allow paramedics to carry buprenorphine, which effectively reduces the symptoms of opioid withdrawal and is shown to improve participation in addiction treatment programs. When administered in conjunction with counseling and other services, it is known as Medication Assisted Treatment, or MAT.
Elnahal’s directive, effective June 24, is based on recommendations from leaders of the state’s county-based mobile intensive care system. Technically, it adds buprenorphine to the list of medications available for mobile intensive care units — crews trained to administer complex medications, insert a breathing tube or provide injections, techniques that not all crews are credentialed to perform — and requires leaders in each county to train paramedics in the protocol; medical directors in each county can choose to authorize the use of the medicine or not.
“Buprenorphine is a critical medication that doesn’t just bring folks into recovery — it can also dampen the devastating effects of opioid withdrawal,” Elnahal said of the medicine, a unique opioid formulation, often sold as Suboxone, that prevents cravings without making the user high. “That’s why equipping our EMS professionals with this drug is so important,” he said.
Camden hospital has been offering it for two years
For roughly two years, Cooper University Health Care in Camden has offered buprenorphine to patients who come into the emergency room after experiencing an overdose reversal with naloxone. Similar programs exist at a few dozen hospitals in New York City, Philadelphia and other cities, according to reports.
But while paramedics in Camden frequently administer Narcan, only half of the individuals they treat agree to be transported to the ER for follow-up care, said Dr. Kaitlan Baston, medical director of Cooper University Health Care’s addiction program. Camden County has one of the state’s highest overdose rates, with more than two dozen deaths a month in 2018.
“Now we have a new option. We can give them that life-saving medication in the field,” Baston said. Patients may still refuse paramedics’ invitation to be transferred to the hospital for continued observation or care, she added. “But in the next 24 hours, as the fog clears and they’re feeling better, they can then go in and get treatment.”
More than 3,000 state residents lost their lives to drug-related issues in 2018 and tens of thousands seek treatment each year, state statistics show. While the number of legal opioid prescriptions — one driver of the current epidemic — has declined in recent years, New Jersey’s death rate has continued to grow, fueled in part by the emergence of a powerful new synthetic opioid, fentanyl, which is many times stronger than heroin.
Treatment options for opioid addiction changed significantly when buprenorphine was approved by FDA just over a decade ago and it is now considered the gold standard in opioid treatment. A landmark study published in the online Journal of the American Medical Association by Yale University in 2015 suggested that individuals using buprenorphine were more than twice as likely to remain in treatment after a month, when compared to those who attended counseling alone without the medication component.
New Jersey goes for MAT
Under Gov. Phil Murphy, New Jersey has embraced MAT and sought to expand such programs by eliminating insurance barriers to the therapy and training scores of providers in the protocol. But the federal government requires buprenorphine prescribers to undergo eight-hour training and limits the number of patients they can treat at any one time to 30 the first year, then rising to 100 the following year. (Since the state program involves administering buprenorphine in urgent situations with patients who are then referred for care elsewhere, prescribers are unlikely to hit the cap.)
Given these controls, access to MAT programs remains limited, and they are often beyond the reach of the most at-risk individuals, including people who are homeless, impoverished or returning to the community from jail, experts note. In Camden, an outsized percentage of the ambulance calls involved reversing ODs among citizens struggling with these issues, something that has become frustrating and demoralizing for the paramedics involved.
“EMS is on the front lines for this,” said Dr. Gerard Carroll, Cooper’s EMS medical director, noting that sometimes crews face ten overdoses a day. “They wake them up, they wake them up, and one day they pronounce them dead,” he lamented.
Carroll said concerns from paramedics prompted a brainstorming session with Baston and Dr. Rachel Haroz, an addiction toxicologist in Cooper’s emergency department; one possible answer they discussed was to offer buprenorphine to patients earlier in their cycle of addiction, even starting in the field following an overdose.
“Our hope was, that when these patients were starting to feel dope sick, we can say, ‘here’s a drug that can start you on the road to recovery,’” Carroll said. “Often (policies) trickle down from the hospital, but this was really EMS-driven,” he added.
How it works
Buprenorphine works by locking onto opioid receptors in the brain, blocking them from absorbing the impact of drugs like heroin; as such, it counteracts the symptoms associated with opiate-withdrawal and shields the patient from the impact of other opiates, like heroin. As Carroll said, with buprenorphine, “You’re not in withdrawal, you’re not high, and you’re protected from the other scary drugs.”
The trick is the timing, experts said. A drug user must already be experiencing certain withdrawal symptoms for buprenorphine to work best; if administered too soon, it can actually exacerbate the excruciating withdrawal symptoms. But naloxone speeds up the withdrawal process, compressing symptoms that normally develop over a day or more into minutes — and presents paramedics with an opportunity to intervene with buprenorphine.
Under New Jersey’s program, paramedics will be trained to accurately assess the withdrawal process and must consult with an emergency-room physician on the proper dose before administering buprenorphine following a Narcan reversal. While this process is complex, Baston said the skills and monitoring involve “so much less than a heart attack” patient would require from paramedics.
The only real danger, Carroll noted, is the possibility that the buprenorphine could enhance withdrawal symptoms — something that can be addressed by increasing the dose. And withdrawal from opioids is “miserable, but not life-threatening,” like detoxing from alcohol or benzodiazepines such as Valium or Xanax, he added.
Elnahal’s directive calls for any expense associated with the addition of buprenorphine to be added to the patient’s bill, but Carroll said in reality many of the costs from these emergency runs aren’t recovered; individuals may lack coverage and it can be hard to account for every bandage, syringe and respiration bag used during a chaotic call, he noted. “A six dollar pill is such a win,” he said of buprenorphine, which could reduce a patient’s medical cost significantly over time if they are connected with treatment.
Patients have the right to refuse the treatment and can still decline the team’s offer to be transported to the emergency room, where they can get medical care for other conditions and connect with counseling and other recovery services. “The sad but true thing is, if I can’t convince you today” to accept buprenorphine, Carroll said, as if speaking with a drug user following an overdose reversal, “hopefully you will survive in the interim — but I’ll see you again.”