A New Approach to Breaking the Cycle: Creating a Shift in Emergency Medical Services to Address Substance Use Disorder
September 15, 2020 | Timothy Seplaki
Emergency Medical Services (EMS) personnel arrives on a scene to find a middle-aged man unconscious and not breathing, in the bathroom, suffering an apparent opioid overdose. Both EMS clinicians recognize the patient (it would be the third time this week they treated him with naloxone, the medication used to reverse opioid effects). As they continue to ventilate the patient after administering the drug, the patient’s eyes open and he sits upright pushing the oxygen bag valve mask away from his face.
The patient looks at the emergency personnel around him with a slightly dazed look as a paramedic starts asking him if he knows where he is, his name, and what day it is. The patient pauses for a moment before successfully answering the questions. “Do you want to go to the hospital?” the paramedic asks. The patient looks around the room and responds that he doesn’t want to go. The second EMS clinician leans in and asks “You know you almost died, right? Are you sure you don’t want to go?” The patient responds that he is sure. Clearly frustrated, EMS quickly places the computer tablet with the Refusal of Care Against Medical Advice form in front of the patient and obtains a signature knowing they will likely be back again in a few days, or perhaps again before the end of their shift. What they don’t realize is that they are often the only medical professional that person will see that day, making this a critical opportunity to invoke a change in this person’s life—sadly, a critical opportunity missed.
Finding a Better Way
Between January 1, and June 30, 2020, 1,595 people died due to a suspected opioid overdose in New Jersey—that’s more than eight victims dying a day of a preventable disease. Each day in 2020, New Jersey EMS clinicians administered naloxone an average of 37 times for suspected opioid overdoses. That is 37 chances to offer help and resources for recovery. However, in those precious minutes after initial patient recovery, it is all too common that EMS is focused only on the patient’s physical response to the naloxone, leaving the patient with little options to make a change in their lives. At the same time, EMS grows more frustrated (creating compassion fatigue), treating the same patients several times a week and in some cases, creating an endless cycle. Repeating the exact same behavior and expecting the outcome to change has resulted in stagnation. Meanwhile, lives are being lost, and EMS burnout is a reality. We urgently need to do better, and we can do better.
Creating a Paradigm Shift in EMS
While EMS has evolved since its formal recognition in the early 1970s, the focus is still on treating physical emergencies with little to no focus on mental health or complex psychiatric trauma. However, there have been recent efforts to break the stigma of both mental health and substance use disorder (SUD). For the patient, that means treatment beyond the naloxone reversal. With EMS being on the front line and having direct contact with the SUD population, it is imperative that attention be shifted to the importance of aftercare, incorporating recovery resources, and mental health awareness. The latter must include self-awareness. EMS personnel are often lacking when it comes to self-care, likely because mental health has been interpreted as a weakness and is often stigmatized. EMS clinicians should be reminded they are human and vulnerable like everyone else, and there is a need to focus on themselves and each other. It is OK to ask for help for themselves. If we don’t take care of the clinician, how can we take care of the patient? By accepting vulnerability in ourselves, we can better respond to our patients suffering from mental illness or substance dependence by encouraging them to seek help through resources brought to their attention.
EMS Clinicians Are Not Counselors
EMS clinicians are not trained to be counselors, nor is counseling the goal of EMS post overdose care. The goal is to take full advantage of those critical few minutes after the patient is revived from an overdose—when only EMS has access—and utilize that time to bring awareness and support to an individual who may or may not know where to turn for help. EMS clinicians should be trained on treating SUD as a chronic disease, understanding the components of addiction treatment and harm reduction, motivational interviewing, and proper communication with individuals following treatment from a suspect opioid overdose. Additionally, EMS clinicians need to be fully informed and aware of recovery resources that are available locally, regionally, and statewide, and have access to materials to provide patients post overdose. New Jersey has implemented a course to address these critical topics.
Five Minutes to Help
In 2019, the New Jersey Office of Emergency Medical Services rolled out “Five Minutes to Help.” This innovative program was developed in partnership with the Rutgers University’s Center for Public Health Workforce Development and Seton Hall University’s School of Health and Medical Services, who developed the online module. The "Five Minutes to Help" program consists of an online and a classroom component. The program's goal is to educate first responders on the foundations of motivational interviewing and how to apply it to individuals treated for a suspected opioid overdose, provide recovery resources, and address the stigma of SUD. It also includes EMS Opioid Resource Kits, which were distributed to EMS agencies around the state. These kits contain valuable information that is to be provided to the patient, which discusses SUD and what resources are available locally and regionally. It also allows patients to know that help is just one call away.
Evoking the Change
One of the first steps to change perceptions is for EMS clinicians first to recognize the basic need for help. Most individuals choose the field of EMS because, at some point, they have the desire to help people. For chronic users of the 911 system, EMS clinicians can get to know these patients on a first-name basis. They can (and often do) build trust and rapport with the patient. However, not all relationships are created equal. A patient with SUD is often seen differently from a patient with diabetes who has poorly controlled blood sugar levels. Often the reason is the misconception that SUD patients “choose to use.” When EMS treats the diabetic having a hypoglycemic event with dextrose, they will typically make sure the patient knows to eat a meal, so their blood sugar won’t drop again. They give the patient instructions or “resources” on preventing a reoccurrence. But for the patient with SUD, the options are only “go to the hospital or sign a refusal of care.” EMS may repeatedly return to the same patient in both cases, however, there are no instructions or resources given to the patient with SUD.
If EMS can change the perception of patients with SUD, they will see that building rapport and encouraging the patient to seek help from resources they provide can be mutually beneficial. For EMS, it reduces the call volume, and often the financial cost, of repeated responses for the same patient—and the patient gets the help they need to break the cycle of substance dependence. EMS clinicians need to be aware that patients often won’t accept help the first, or sometimes even the third time they meet. However, if they are consistent in their message, EMS clinicians may be able to do what they set out to do every day, make a difference, and save lives.