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Chasing a Killer

February 02, 2017 6:00 PM | Rob Layne (Administrator)

As America's opiate problem explodes, the nation's fire service finds itself on the front lines of a full-fledged public health crisis. As responders' resources are stretched and as opioid-related deaths climb, fire officials are faced with tough challenges: How much should the fire service be expected to do? And is there a better way to do it?

BY JESSE ROMAN

The 911 dispatcher’s updates blaring through the truck cabin grew increasingly darker as Daniel Goonan raced to the scene of a drug overdose last October—a desperate little boy; an unconscious mother dying on the kitchen floor; opiate use was suspected.

“You could hear the situation building over the radio—the operator talking to this nine-year-old, telling him how to do CPR on his mother,” Goonan, the fire chief in Manchester, New Hampshire, recalled. “This was a kid who was getting ready to go to school, eating his Cheerios, and all of a sudden he looks over to see his mother lying there purple.”

When Goonan and his team arrived, they administered naloxone hydrochloride, an opiate reversal medication that can almost immediately counteract the deadly effects of an opioid overdose—but after the first dose the woman remained motionless. After a second dose, her breathing finally returned, all while “the little boy is sitting there at the table,” Goonan said somberly.

For the Manchester Fire Department and for thousands of others in this opiate-riddled New England city of about 110,000, the scene has become common. Through the first 11 months of 2016, Manchester had 721 opiate overdoses—an average of more than two per day—and 88 opiate overdose deaths. The fire department and local ambulance services have administered nearly 1,000 doses of Narcan, the brand name for naloxone. More than 100 overdose victims have been found unconscious, barely breathing, and dying in hotels, restaurants, and other public buildings, or in parked cars—even while driving. At least 65 people have been brought back from the brink of fatal overdoses more than once in 2016, including eight cases where first responders revived the same person twice within 24 hours.

Goonan, a 32-year department veteran, grew up in Manchester, a brick-clad former mill city on the banks of the Merrimack River, and admits that drugs have always been prevalent here. “But I’ve never seen the problem so terrible,” he told me. “It’s like nothing I ever expected.”

The rise of opiate abuse is hardly unique to Manchester. Opiates in the form of prescription pills, heroin, and increasingly powerful synthetics like fentanyl have indiscriminately swept across the United States like a plague, infecting all types of communities—from rural hamlets in Appalachia and the rust belt to the nation’s largest cities—with equal ferocity. In 2015, the most recent year tracked by the Centers for Disease Control (CDC), more that 52,000 people in the U.S. died from drug overdoses, or about 144 each day, with the majority of those deaths opioid-related. Nationwide, fatal opioid overdoses increased 652 percent from 2000 to 2015, according to CDC statistics, and every indication is that the problem has grown worse in 2016. Many states have all but declared full-fledged public health emergencies.

The fire service is dealing with several challenges as the opioid crisis explodes. For one, call volume has risen with overdoses, leaving departments to bear a slightly heavier load, typically with the same or fewer resources. In addition, some departments have felt an economic toll as naloxone prices skyrocketed—from $6 per dose to $45 per dose since 2010, according to one chief interviewed for this story—as demand for the drug increases. To carry the slack, in some cases state and federal governments have provided funding to departments to purchase the medication, while in some communities private organizations have donated hundreds of doses of the life-saving drug.

For the typical line firefighter, the biggest change has perhaps been adjusting to an expanded role as the opiate crisis worsens. Previously, only paramedics or higher-level EMTs were allowed to administer drugs in most states; over the last couple of years, however, numerous jurisdictions have rushed to expand the types of responders allowed to carry and administer naloxone. Training and oversight have been ramped up as a result, and for the most part states and agencies have met the challenge to get members adequately trained before supplying them with the drug, said Thomas Breyer, a former firefighter and paramedic in Ohio who is now the director of Fire/EMS Operations at the International Association of Fire Fighters (IAFF).

“Training is critical because this is a change for a lot of providers, and when you administer any kind of emergency services you want the responder to have some muscle memory—see it, do it,” Breyer said. “It’s not as simple as ‘here is a new medication, here’s how to deliver it,’ and then give them a pat on the back and let them go.”

Even with training and preparation, the crisis can at times overwhelm responders. Last August in Huntington, West Virginia, emergency responders saved 26 overdose victims in the span of less than four hours. In Marion, Ohio, a town of 35,000 people, the city fire and rescue department dealt with 30 overdose hospitalizations and two deaths during a frantic 12-day stretch in 2015.

“I hate to see Marion making the news because of this, but we need some help,” said Rob Cowell, the town’s fire chief. “We’ve picked up overdoses from people who were 14 years old all the way up to 67. It’s been all over town, across every socioeconomic class. It’s a national problem that we are trying to deal with on the local level, and we are swimming in it and having a hard time keeping our heads above water.”

SEARCH FOR SOLUTIONS

In some places, it’s easy to see why fire departments might feel like they’re sinking. In Ohio, opiate-related drug overdose deaths increased a staggering 775 percent from 2003 to 2015, according to the Ohio Department of Health, growing from 296 deaths to 2,590. Massachusetts had 1,747 opioid drug deaths in 2015, up from 532 in 2010, according to the Massachusetts Department of Health. Similarly dramatic increases have occurred in New Hampshire, New Mexico, Alabama, West Virginia, Maine, North Dakota, Indiana, Pennsylvania, Georgia, and elsewhere.

The opioid crisis and the changes it has brought for the fire service have produced frustration in some responders. Last February, a firefighter in Weymouth, Massachusetts, was suspended 90 days without pay for a Facebook post that suggested letting overdose victims die. “I for one get no extra money for giving Narcan and these losers are out of the hospital and using again in hours,” the post said. “You use, you should lose!” The department quickly issued a statement denouncing the post and said it did not reflect its philosophy or values.

The vast majority of firefighters and EMTs, however, have met the new challenge with resolve, viewing it as a necessary response to a community crisis. “We are an all-hazard department and so it really doesn’t matter what the problem is—if lives are on the line, we believe there is a social and civic responsibility to address it,” said Matthew Levy, the medical director of Howard County Fire Rescue, a county in Maryland located between Baltimore and Washington D.C. “Whether it is an evolving threat like terrorism or an infectious disease like Ebola, when the community calls on the fire service, we have that responsibility to respond. Saying it is not our problem is not the answer or a long-term solution.”

While difficult hurdles remain for some fire departments, most have adjusted and have handled the increased cost, training, and call volume resulting from the drug crisis, Breyer and others told me. It’s the personal toll that has been the hardest for some responders to overcome. Bringing a person back from the brink of death, only to find them blue and unconscious from another overdose a week later, is sometimes difficult to bear, they said. That’s the dark reality of the opiate epidemic that responders see every day.

“It causes first responders to say, ‘there has got to be a better way,’” Breyer said. “If I make the same run on the same guy week after week, we’re not solving any problem, we’re just making sure the same person doesn’t die. But we’re not helping these people all the way—this person needs treatment.”

The mounting desperation in communities has led many fire departments to think differently about the crisis and to assume a larger role in finding solutions. “It’s to the point here where folks begin to realize that this is not just a problem that someone else’s family has to deal with—we’ve had very tragic overdoses in this county, including family members, friends, and close relations of personnel at the fire department,” Levy told me. “When you look at the sheer numbers and impact on the community and put it in that perspective, you start to realize that we need to begin to craft more out-of-the-box strategies.”

One of the more innovative strategies is Manchester’s Safe Stations program. Beginning last May, drug addicts seeking help were invited to visit any of the Manchester Fire Department’s 10 fire stations—24 hours per day, seven days a week—to begin their road to recovery. The program works in partnership with a recovery center called Serenity Place, which is located adjacent to the central fire station downtown.

Chris Hickey, Manchester’s director of emergency services, got the idea for Safe Stations last spring when a relative of a Manchester firefighter showed up at a station looking for help. He was homeless, addicted, and desperate. “When he started talking to us it was apparent he was serious about getting help, but he said there was nowhere for him to go—he had made calls and went to a few websites, but nothing was happening,” said Hickey, a longtime EMS provider in the city. “I was doing some work at a local recovery center at the time. I contacted them and they said just bring him in.”

The experience gave Hickey an idea: instead of merely treating the symptoms of addiction by rushing around the city bringing addicts back from death, perhaps the fire department could play a larger role by getting addicts into treatment. Hickey took the idea to department leadership, and the program was up and running within weeks. According to Goonan, “We jumped into the program with both feet—our thinking was, ‘let’s stop talking and let’s start doing something.’” When addicts looking for help arrive at a Manchester fire station, they are greeted with a quick physical and mental health assessment. A counselor from Serenity Place is summoned to the station to meet with the patient, who can register on the spot in the center’s outpatient program. On average, a patient sees a licensed drug and alcohol counselor within 12 minutes of entering a fire station.

“When someone is ready to make a change you have to get them at that moment,” Goonan said. “They are greeted with no judgment, just a handshake and a comfortable place to go. Historically this is what the fire service does—help people.”

When the department first opened its doors to addicts, nobody knew what to expect. Goonan thought they’d see maybe five to 10 people a month. From May 4 to December 1, though, there have been a total of 821 visits to Manchester fire stations from people looking to get clean, an average of nearly four per day. Patients have ranged in age from 18 to 70, and have come from all over New Hampshire, as well as a substantial number from Maine, Massachusetts, and as far as Alabama. More than 400 patients have been brought into the Serenity Place recovery program through Safe Stations.

“Some use us as a first option, some as a last,” Hickey said. “A lot of people who come in are broken. They are mentally worn out, physically a mess. Many had made phone calls and got on waiting lists, but nothing happens and they end up frustrated.”

“UNINTENTIONAL BOOST”

The proactive rather than reactive approach to the overdose epidemic has also lifted spirits inside firehouses, Hickey told me. At first, some firefighters were wary of the idea, and worried that violence might follow addicts into the stations. But in the nine months the program has been operating there hasn’t been a single incident. Instead, the program “has worked wonders for our department mentally,” Hickey said. “We were getting tired, angry, and frustrated going to dozens of overdoses every month, seeing families ripped apart, doing CPR, watching kids do CPR on their parents because they had overdosed. But these people are coming to us before they overdose, before they are dead, and it has quite unintentionally given everyone a boost.”

Goonan himself handles many of the intakes, like the 22-year-old woman with two young children suffering from endocarditis who, when asked her drug of choice, replied, “anything I can get my hands on.” Or the 61-year-old house painter who became hooked on pain medication when he hurt his back on the job and two years later was addicted to heroin and crack.

“He told me ‘I’m desperate for help, I’m going to lose everything I have ever had—my wife, my home, my children,’” Goonan told me. “We see people like him every day. I think the stigma is starting to lift a little bit. People are more willing to come in and admit they have a problem.”

Manchester Fire Department officials believe the program can work elsewhere and are helping others adopt it, including the nearby city of Nashua, which recently started its own version of Safe Stations, and a fire district in the Bronx that is planning to launch a pilot program this year.

Community engagement and cooperation from various public and private organizations, ranging from hospitals, safety agencies, health departments, local charities, and church groups, have been key to the program’s success, Hickey said. “We now have open lines of communication with all of these groups, which is a huge advantage,” he said. “I think that is one of the biggest first steps to addressing this issue.”

That holistic community approach is one others should try to emulate, said Breyer, the fire and EMS director at IAFF. “If we really want to solve the opioid epidemic, fire, EMS, and all these public safety agencies need to be a part of the bigger solution,” he said. “We all need to realize that we can’t operate in silos. We need public health, social services, mental health, fire—we need everyone working together through a network.”

Many fire departments across the nation are starting to take that approach. Beginning December 1, overdose victims transported to the hospital by fire and rescue in Marion, Ohio, are now met in the emergency room by a drug councilor, a significant shift for the city.

“It used to be that an overdose was charged with possession [of a controlled substance], but we’re not doing that any more. We’re just trying to get these people help,” Cowell said of the program, which has involved coordination between fire and rescue, police, and a local hospital and counseling center.

Howard County, Maryland, recently formed a community-wide drug task force with representatives from the fire department, police, health department, corrections, hospitals, and other stakeholders.

“We all see this problem from different angles, and so I think the most impactful thing we can do is come together to share ideas, observations, and trends,” Levy, the fire department medical director, told me. “We are trying to break down those barriers and begin to create a plan for a comprehensive solution.”

The group is working to create an interagency data dashboard where the various agencies can view each other’s information with the hopes of uncovering patterns that can lead to better-targeted intervention. They are also discussing policy changes, such as making naloxone nasal spray publically available in strategic places across the county for the public to use in overdose emergencies.

“This is not a problem that is going away soon—this is not Ebola, or Zika, not something that comes and goes,” Levy said. “This is a problem of epidemic proportions and it is going to be with us for a long, long time.”

It’s too early to know the impact these initiatives will have, but there’s no doubt it will continue to be an uphill slog. Despite efforts to combat the roots of the problem, initial estimates in Marion, Howard County, and Manchester are that each had a record-high number of opiate overdoses again in 2016. Marion had more overdoses and deaths through the first 11 months of 2016 than it did in all of 2015; Howard County averaged about 22 percent more opiate-related overdoses per month in 2016 than it did the year before; and in Manchester, total opiate overdoses were up about 6 percent through November compared with 2015.

But there’s hope, too, and signs that Safe Stations is making progress. From August through November, Manchester saw 51 fewer overdoses and five fewer deaths than it did during the same period in 2015. Goonan and Hickey are hopeful that the trend will continue, but they are also realistic about the foe they are up against.

“We could be trending lower for months, and the next thing you know a new dealer comes in with a new synthetic opiate and we have seven or eight deaths and people start saying it’s not working,” Goonan said. “But in my professional opinion we are certainly saving lives, and every time someone walks through our front doors we are giving them a real shot at recovery.”