Last week, Hennepin Healthcare Emergency Medical Services Assistant Chief Ryan Mayfield responded to an overdose call—a common enough scenario, especially on a summer Friday. Hennepin EMS paramedics treat about 10 to 20 overdoses a day.
In this case, bystanders told the 911 dispatcher that the man who had overdosed was not breathing, so they had started CPR. They also gave him naloxone, a drug that reverses opioid overdoses.
When emergency response crews arrived, the man was awake, breathing and talking; he’d likely been given several doses of Narcan. But his heart rate was rapid, his joints ached, he was restless, sweating and had goosebumps all over his body, Mayfield said. In other words, he was experiencing moderately bad withdrawal symptoms.
The paramedics realized it was a perfect opportunity to use their latest tool to combat the opioid epidemic. They asked the man if he’d ever taken Suboxone, a drug used to reduce dependence on opioids that can also prevent withdrawal symptoms if taken in a timely manner.
The patient replied that he had taken it before, and it had made him feel bad. Suboxone works best when given in a very specific time window, usually within 30 minutes of taking Narcan. The paramedics explained that he’d probably gotten it too late that time, but that this time would likely be different. Eventually, he agreed to try it.
“Within about 15 minutes, by the time we got to the emergency room, he was much more relaxed,” Mayfield said. “He didn’t have quite the same look of discomfort and pain.”
It was just the second time the drug had been used in the field by Hennepin EMS. This month, paramedics were trained to administer Suboxone in order to capitalize on the short window of time when it is most effective to jump-start recovery from opioid use disorder. They started carrying it on ambulances last week, becoming one of a handful of paramedic systems in the country that administer it.
Fatal opioid overdoses have increased exponentially in the past few years, especially among certain races, said Dr. Aaron Robinson, the assistant EMS Medical Director for Hennepin Healthcare. The rate has more than tripled for Black Minnesotans, from 59 deaths in 2019 to 212 in 2021; and it quadrupled for American Indians, from 27 deaths in 2018 to 112 in 2021.
“This program is especially going to benefit these people a lot, and I’m really happy about that,” he said.
Camden, New Jersey, paramedics started offering the drug to patients in 2019, after a small pilot trial indicated it could increase the odds that patients will seek treatment.
“We were pretty excited it worked as well as it did,” said Gerard Carroll, EMS Medical Director at Cooper University Health Care in New Jersey. “We knew what the medicine would do, but we weren’t sure how often people would be willing to take it.”
In order to start the conversation about Suboxone, the situation needs to meet several criteria, he said: Patients must regain capacity to talk coherently and be experiencing mild to moderate withdrawal symptoms.
“We don’t want to cause withdrawal symptoms,” he said.
Data showed that the Camden patients who took Suboxone suffered fewer withdrawal symptoms and were more likely to participate in outpatient addiction follow-up care. They were no more or less likely to overdose again. The study concluded that the program could be a “promising model” for “a patient population that often has limited contact with the health care system.”
Now, Camden paramedics have treated over 200 people with Suboxone, and all have reported an improvement in withdrawal symptoms, Carroll said. Over a third went to their first follow-up appointment for long-term treatment.
At Hennepin, the idea was hatched about a year ago during a meeting with addiction specialists, when one specialist mentioned how helpful it would be to see patients within 30 minutes of receiving naloxone. That window of time is critical because withdrawal has already happened, so the drug works to alleviate symptoms instead of aggravating them.
Paramedics see a lot of patients within 30 minutes, Dr. Nicholas Simpson, Emergency and Hennepin EMS Physician at Hennepin Healthcare, pointed out. “That 30-minute window is the critical piece. They’ve had this experience, and for somebody who’s had this experience, they often say, ‘I never want to take this again,’ and we can offer them this door out,” he said.
It’s a chance at recovery that realistically can only be offered by paramedics. In the case of the man treated by Mayfield’s team last Friday, it’s extremely unlikely the patient would have arrived at the hospital within that 30-minute time frame.
Carroll confirmed the tight timetable makes it unrealistic for ER doctors to offer Suboxone.
“In the emergency department, you have to wait,” he said. “You have to be registered, triaged, see the nurse and the physician. You could be very sick and waiting a very long time before we can get it to you in the hospital.”
Patients are unlikely to take Suboxone if the window is missed and it means putting themselves back into withdrawal, Carroll said. That system had left paramedics frustrated that the effects of saving a life with naloxone often felt like little more than a Band-aid, Simpson said.
“It’s exhausting to see the opioid numbers continue to rise, and yes, we can reverse you in the moment, but it seems hopeless to impact lasting change,” he said.
It’s not uncommon for paramedics to see the same patient overdose again, sometimes within hours of the first overdose, Mayfield said.
“I hope this helps patients and responders to have something in their toolbox that could have a longer-lasting impact than a few hours,” Simpson said.
In the field, paramedics can administer drugs, but not prescribe them. So, after that initial dose of Suboxone, paramedics bring the patient to the hospital where they can get a prescription and be connected to resources. Ideally, hospital staff work with community partners to find a culturally specific recovery program, Robinson said.
“Patients who have had massive heart attacks go home on three to four medications,” Robinson said. They might be enrolled in a cardiac rehabilitation program, he explained, and they would definitely be seen for followup appointments.
While there is a similar risk of death in patients released from the hospital following an opioid overdose, “we’ve really had nothing,” Robinson said. “So this is a step in the right direction.”
When the timing isn’t right
Research on the Camden paramedics has found that 7 to 10 percent of overdose patients are offered and agree to the Suboxone intervention. In addition to those who don’t go into withdrawal, some are not ready to engage in treatment. Others are distrustful of the medical system.
And the timing often isn’t right. On a recent afternoon, Hennepin paramedics responded to another overdose call: A man was not breathing and bystanders had administered a couple of doses of naloxone. Paramedics and fire crew arrived and started CPR and gave more naloxone via an IV. When the man finally became responsive and moved his arms, bystanders and family breathed sighs and shed tears of relief.
“How are you feeling?” Lukas, one of the paramedics on the scene, asked. The man confirmed he’d been smoking fentanyl.
Lukas and Matt transferred the patient to the ambulance in a stretcher, explaining that he’d go to the emergency room to get the drugs out of him safely. Lukas monitored his breathing en route, administering more small doses of naloxone based on his oxygen levels, covering him with a blanket as he started shivering.
Although the man mumbled responses to questions, he was not alert enough to start the conversation about Suboxone.
With the naloxone, his life was not currently endangered, Lukas explained. “He was lucky enough to have those bystanders,” he said. But because opioids linger in the body longer than naloxone, 15 percent of patients experience a “re-overdose,” he said, so hospital staff monitor overdose patients for several hours.
And like all patients who overdose and stop breathing and are revived with naloxone, the man faces a high risk of death after he’s released from the hospital: “There’s a 1 in 10 chance you’ll be dead in 12 months,” Carroll said, usually due to another overdose.
While a program that reaches a small percentage of overdose patients might not seem like a lot, Carroll said, it’s a decent shot at getting someone into long-term treatment — and saving their life.