Denton County Ambulances Carry Naloxone for Overdoses
Denton Paramedic Bert Witherspoon shares his knowledge of Narcan
Sirens blare in the background as an unconscious woman sits slouched over in the passenger seat of a car. Medics gather the necessary tools and begin to swarm around the vehicle, prepping the woman for Naloxone. Within moments, the woman comes to, dazed and confused, but alive.
Since its debated conception in the 1990’s, the opioid crisis has continued to grow on a worldwide scale. Naloxone, or Narcan, has been a tool used by those in the medical field since its approval by the FDA in 1971, although it was not as heavily in demand.
Denton county, on occasion, has its run-ins with opioid overdoses similar to any other area. Twenty-year EMT-P and Scared Cross president Bert Witherspoon claims that, through his line of work, he’s found that opioids can be found in any community.
“It’s different in every place, but its not nonexistent in any place,” Witherspoon said. “Every place has narcotics overdoses. Depending on the area, it gives us an idea on whether we can anticipate more or less overdoses. Data can always be pulled to see which places are using more Narcan, but that is all up to the medical directors of that area, because while one medical director may be more laissez faire with the administering of it, another may be more conservative.”
Speaking as a practicing paramedic in the Denton area, Witherspoon says that, during his shifts, it is not uncommon for Narcan to be used for overdoses every 2-3 weeks.
A major reason as to why Naloxone has grown in popularity over the years, is because it has very little to no side effects. It is widely used to reverse overdoses; however, it can be used outside of narcotics-overdose cases as well. If someone were found unconscious and unresponsive and paramedics aren’t entirely sure of a possible overdose, they too could be given Narcan solely for resuscitation.
“Titrate-to-effect means you can give the amount that the patient will react to,” Sacred Cross paramedic Tyler Smith said. “If you do push it too quick, they get out of their high and they get very aggravated. They will get combative and they will fight because you’ve taken them out of their high that they paid for.”
There has been much speculation as to whether Narcan is helping or hurting the opioid epidemic. Some argue that Narcan only allows the problem to persist, as Narcan can be used repeatedly to revive overdose victims. Others see Narcan as a tool that helps to preserve the right to live, even for those who overdose continuously.
Outrage has been gaining momentum as certain officials have taken others’ lives into their own hands, deeming that after a certain number of times receiving help with Naloxone, medics will not be sent to aid someone with a history of chronic overdose.
Thus far, the majority of those who regularly see and treat overdoses concur that the problem is only being temporarily fixed. As the epidemic grows each day, those who are working in the field can only do so much as we wait for the cure to this world-wide disease.
Humanizing The Epidemic
A former homeless's struggle with substance abuse
Denton, TX – The cafeteria is empty, but he’s already there, sitting in front of a computer at a table sporting glasses, black and white PUMA running shoes, blue jeans and a blue hoodie with his name tag.
Myles Wood, 30, a senior program coordinator at Our Daily Bread has been working there for two and a half years. He came to the community soup kitchen in 2012, when he was homeless.
Wood said his main issue was substance addiction and PTSD (Post-Traumatic Stress Disorder) that led him towards homelessness. During a period of eight months, his heart stopped three different times due to substance dependence. When it came to drugs, he used “anything and everything.”
His battle with PTSD that led to substance disorder started in 2005 in an accident that handicapped his father and years later caused death.
Justin Watts, 32, an assistant professor at the University of North Texas and a national certified counselor explained that 80 to 90 percent of substance dependent people have a co-occurring trauma.
“On the more severe expression of trauma, PTSD would be a diagnosable condition,” Watts said. “Trauma would be, you know, anything along the lines of just a very emotional response to a horrible event.”
Wood said that when it came to drugs, he was all over map as long as he could feel numb. His drug of choice was weed, but he experimented with other drugs varying from hydrocodone – a synthetized opioid – to LSD.
According to Watts, when people switch from opioids to stronger drugs, such as fentanyl and heroin, it is likely because they have developed tolerance to the opioids when it’s no longer working effectively to control their pain. According to the National Institute on Drug Abuse, individuals who used non-medical pain killers over a period of 10 years were 19 times more likely to engage in the use of heroin.
Wood said that one of the outcomes of opioids is that it serves as a muscle relaxer, and the heart being a muscle starts to unwind to the point in which the organ no longer beats. He had similar symptoms to the ones present in opioids in one of the episodes in which his heart stopped to Xanax – a common drug prescription that dulls the central nervous system.
Watts explained that how people get dependent on opioid varies from situation to situation. In most cases, it starts when treating legitimate pain as in post-surgery circumstances or chronic pain. Even after rehabilitation from substance abuse from opioids there is still the possibility of relapse.
For Woods, Denton County Mental Health and Mental Retardation (MHMR) played a key role on his road to recovery from substance dependence.
“Recovery is a life long process,” Watts said. “When you talk about addiction it’s a very isolating disease and many times people have not developed ways to cope with emotional dysregulation.”
One of the many solutions to solve the opioid crisis, according to Watts, is treatment for mental health, trauma and the destigmatization of addiction. As he put it, the use from opioid to stronger drugs like fentanyl and heroin are just solutions to someone who might be abusing substances to solve underlying issues.
Justin Watts, Ph.D., estimates that at least 80 percent of addicts are victims of trauma at some point in their lives, and at least half have mental health issues.
“A child who has four to five traumatic experiences is 400 percent more likely to be a drug user,” Watts, a professor in the department of rehab and health at the University of North Texas, said. “It’s not that the event is universally traumatic, it’s that the child perceives it that way.”
Those traumatic events, which could range anywhere from physical abuse to a depressed parent, rewire children’s brains for a world that isn’t real once they are away from the trauma, Watts said. The children are then at increased risk of developing an addiction if they turn to substance abuse as a way to cope.
Addiction is a complicated disease that can be boiled down to, “repetitive behavior that persists despite negative consequences,” Watts says.
The brain of a person who is addicted has been physically changed, to the point where the decision-making part of their brain has been damaged.
Underlying mental health issues are another reason someone might develop an addiction.
“Patients with depression and anxiety disorders are much more likely to become dependent on alcohol and drugs than the general population,” Dr. David Sack said in an interview in 2010. “The majority of these clients experience psychiatric symptoms first and attribute their drug use to trying to reduce or eliminate their negative emotions.”
Sack is an addiction psychiatrist, and the chief medical officer of Elements Behavioral Health, who has appeared on Good Morning America and Dateline NBC to discuss addiction.
Eventually, he said, their problems multiply. Their psychiatric medicine “become[s] less effective. Psychiatric hospitalization becomes more likely and the risk of attempting suicide escalates.”
Genetics also affect a person’s propensity for addiction.
“Genetics play a large part in the development of addiction, but we aren’t sure of their exact role,” Sack said in an interview over the phone.
He says that around 50 percent of the risk of becoming an alcoholic comes from genetics. For cocaine he puts the risk at 60 percent, and for opiates 30 percent.
He is quick to point out that genetics are not the primary cause of addiction. Trauma and mental health issues have the biggest impact, he said.
Even if genetics were the primary cause, we don’t know which genes affect addiction.
“There’s no evidence so far on how a particular gene contributes [to addiction], and it’s probably not one gene, it’s probably multiple genes working together,” Sack explained.
People in their 20s and 30s can be more susceptible to substance abuse issues than older adults.
“The college age group is at risk because they do not always have life experience or resources to fall back on,” Sack said.
For example, a stressed student might turn to drugs or alcohol instead of identifying and working through the problem with a counselor.
Recovery from addiction is tough. Between 40 and 60 percent of all addicts in recovery will relapse at least once, according to data from the National Drug Abuse Institute, and many will relapse multiple times.
“I tell people ‘treatment is easy, just change everything!’” Watts said, jokingly.
The current standard of care is integrative treatment, also known as holistic treatment, which attempts to treat the full person, not just one aspect of their addiction. A person addicted to opiates, he said, would be treated with prescription medication to treat their physical dependence, while also undergoing some type of personal counseling to help resolve any underlying trauma.
“Physical and mental issues have to be fixed together,” Watts said.
The Lone Star State Chooses a Side in Polarizing Drug War
Since the ratification of Senate Bill 1462, drug companies' positions seem to align with that of Texas lawmakers.
If one were to guess the leading cause of death in young adults in North Texas, it might seem a safe bet to assume heart disease, or perhaps traffic accidents. Unfortunately, the truth is far more bleak — and potentially preventable.
As of 2016, opioid overdoses officially surpassed cancer and coronary disease as the number one cause of death in Texas amongst 25 to 54-year-olds. The death toll of prescription opiates and their street-drug counterpart, heroin, has skyrocketed over the past decade to what can only be described as pandemic proportions.
Although Texas is trailing other states in the percentage of overall opiate overdose cases, the lone star state is home to three of the highest-ranking U.S. cities to be affected by the opioid crisis, according to the Centers for Disease Control and Prevention.
Texarkana, Odessa, and Amarillo all have at least eight percent of their population abusing physician-prescribed drugs, including Hydrocodone, Percocet, and the controversial semi-synthetic opiate OxyContin.
EMTs and paramedics all over the U.S. have their schedules filled with responding to overdose cases. In many cases where the victim is still alive but unresponsive, first responders have been trained to administer the life-saving drug naloxone, an anti-overdose branded under the names Narcan and Evzio.
Naloxone is a narcotic blocker designed to be administered at the first signs of opiate overdose. Given by way of nasal mist, the drug can be rendered at full efficacy within five minutes, and is effective in under two minutes if administered intravenously.
Originally only available by prescription, “take home” Narcan first took off in Scotland, where opioid rates were skyrocketing. The World Health Organization listed naloxone as crucial to saving lives in their 2016 WHO Essential Medicines List (EML.).
In February of 2016, Walgreens president of pharmacy and retail operations Richard Ashworth announced in a press release that, along with Director of National Drug Control Policy, Michael Boticelli, the drugstore chain would be offering Narcan for sale as an over-the-counter medication.
“Walgreens pharmacists play an important role in counseling patients on the safe use of their medications, and now we are leading the way in retail pharmacy’s fight against prescription drug abuse,” said Ashworth. “We understand the challenges our communities face, and we stand ready to help our patients and customers lead healthier lives. When the stakes are this high, the solutions must be comprehensive.”
This announcement came after Texas legislature voted to ratify Senate Bill 1462, which allows for naloxone to be available without a prescription. Governor Greg Abbott faced wide criticism in 2015 when he vetoed House Bill 225, which would have also provided for the opioid antidote to be sold over the counter.
Gov. Abbott insisted that he was for the life-saving measures provided in HB 225, but felt that the proposal was not far reaching in measures to prevent future misuse.
When Senate Bill 1462 came along, however, there seemed to be no hesitation. Gov. Abbott approved the bill within minutes of presentation, calling for non-prescription access to naloxone to be available immediately to Texans.
The communities that have been hardest hit know all too well that the latest government and pharmaceutical measures aren’t a quick fix. even where the the take-home naloxone program first began. officials aren’t blinded by a quick fix, however the antidote being readily available does bring hope.
Roseanna Cunningham, the Irish Minister for Community Safety and Legal affairs, spoke to the World Health Organization about her take on the drug’s availability.
“This is about buying time,” notes Cunningham. “It doesn’t mean that you don’t have to have very serious, very fast emergency medical intervention, but it gives you time to get that intervention into place.”
As of Spring 2017, over-the-counter naloxone is available at 704 Walgreens Pharmacies and 715 CVS Drug stores in across Texas.
Opioids are abused the most out of all prescription drugs, according to the National Institutes of Health (NIH). However, that has not stopped doctors from prescribing them to patients nationwide, as they are seen as the most popular choice for pain management.
With the abundance of opioids that are used in medicine, it is also common for someone from any demographic to receive them for a prescription and not even know what they are. But what exactly is an opioid?
Opioids act on the opioid receptors in the brain. These receptors control pain and the reward system in our bodies. While these drugs are able to help us cope with pain, they also leave the chance for addiction, which comes from the opium poppy plant.
The opium poppy plant has been used throughout human history as a pain reliever, and a recreational drug.
From opium, substances with similar chemical makeup like morphine and heroin were created. Prescriptions drugs like Percocet, Oxycontin, and Vicodin were also created, all of which can also lead to addiction.
Synthetic and semi-synthetic drugs are also used with patients, although synthetic opioids, specifically Fentanyl, are extremely dangerous and are much more potent than its natural counterparts.
With these drugs used so often by doctors, addiction isn’t easily combated. These drugs are able to provide a sense of euphoria in the brain’s reward system for patients, resulting in the repetitive behavior of using the drug, even when not necessary.
This continued use tampers with the body’s chemical balance and builds a tolerance in the patient. As this tolerance builds, patients will have to take more than the suggested dosage to get the desired feeling from the drug, which can lead to overdose with such use.
According to the New York Times, prescription opioid-related deaths have leveled off, but deaths from heroin and fentanyl are still rising. In states like Rhode Island, Pennsylvania, and Massachusetts, where the crisis is particularly strong, fentanyl is now involved in over half of all reported overdose deaths.
Overdoses from prescribed opioids are a critical factor in the increase over 15 years of opioid overdose deaths. The amount of prescription opioids sold to pharmacies, hospitals, and doctors’ offices nearly quadrupled from 1999 to 2010, while deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have more than quadrupled since 1999. according to the Centers for Disease Control and Prevention.
Young adults aged 18 to 25 are the largest demographic that abuse prescription opioid pain relievers, ADHD stimulants, and anti-anxiety drugs, according to the National Institute on Drug Abuse. Younger adults and teenagers are prescribed the same addictive medications, and in some cases, even receive medication from friends or family members.
The controversy in the opioid crisis persists because of the lenient attitude that still persists with medications. Opioids assist many patients across with their recovery and pain management, but that does not mean that there are not any alternative medicines that can be used.
Yoga, meditation, massages, and other forms of physical therapy have all been recently implemented by doctors to assist with pain management, instead of relying solely on opioids. These treatments work by focusing on helping patients manage pain and stress naturally, instead of relying on opioids to temporarily stop the pain.
Unlike opioids, these alternatives do not have any side effects that come with treatment.
These alternatives can also be cheaper than actual medication, as even weight loss and exercise can be beneficial to pain management, according to Harvard medical school.
Non-opioid medications have also been used in place of opioids, to avoid the habit-forming nature of the medicines. Based on a study done by the Washington Post, patients were given either acetaminophen with ibuprofen or one of three commonly prescribed opioids: oxycodone, hydrocodone or codeine. All participants reported essentially identical declines in pain, about four points on the scale.
While alternatives are available, getting away from opioids on a grand scale will not be easy. While states use electronic databases called prescription drug monitoring programs (PDMPs) that track controlled substance prescriptions, there’s still no clear efficient way to cut back on opioids. However, with the national coverage that this crisis has gained, as well as the continuous research into alternative medicine, patients and doctors alike are able to consider other, safer choices for treatment.