The state of Massachusetts just passed an emergency protocol change requiring all paramedic ambulances to carry non opioid pain management alternatives, including Ibuprofen PO, Acetaminophen PO and Ketorolac IV or IM.  Acetaminophen IV is optional.  The changes are to take place January 1, 2018.

Massachusetts Pain Management Protocol

Emergency Non-Opioid Pain Treatment Options Update

Here is the dosing regime:

Adult

Acetaminophen 1000 mg IV or PO

Ibuprofen 600 mg PO

Ketorolac  15 mg IV or 30 mg IM

Pediatric

Acetaminophen 15 mg/kg IV or PO to max 1000 mg.

Ibuprofen 10 mg/kg PO to max 600 mg.

Ketorolac 0.5 mg/kg IV or IM to max 15 mg.

The Massachusetts protocol includes the following note:

All pain medications have contraindications-do not administer medications in

such circumstances. These contraindications include but are not limited to:

Ketorolac and ibuprofen are contraindicated in head injury, chest pain, abdominal pain,

or in any patient with potential for bleeding, ulcer, or renal injury; likely to need surgery

Acetaminophen is...

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The Connecticut Office of Emergency Medical Services (OEMS) in conjunction with UConn John Dempsey Hospital has just released a free 1 hour on-line EMS CME: The Opioid Overdose Epidemic: The EMS Role.

The auto-narrated program discusses the background of the opioid epidemic, Connecticut death statistics, Connecticut CORE initiative, the science of addiction, the dangers of fentanyl and fentanyl analogs, opioid overdose treatment, provider safety, prevention initiatives, data collection, harm reduction, and stamp bag recognition.

It can be accessed here:

The Opioid Overdose Epidemic: The EMS Role

You will just need to create an account with Train Connecticut, which is quick, easy and free.  On completion of the course you will be able to download a CME certificate.

Across the nation harm reduction workers are going out in the street, meeting heroin users face to face and testing their powdered drugs for fentanyl.  They are not afraid because they know that touching fentanyl cannot kill you.  They do take precautions.  They wear nitrile gloves when they dip the tester strip into the powder.  If one red line comes up instead of two, the powder contains fentanyl.

Fentanyl Test Strips

“Be careful,” the harm reduction worker warns the user.  “Put two in the cooker instead of five.”

They take the user’s dirty needles and exchange them for clean needles.  If the user doesn’t have Narcan, they give them a kit and the training on how to use it.

“Be safe, brother,” the worker says.

“God bless,” the user answers.

In Hartford, harm reduction workers report most of the bags they test contains fentanyl.

Greater Hartford Harm Reduction Coalition

The latest death statistics out of the Connecticut Medical Examiner’s office confirm this preponderence of fentanyl.

Connecticut Accidental Drug...

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539 people in Connecticut died of accidental drug intoxication deaths during the first six months of 2017, which projects to 1078 for the year, an increase of 17.5% over 2016, according to the state Medical Examiner’s Office.

Fentanyl continued to fuel the rise in deaths.

Fentanyl was present in 322 deaths during the first half of 2017, which projects to 644 for the year, an increase of 34% from 2016.

(Graph: P.Canning)

Fentanyl was present in more deaths than Heroin.

Fentanyl was present in 322 deaths in the first six months, projecting to 644.

Heroin was present in 257 deaths in the first six months, projecting to 514.

Heroin and Fentanyl together were present in 177 deaths, projecting to 354.

Heroin without Fentanyl was present in 80 deaths, projecting to 160.

Fentanyl without Heroin was present in 145 deaths, projecting to 290 deaths.

(Chart: P.Canning)

No end in sight.

Full data can be viewed here, including all opioid and other drug deaths.

Connecticut Accidental Drug Intoxication Deaths Office of the Chief Medical Examiner

In view of Hurricane Harvey and the rescue efforts now underway, I am posting notes from my journal when I was posted in Gulfport, Mississippi in the aftermath of Hurricane Katrina.

Day One: Waiting

On the morning of September 17, we meet at the office and a chair van driver takes us up to the airport. There are five of us: two medics, two EMTs, and a mechanic. When we go through the ticketing the airline agent puts a red mark on our tickets and says, we’re all special. I am thinking, isn’t this nice. They are recognizing our efforts and are going to be upgrading us to first class or maybe giving us complimentary access to the VIP lounge while we wait for the flight.

When we go through security, we find out what the red mark means. We have been tagged as security risks (probably because we bought our tickets at the last minute). We stand with our feet spread, arms held out while we are beamed with electronic wands, and then frisked, and have to watch as they painstakingly go through every item in our bags.

The flight is...

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One of the main reason opioid overdose deaths have been increasing is the rise of fentanyl sold either combined with heroin or in place of heroin.  Fentanyl, which is 50 times stronger than heroin, has a stronger affinity for the opioid receptors in the brain than heroin.  Toxicologists have said that while naloxone is still capable of knocking the fentanyl and other fentanyl analogs off the receptors, it may, in some cases, require a larger dose of naloxone.

A research paper, Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing, published recently in Prehospital Emergency Care, concludes that the number of patients receiving multiple doses of naloxone is increasing. 18.2% of prehospital patients in their study who received naloxone required more than one dose.  The researchers used data from the National Emergency Medical Services Information System (NEMSIS) from 2012-2015.  Over that 4 year period multiple naloxone administrations increased by 26%.  Patients in the Midwest and Northeast...

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You carry four 100 mcgs vials of Fentanyl in your controlled substances kit.  How much would those vials be worth on the street?

Let’s do the math.

100 mcgs of Fentanyl is the equivalent of 10 mgs of Morphine.

Morphine is 50% as strong as heroin.

Morphine is the equivalent of 50% pure heroin.

A bag of heroin in Hartford contains 0.1 grams of powder.

0.1 grams of 50% pure heroin is 50 mg of heroin and 50 mgs of filler.

50 mg heroin is the equivalent of 100 mg morphine.

100 mg Morphine is equivalent to 1000mcgs of Fentanyl.

1000 mcgs of Fentanyl is 10 vials of 100 mcg Fentanyl.

A 0.1 mg bag of 50% pure street heroin is the equivalent to 10 vials of 100 mcg Fentanyl.

A bag of heroin costs $5 on the Hartford streets.

Each 100 mcg vial of Fentanyl is worth 50 cents.

Four 100 mcg vials of Fentanyl is worth $2.00.

When was the last time you were held up at gun or knifepoint for your controlled substances by a heroin user?

Ever wonder why 100 mcgs of Fentanyl doesn’t touch the...

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While headlines of deadly Fentanyl creating Haz Mat scenes and causing first responders to be hospitalized continue to dominate the news, on July 10, 2017 with little fanfare, the US Institute for Occupational Health and Safety removed the statement “skin absorption can be deadly” from its Fentanyl page.

You can read their safety recommendations here:

Fentanyl: Preventing Occupational Exposure to Emergency Responders

A rational article on what is becoming an increasingly hysterical situation was published by STAT.

Are people really falling ill from touching fentanyl? In most cases, scientists say no

Here is an informative passage:

Juurlink said the real culprit in these cases may be a phenomenon known as the nocebo effect, in which the mere suggestion that a substance can be harmful causes people to suffer negative effects after exposure. In medical research, for example, being informed of side effects related to a pill or procedure can bring on real-life symptoms.

“If in a moment of panic, a person sees powder on their skin and they’ve read...

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The call is for a possible overdose.  A tall attractive young woman in leopard skin pants, and a Ginger from Gilligan’s Island hairdo, meets us at the apartment door.  She is high. Her balance as she sways in front of us is so bad it is making me dizzy just looking at her. “Thank you for coming so quickly,” she says.

“Is he breathing?” I ask.

“Yes, but he won’t wake up. He had his methadone dose upped today and he took some of my benzos. I did CPR on him.”

The apartment has hardwood floors, high ceilings and big windows that look down on the city from the 4th floor of the recently renovated building. I follow her as she stumbles down the hall. “This way.”

A bare-chested bearded man in his thirties lays on the bed, clearly on the nod, but breathing. He has a strong pulse. Some stimulation and he sits up with a jerk to see me, my partner and four firefighters.

“What did you do?” he says to his girlfriend. She begins to cry.  “I saved your life,” she says. “I did CPR on you. 30 and 1. I threw cold water on you. You almost died.”...

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Thesis:

People addicted to prescription painkillers who buy their pills on the black market switch to heroin because it is a better economic deal (cheaper and stronger).

The Situation:

When a person’s painkiller prescription runs out or their tolerance outruns their prescription, and the user still needs opioids to keep from being sick, the user turns to the black market and buys painkillers on the street.

In Hartford, the going rate for oxycodone is $1 per milligram.  A 30 mg oxycodone costs $30.  The same person who sells them oxycodone often also sells heroin.  Heroin in Hartford goes for $5 a bag.

For $30 you can buy 6 bags of heroin.  (This is without any discount.)

If the strengths were equally priced, a 30 milligram oxycodone would be the equivalent of six bags of heroin.

It is not.  Heroin is not only cheaper than oxycodone, it is stronger.

Let’s do some math.

The Math/Assumptions

An oxycodone 30 mg is the equivalent of 15 mg morphine IV.  (1)

Heroin is at least twice as strong as...

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