The Pain of Opioid Responses

National Volunteer Fire Council logo and firefighter

By Tom Miller

Responses to opioid emergencies are far from routine. What used to be purely medical responses have now turned into potentially complex incidents requiring a high level of situational awareness.

The National Institute on Drug Abuse reports that from 2002 to 2017 there was a 22-fold increase in the total number of deaths involving “other synthetic opioids,” e.g. fentanyl, carfentanil, ohmafentanil, etc. in the United States. This increase has been felt by fire departments and emergency medical providers across the country. First responders are administering Naloxone (Narcan) at rates so high that, in many cases, supply cannot keep up with demand. These responses pose many new challenges for those on the front line.

The Response

The first challenge posed by the high number of opioid responses is, like all incidents we face, that of responder safety. Calls related to opioids are not just limited to overdoses. Fires in vacant buildings pose a risk as firefighters in many jurisdictions are crawling through structures that are littered with uncapped needles and other paraphernalia. Areas with needle exchanges and “risk reduction” shelters where drugs can be used “safely” have brought influxes of the homeless into areas that lack sufficient resources to cope with the surges. The homeless seek out shelter in abandoned houses or buildings and, as colder weather sets in, use improvised heating methods, including building camp fires in the middle of rooms. These situations pose real dangers to firefighters, who often must contend with breaching doors or walls to access the structures. Members may also have to deal with improvised alarm systems or booby traps intended to provide early warning in case law enforcement shows up.

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Another part of the safety challenge is the dangers posed by often responding to scenes without law enforcement support. In some jurisdictions where needle exchanges have been operating, law enforcement views an opioid response as a “medical/social” issue and not a crime scene. First responders who administer Naloxone are often confronted with a patient who is physically aggressive when their high is ended abruptly. There are numerous documented incidents of first responders and emergency room staff being physically assaulted by patients whose drug experience was ended, even if it was necessary to save their life. Ambulances have been stolen from ERs and scenes of other calls by drug users. Sadly, some first responders have had to deal with others coming into the scene searching for leftover drugs, cash, or other valuables while patients are being treated, even while CPR is being administered.

The second major challenge is dealing with the potential exposure and/or secondary contamination to fentanyl or one of its adulterates. There has been a great effort by the major fire service organizations – including the National Volunteer Fire Council (NVFC), International Association of Fire Chiefs (IAFC), International Association of Fire Fighters (IAFF), National Fire Protection Association (NFPA), and Department of Homeland Security (DHS) – to ensure that accurate and scientifically validated information is readily available about the potential risks and effective countermeasures that will keep responders safe. The key to a safe response is wearing the proper personal protective equipment (PPE) and being cognizant of the real and potential dangers posed. DHS, with the help and support of more than 20 public safety organizations, published solid guidance on the PPE to be used for these types of incidents not involving fire. Many local departments are carrying Naloxone for intervening use on first responders only and not for the patients.

The last challenge I want to address in this article is that of “compassion fatigue.” Responders are now faced with run volumes that have significantly increased, a taxation on resources not seen in the past, and a patient population that is not always grateful for being helped. There are countless incidents of departments running the same person two, three – even four – times within a 24-hour period. Responding to people who inflict the harm on themselves takes a heavy toll of first responders. Many agencies have had the responsibility of administering Naloxone thrust upon them with little input or training. For some departments, mostly volunteer, that don’t run first responder programs, the new mandates are creating problems with personnel, budgets, and mission drift. Although we can all agree that the opioid epidemic is a national crisis, the disagreement begins when the question is asked as to whose responsibility it is to deal with patients who don’t seem to want help or recovery – patients who fight when revived, refuse treatment or help, and then re-overdose hours later.

Given these challenges, some key factors departments and responders should keep in mind when it comes to opioid response are as follow:

  1. Always maintain situational awareness – where you are; who is around you; scene size-up considerations; call history for the address; checking in with dispatch regularly; doing personnel accountability reports (PARs); minimizing time on scene; etc. Your behavior can go a long way in keeping you and your crew safe.
  2. Develop good standard operating procedures or guidelines. Work with partner agencies on developing strategies and tactics that ensure everyone goes home. Include conducting solid risk/benefit assessments and decontamination – emergency, mass, and technical – in your planning. Make responder safety the #1 priority.
  3. Train on recognizing the indicators that fentanyl and its adulterates are present.
  4. ALWAYS wear the proper PPE! Inhalation of aerosolized adulterates is the primary route of exposure hazard to first responders. When on scene or in the back of the rig treating the patient, wear an N-100 particulate mask and nitrile gloves – preferably black so as to enhance the color contrast these substances pose.
  5. Be sure to monitor the emotional and mental well-being of your responders. Conduct after-action reviews, let them vent their frustrations, and have a plan to get them professional help if needed.

Knowing the dangers and preparing for them will go a long way to help your responders from dealing with the pain of an opioid response.

Tom Miller has 34 years of experience in the fire service. He is a Pro Board-certified Firefighter I and II; Driver Operator – Pumper; Fire Instructor III; Hazardous Materials Technician and Incident Commander; and is certified as a swift water rescue technician. He is state certified as a Fire Officer I and II and has extensive training in all aspects of emergency management and response. He is West Virginia’s Director to the NVFC, where he serves on the Health, Safety, & Training and Standards & Codes committees, along with chairing the Hazardous Materials Response Committee. Tom serves as a principal on the NFPA 472/473/1072/475 Technical Committee for HazMat and WMD Response and is on the Joint 1001/472 Task Group. Tom is active with the various committees for the West Virginia State Firemen’s Association.

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