Uberdose: 911 for People Who Should Call for Help, But Won't

To a certain extent, I think we all knew this was coming. For as long as there have been efforts to equip police officers and public transit workers with naloxone -- "the overdose antidote" -- to reverse opiate overdoses and resuscitate dying patients near instantaneously, it was almost a given that someone was eventually going to pipe up and say, "There should be an Uber for heroin overdoses."

It's taken awhile, but with the reports coming from Chicago last week of 74 reported heroin overdoses in 72 hours, I think it's safe to say it out loud: "There should be an Uber for heroin overdoses."

For all opiate overdoses, in fact; for any overdose that could be reversed if someone nearby happened to be carrying naloxone (a.k.a. "narcan") and got an alert on their phone that said "Somebody's on the verge of dying around the corner and you can save their life right now."

There should be an app for that.

It's not all that far-fetched of an idea, really -- especially if you're a drug addict who's watched friends die from an overdose, or a parent who's lost a child.

Like bystander cardiopulmonary resuscitation (CPR) and the automatic external defibrillator (AED) before it, one could argue that it was only going to be a matter of time before common sense prevailed and the possibility of saving someone from a premature death by giving them a basic life-saving skill would no longer obstructed by antiquated legislation or the monopolistic tendencies of the established public order. Untold thousands of parents, spouses, siblings, children, and friends would likely agree: there should be an app for overdoses.

But before I explain why I think there should be an app for overdoses -- or at least an alerting system separate from the "public" 911 system (and, yes, full disclosure: my organization, Trek Medics has an alerting system that could do this.)

I'd like to first explain why I think orthodox 911 systems alone, including your own, will never be able to prevent as many overdoses as it believes it can, and why an emergency alerting system detached from centralized emergency call centers could help immensely in preventing more premature death.

As a paramedic that worked along the U.S.-Mexico border until 2010, my colleagues and I responded to a lot of heroin and painkiller overdoses. Some of them we got to in time, while in others we got there too late -- not to mention the many we never heard about. Unlike a lot of the other deaths we witnessed in the course of our work, fatalities resulting from opiate overdoses were almost always preventable, and the number one reason behind every death was time; we simply didn't get there when we were needed. There are a number of problems that keep paramedics from reversing overdoses in time, many of which centralized 911 systems cannot fix -- or even cause themselves.

911 is only good when you call it

First and foremost, in the U.S., Canada and other countries where there's a unified emergency access number for police, fire and emergency medical services (E.M.S.), asking a drug user who's witnessing an overdose to dial 911 and send for help is tantamount to calling the police and asking them to arrest you and take you to jail with all the evidence against you packaged up and ready to go for easier booking. No one's eager to make that call. In the same vein, equipping EMT-Basics, volunteer firefighters and law enforcement officers with naloxone is definitely a good start, and certainly makes for good press, but it's ultimately a passive approach with limited scope that leaves the lifesaving administration of naloxone to largely incidental occasion -- i.e., "I happened to trip over him while walking under the highway overpass and noticed he had a needle dangling from his arm."

Few, if any, lifesaving awards have ever been given out to drug addicts

While several U.S. states have passed "Good Samaritan" laws that offer immunities and/or other legal protections to bystanders who report an overdose in progress, it's quite possible that such legislation, coming from the mouths of lawyers, politicians, and police chiefs translates in the minds of drug abusers into something more akin to, "Good Samaritan today, law-breaking junkie tomorrow." I haven't seen any data yet, but I've a suspicion that the instances of witnesses invoking Good Samaritan protections are probably pretty low in suburban and rural communities where everyone knows your name.

Opiate abuse is typically an introverted activity

Overdose victims are often found by emergency responders only after considerable trouble and in hard to reach places that are purposely removed from easy public access, making it very inconvenient for crews to bring in their gear and gurney, administer their drugs, and remove the patient. Such behavior is very rational: Nobody wants their spot blown up, and by bringing in the cavalry when maybe all you needed was someone within the community who knew what to do, there's a strong chance the official entourage will end up scattering the people who will need help later to deeper and darker corners. This is particularly worrisome in the cases when there's "bad" heroin going around: where there's a higher risk for users to overdose, you don't necessarily want to shoo them into the woods.

In the event that a companion opts to call 911 for his/her overdosing friend, it's often not before considerable efforts have been made to seek alternative home remedies in order to avoid the prospect of having to call 911 -- including cold showers, face slaps, and banging heads against the floor, to name a few. These are the panicked, yet predictable reactions of an unprepared community that's literally choosing between life and jail for both, or maybe death for one and likely no jail for the other. This panic, reinforced by a natural aversion to self-incrimination, can be so pronounced that it's not unheard of for would-be Samaritans to go as far as to drag their overdosed friend to the front lawn or street curb, call 911, and flee the scene. This effectively turns them into fugitives and leaves the task of finding the unresponsive patient to emergency responders equipped with sketchy information taken from a very reluctant 911 caller. Damned if you do, damned if you don't.

These are just a few of the factors weighing in the heads of drug users who are witness to an overdose. The paralysis of the panic and paranoia -- not to mention the adverse effects of the drug itself on the decision-making faculties -- inevitably leads to delays in action, which further leads to delays in getting oxygen back to the oxygen-starved brain and heart, and thus increases the chances for both premature death and permanent neurological disability.

And why? Because junkies and addicts deserve what they get? I would leave the right to respond to that assertion to the family and friends of those who've lost loved ones prematurely.

Pomp vs. Circumstance

There's a strong case to be made that bystander-administered naloxone programs could be as effective as orthodox 911 systems in responding to overdoses, administering naloxone, and managing the patient, if not more effective. Such a system would undoubtedly be cheaper and would certainly be better equipped to provide post-overdose care as it could technically even include direct admission to inpatient or outpatient treatment facilities -- something most U.S. paramedics are legally forbidden to do. By law, paramedics in the U.S. have basically two options to offer an overdose they just revived: "go to jail with this police officer, or go with us to the hospital (and jail after)."

"Everyday they don't never come correct" - Flavor Flav

Equipping friends and family and fellow drug users to administer naloxone is also likely a safer approach to the prehospital treatment of overdoses than orthodox 911 systems can offer, and for two reasons:
  1. Giving naloxone for a heroin overdose always carries the very real risk of solving the medical emergency while simultaneously creating a behavioral emergency that can be equally, if not more, dangerous to both patients and bystanders. Being pulled from a deep, euphoric sleep to find trusted, familiar and/or non-threatening faces is a lot more manageable from a behavioral perspective than being awoken by a scrum of public safety personnel with diesel engines running and radios chirping. Imagine the circus: a couple of paramedics with weird goggles sticking needles in your arm (and possibly damaging your "good" veins); a handful of firefighters in suspenders and big pants; and two police officers with shiny badges and handcuffs, digging through your wallet. All of this for someone who's quite literally just been pulled back from the great white light, and who now likely finds themselves in the throes of severe withdrawals. If there was ever a buzz-killer, naloxone administered by the full public safety platoon is it.
  • About those needles: Thank God for nasal naloxone, but the protocols in many E.M.S. systems across the U.S. still require paramedics to start an intravenous line for patients who overdose on opiates. Intravenous drug users are clearly at a higher risk for having infectious blood-borne diseases. Not only does starting an intravenous line on these patients pose risks for the healthcare professionals treating them, but unnecessary needle sticks also put drug users at greater risk for hospital-acquired infections -- a very clear sign that we're over-treating as a society, if there ever was one.
  • Dan Bigg, Director of the Chicago Recovery Alliance, shared similar sentiments, according to the
    : "The best thing would be to have [narcan]... And watch each other's backs."

    You'll go to jail for this?

    Liability doesn't really seem too much of a problem either, especially when you consider who the trained responders might include: like public health practitioners, community advocates and the drug users themselves, among others. Let's be clear: Nobody's asking the local boy scouts troop to respond to a heroin den.  There are certainly more creative and appropriate solutions.

    In Baltimore, for example, the foundations for such a response team were detailed in a New York Times article about a program that trains strippers and bouncers in five minutes to carry and administer naloxone. It described these prepared responders as, "a group of health workers trusted and integrated on the streets, empathizing with those plagued by poverty, and meeting the people eye-to-eye to help them see another day." I suspect people like these would be willing to risk the liability.

    Medical Misdirection

    Some of the major players in making naloxone accessible to the public at large include the E.M.S. medical directors at the state, county, and city levels, under whose license prehospital professionals can legally provide care. These doctors decide what medical interventions can and can't be performed by E.M.S. professionals and bystanders within their jurisdiction, and many are resistant to making naloxone as easy to buy as a tourniquet. But if the degree of uniformity shared by E.M.S. protocols across the nation is to be any sign, what these medical directors are deciding can and can't be done isn't necessarily based on evidence. This lack of evidence is true for many medical interventions performed by E.M.S. professionals in general -- it's hard, if not unethical, to get informed consent for a research study from someone who's unconscious or believes they're about to die, and the debate is definitely needed. But there should be little question left about the efficacy of bystander-administered naloxone in reversing opiate overdoses: this stuff saves lives.

    Similar to the debates surrounding bystander C.P.R. training in the '60s and '70s, many of these medical directors can't imagine the public at large capable of performing such a high-risk medical procedure, or even doing it correctly. Well, it's either that or death, and compared to the damage caused by chest compressions during CPR, naloxone seems little more than a nasal decongestant.

    Good Ol' Uncle Pharma

    Of course, all of this talk about Uber for heroin overdoses is probably a bit on the wishful thinking side at this point as the makers of naloxone have been under investigation for price-gouging. In Massachusetts, it was reported that as soon as the Governor declared opiate overdoses a public health emergency, the prices "skyrocketed." According to State Attorney General Maury Healey, "Our office has heard regularly from local law enforcement and public health workers worried about their ability to maintain supplies" -- the moral equivalent of jacking up the price of gas as the hurricane evacuation begins.

    It's a shame, really, because if the makers and distributors of naloxone just only took a page from the playbook of the CPR/AED industrial-complex, they'd be able to get naloxone in every first aid kit ever made ever again.

    Social entrepreneurship at its purest

    There is one last reason why an Uber-style dispatch system run at the community level is not only a good idea, but likely inevitable: These are the times we live in. In a world where everything and anything is becoming available on-demand, and orthodox 911 systems continue to be a victim of their own success, some person will have the compassion, the motivation and the common sense to meet demand where it's highest, and prevent a lot of senseless death. Since Sept. 11, the United States government has been pumping trillions of dollars into any and every public safety and health agency to prepare for terrorist attacks and active shooters, "even though", as Nicholas Kristof wrote in the New York Times, "[overdose] kills more people in America than guns or cars and claims more lives than murder or suicide."

    Perhaps we can do better. Maybe there's an app for it. Or maybe we should just give naloxone to taxi drivers.

    Whatever the solution, it's long overdue.

    Graphic by Sean Jones for Trek Medics Intl.