Volume 18 Adapted from Bernd Krämer, via Wikimedia Commons. Olympus Playground in Munich, Oct 2015
 

Signing Their Lives Away

By Mary Killeen McCans

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Image Credit: "Pills and a Needle," by US Department of Agriculture, via Flickr

"313 main, your second ambulance requested by 313-A. Cardiac arrest, 21-year-old male." We responded with lights flashing and sirens blaring, and arrived at the scene: a small house in a neighborhood in close proximity to the local college. Outside, a police officer was talking to a group of four male students, residents of the house and roommates of the patient. As I entered through the side door, I noted cans of Coors Light scattered around and felt my boots stick to a kitchen floor that was overdue for a cleaning. I continued through to the living room, where an all-too-familiar scene was unfolding. The patient lying supine on the floor, his face an eerie shade of blue, with a trail of vomit from the corner of his mouth to the floor surrounding his head. A police officer performing chest compressions, an EMT preparing a dose of Narcan, and a paramedic pushing medications through an IV line while monitoring the EKG reading. Drew, a medic of about 30 years and my partner for this shift, entered behind me. The lead paramedic turned to him and gave a report, "21-year-old male, friends found him on the floor. We don't know how long he was here. Needle and baggies in his pocket, probably a heroin overdose. Three doses of Narcan from police, two from me, three rounds of epi, three shocks, no response. I'm not seeing any electrical activity on the monitor." Drew replied, "Have you checked for lividity? I don't know the chances on this one." The lead rolled the patient to his side and noted the pooling of blood on his back, a sure sign that we could not bring him back. A police officer left the room to notify the patient's friends. We heard a few words being spoken in the officer's calm and collected tone, then a loud crash as one friend hit the kitchen wall, hard. At first, the friend screamed, but as he went on, his voice grew softer and clearly upset as he said, "That's the second one this week."

It is becoming common in the suburbs of Philadelphia for young people to lose multiple friends to opioid overdoses. The number of heroin and opioid related deaths in the Philadelphia suburbs, where I volunteer as an EMT, has grown exponentially between 1990 and 2017. In 1995, the New York Times first recognized the growing heroin crisis in the Philadelphia suburbs, reporting that "Heroin-related deaths in the suburbs have skyrocketed since 1990, when there were 14 fatalities in Bucks, Chester, Delaware and Montgomery Counties. Last year [1994], there were 73" ("Heroin Deaths Rise in the Philadelphia Suburbs"). Since that article was published, the problem has only worsened. In 2016 in just one of the regions mentioned, Delaware County, 121 opioid-related deaths were recorded (Drug Overdose Deaths on the Rise in Delco). The epidemiology of the heroin epidemic is idiosyncratic among drug epidemics; morbidity and mortality rates in the suburbs of Philadelphia continue to climb while rates in the City of Philadelphia remain relatively constant. In March 2015, the Philadelphia Inquirer reported, "In 1999 in just the seven counties rimming Philadelphia, 310 drug deaths were reported. In 2013, the toll, apparently driven largely by heroin, was 781. That year in the city (with less than half the population), 402 died" (Overdose Epidemic Surges). Year by year, the death toll climbs while government agencies and healthcare systems race to understand the causes and consequences of a drug epidemic that plagues the City of Brotherly Love and its suburbs unlike any crisis before it has.

The population of heroin overdose victims differs greatly from that of most other drugs - the most at risk group for addiction is white males between the ages of 18 and 25 ("Opioid Crisis"). The Centers for Disease Control and Prevention reports that nationally, the rate of heroin use in non-Hispanic whites saw a 114% increase between the 2002-2004 statistics and 2011-2013 statistics. During the same time period, use among people with annual household incomes of more than $50,000 saw a 60% increase and people between the ages of 18 and 25 saw a 109% increase ("Today's Heroin Epidemic Infographics"). The demographics of heroin users diverge from most common trends in drug abusers. The heroin epidemic can't be attributed to poverty or lack of education—so what is driving the opioid crisis?

"313, Cardiac Arrest, 23-year-old male. Haverford Section of Lower Merion." As we head to the scene, a police officer informs us that it looks like an overdose. We arrive at the home, a nice Colonial that looks strikingly similar to my own house, which is only about 5 minutes away. I enter to find a perfectly cleaned living room, and note the smell of Italian food flowing from the kitchen. I climb the stairs and see five or six police officers occupying the bedroom where the patient is located. The first thing I notice as I follow my partners in is that I could be friends with whoever lives in this room, maybe even date them. The bed is neatly made, the desk contains family pictures from a college graduation and vacations at the shore, and, most impressive to me, one whole wall is covered by a bookshelf full of my favorites—Peter Pan, To Kill a Mockingbird, Something for Joey, and Of Mice and Men among them. And on the floor of the beautifully kept room is a young man lying supine with an eerily blue face, but taking agonal breaths, which are small, gulping breaths that signal severe respiratory distress. So, I go to work. We start artificially ventilating with a bag valve mask and oxygen, administer more Narcan, take vital signs, and attach the cardiac monitor to the patient's chest. Within 5 minutes, he sits up, still dazed and confused, and coughs.

We prepare to transport to the hospital and move the patient to our stretcher. On the way to the Emergency Room the patient tells me how his addiction developed. In his senior year of high school, he was injured during lacrosse season. He had surgery, and his doctor prescribed pain medication. A few months later, he was still in pain and his doctor filled another prescription. By the next visit, his pain was no longer something to complain about, but he said that it was and asked to have the prescription filled because he noticed that the medication "took the edge off" of other pains in his life- a failed test, a fight with his girlfriend, or the stress of the first semester of college. The following visit, his doctor recommended alternative treatments and neglected to fill a prescription. He found it pretty easy to buy some pills from friends at school, and eventually he used the medication just to get through each day. By junior year, pills were too expensive, and he met someone at school who could hook him up with "pure" heroin, which they claimed was "basically the same thing." He used through his senior year, and since he kept mediocre grades and snorted rather than injecting so as to avoid scars, no one noticed.

He graduated and moved home, all the while his addiction worsening. He soon began injecting to get a "better high." His parents took note of his changing behaviors and eventually discovered what was going on. They enrolled him in a comprehensive, inpatient rehab program and he followed the treatment plan, knowing it was best for him. He has been clean for thirteen months. He explains to me that it had been a rough week at work, and he just fell back into his old habits. He made the near-fatal mistake of injecting the same dose he took before detoxing in rehab, so his body had lost its high tolerance and the once-normal dose almost killed him.

This patient's story may seem far-fetched, but his narrative is commonplace amongst young, suburban heroin addicts. In many cases, addictions begin with legal prescriptions. The heroin epidemic again violates normal drug addiction trends in that often, addicts are young athletes, students, or professionals who receive their first "hit" from a physician.
In 1992, the Office of National Drug Control Policy published a bulletin entitled "The Heroin Situation: A Status Report." This six page document displays the problematic mindset that led to the severe opioid epidemic our country, including the Philadelphia region, is experiencing today. The bulletin explicitly states that "a massive increase in heroin use and addiction is not likely." The publication cites that younger people are not interested in heroin because of its known addicting and isolating nature, that "new heroin users are experienced drug users," and that the population of heroin users is aging. The Office of National Drug Control Policy's prediction was severely mistaken because it didn't assess the looming threat of legally prescribed opioids.

Before 1995, opioids were almost exclusively prescribed to terminally ill cancer patients, victims of trauma, and patients recovering from major surgery (Anderson 1). In 1986, a study conducted on just 38 patients suggested that opioids were a safe and minimally addictive class of drug. This study blatantly violated statistical guidelines for clinical studies; the sample size, scope, and length of the study were all far too small to reach a sound scientific conclusion regarding the addiction potential of opioid medications. Still, in the 1990's pharmaceutical companies encouraged physicians to prescribe opioids in a wide scope of situations, because this singular study suggested that opioids were not addictive (Anderson). Opioid prescriptions for long term pain management and less severe injuries became increasingly common, and throughout the next decade opioid prescriptions steadily rose. As physician-sanctioned opioid use became more common, the heroin crisis that the Office of National Drug Control Policy never expected tightened its grip on suburban America.

Dr. Matthew Salzman is an Emergency Medicine Physician and Toxicologist at Cooper University Hospital in Camden, New Jersey, a sister city of Philadelphia. He completed medical school, residency, and fellowship within the City of Philadelphia during the time period in which the heroin crisis unfolded. In an interview in September of 2016, he told me about his early career in the Emergency Room, saying, "Having been taught that physicians are usually bad at treating pain and we needed to be more aggressive with treating pain, I was pretty liberal with opioid prescribing." Before the opioid crisis was recognized, doctors were encouraged to prescribe opioids because they were thought to be a highly effective form of pain management that boosted patient satisfaction and diminished patient discomfort. What began as a standard of care intended to improve patients' quality of life unfortunately sparked a wildfire of addiction.

To be explicitly clear: opioids do not cause addiction in the majority of patients. The issue is that opioids are prescribed so frequently that the number of patients who do become addicted is troublingly large. According to the Centers for Disease Control and Prevention, in 2012 more than 250 million opioid prescriptions were written for a total population of 319 million people (Anderson). The over prescription of opioids means that though a minority of patients become addicted, they constitute a large portion of heroin and opioid abusers. One study, published in the Annals of Emergency Medicine, found that of 59 heroin addicts, 35 (59%) reported that their addiction began with a legitimate medical prescription (Butler et al.). When writing prescriptions, physicians must consider whether they are signing an order for appropriate medical care or signing a patient's life away.

In recent years, the medical community has recognized the need for change in opioid prescription frequency, and health officials are working to regulate prescriptions and promote alternative pain-management techniques. Many hospitals now utilize prescription monitoring programs and databases, which help physicians to see how many opioid prescriptions have been written for any given patient, even across different states and healthcare systems. Tools like this help providers to recognize addiction and point patients toward recovery. Dr. Salzman described his change of practice in light of current knowledge of opioid addiction risk: "Having learned more about the epidemic, having access to prescription monitoring programs and electronic health records, I've really been much more conservative. I've written very few prescriptions for opioids, and usually it's in the setting of acute traumatic injuries." Dr. Salzman now promotes the use of over-the-counter anti-inflammatory medications, ice, and elevation as pain management, and informing patients of reasonable expectations for pain. He's on the right path, and if physicians like Dr. Salzman work with healthcare systems to continue to fight the heroin epidemic through education, prescription databases, and pain-management education, the number of patients becoming addicted will decrease so that a focus can be placed on rehabilitation for current addicts.

Curbing opioid prescriptions will not completely end the heroin crisis, but it will address a key contributing factor to the epidemic. The heroin crisis may have met its match in prescription databases, alternative pain management techniques, and informed physicians. These tools could decrease the number of opioid prescriptions written by physicians, and allow addiction-ravaged cities like Philadelphia to recover from a quarter-century long epidemic. My hope is that the results of preventative efforts are realized soon, because I am growing weary of seeing boys with eerily blue faces lying supine on the floor.