Opioid Use Disorder and the

Impact of EMS Providers

Anthony Pantaleo, BAS Paramedic IC

EMS Opioid Outreach Coordinator

Division of EMS and Trauma

Bureau of EMS, Trauma, and Preparedness

Michigan Department of Health and Human Services

P. O. Box 30207

Lansing, MI 48909-0207

PantaleoA@michigan.gov

Phone: 517-241-3026

Mobile: 517-614-7792

Objectives

• Discuss current statistics for OUD in Michigan (cognitive)

• Discuss at risk populations for OUD / SUD (cognitive)

• Define addiction (cognitive)

• Describe the neurologic & physiologic changes that take place with an OUD patient (cognitive)

• Discuss what identifies an OUD / SUD patient as a chronic disease patient (cognitive)

• Define the effects of stigma on our daily lives and work performance (cognitive)

• Appreciate the need to stop the stigma with OUD patients (affective)

Is there really an Opioid Crisis

• Why do we need a response to the opioid crisis

• How did we get to the point of calling this a crisis anyway

• Isn’t this just a behavioral issue created by themselves

• What are we really supposed to do

HOW?

The Opioid Problem

• 2017: • CDC reports 70,237 drug overdose deaths in the US

• Of these 47,600 were Opioid involved (67.8%)• 15,000 overdose deaths were due to heroin

• Males aged 25-44 are the highest death rate for overdoses

SOURCE: CDC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, CDC; 2018. https://wonder.cdc.gov/.

Michigan’s Opioid Problem

• Michigan has approximately a population of 10 million • 10th in the nation, per capita prescribing rates of opioid

medications• 2015 & 2016 over 10 million prescriptions dispensed• 2017 9.42 million opioid prescriptions dispensed• 2018 8.11 million prescriptions

• 2017 Overdose data • 2073 hospital admissions for opioid overdoses• 2686 Overall overdose deaths

• 2053 Opioid overdose deaths

• 2018 Overdose data • 2599 Overdose Deaths

• 2036 Opioid Related Deaths (5.5 deaths per day)

MDHHS – Substance Use in Michigan

Michigan’s Opioid Problem

• THE TOP FIVE LEADING CAUSES OF INJURY MORTALITY AMONG MICHIGAN RESIDENTS OVER ONE YEAR OF AGE ARE:

• 22.2 deaths / 100,000 Unintentional and Undetermined Intent Drug Poisoning

• 11.4 deaths / 100,000 Suicide

• 9.6 deaths / 100,000 Motor Vehicle Traffic Crash

• 8.8 deaths / 100,000 Homicide

• 6.3 deaths / 100,000 Fall

Includes ICD-10 codes W00-W19

*Rate are not shown where the number of deaths is fewer than 6

2014-2016 Michigan Resident Death Files, Division for Vital Records & Health Statistics, Michigan Department of Health & Human Services

Vintage 2017 U.S. Census Populations with Bridged Race Categories, National Center for Health Statistics

2018 EMS Reported Overdose Data

Ranking County Per 10K

1 Calhoun39.33

2 Genesee32

3 Wayne26.55

4 Ingham20.55

5 Lenawee20.16

6 Kent18.88

7 Kalamazoo18

8 Jackson16.9

9 Saginaw16.43

10 St. Clair16.26

Ranking County Per 10K

11 Crawford14.38

12 Alpena13.41

13 Clare12.43

14 Roscommon11.66

15 Midland11.2

16 Macomb10.95

17 Newaygo10.42

18 Ogemaw10.36

19 Monroe10.31

20 Iosco10.22

Ranking based on per 10K population

Data obtained from BioSpatial

2019 EMS Reported Overdose Data

Ranking County Per 10K

1 Genesee31.66

2 Calhoun30.15

3 Wayne28.44

4 Jackson26.06

5 Muskegon23.74

6 Ingham17.86

7 Kalamazoo17.18

8 Kalkaska16.86

9 Macomb16.29

10 Monroe15.23

Ranking County Per 10K

11 Saginaw15.16

12 Clare13.74

13 Washtenaw13.52

14 Manistee13.09

15 Iosco12.98

16 Crawford12.95

17 Baraga12.65

18 Lenawee12.2

19 Kent11.57

20 Bay11.23

Ranking based on per 10K population

Data obtained from BioSpatial

Blue 1-10Red 11-20

2019 EMS DataReported Opioid Overdoses

Orange 1-10Green 11-20

2018 EMS DataReported Opioid Overdoses

Data obtained from BioSpatial

2019 EMS Reported Overdose Data

Data obtained from BioSpatial

Naloxone Utilization

• Very widespread use of Naloxone across several disciplines• General Public

• Law enforcement

• EMS Non-Transport agencies

• ALS / BLS Transport agencies

Naloxone Utilization

• EMS reporting data• Average of 3 mg naloxone to any patient who receives it

• Average of over 2000 mg per month statewide for 2019

Data obtained from BioSpatial

Naloxone Utilization

• Protocol• Indications: Decreased level of consciousness associated with respiratory

depression from Opioid Overdose, without other apparent cause (e.g., stroke, hypoglycemia).

• Procedure: Consider administration of Naloxone when: • 1. Ventilations have been established and patient has not regained consciousness.

• 2. There is more than 1 rescuer on scene for personnel safety precautions.

• 3. Treatment goal is to restore effective respirations; the patient need not be completely awakened.

• 4. Per MCA Selection (below), administer Naloxone intramuscular auto injection OR Intranasal via prefilled syringe with atomizer (half the dose in each nostril), OR Narcan® Nasal Spray. May repeat one time in 3-5 minutes if effective respirations not restored.

2017 Protocols

Addiction Defined

• Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

• Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

American Society of Addiction Medicine

Neurologic Changes

• Brain abnormalities resulting from chronic use of heroin, oxycodone, and other morphine-derived drugs are underlying causes of opioid dependence (the need to keep taking drugs to avoid a withdrawal syndrome) and addiction (intense drug craving and compulsive use)• Several areas of the brain & chemicals in the brain are involved and effected with opioid use

• mu opioid receptors (specialized protein cells attached to neurons)

• Triggers the biological brain processes of reward with feelings of pleasure

• Midbrain (mesolimbic) reward system

• Ventral tegmental area (VTA) releases dopamine in the nucleus accumbens

• Causes feelings of pleasure & creates a lasting record or memory with the circumstances & environment it occurred

• This then leads to alteration of norepi release creating the intoxication effect, then the withdrawal effect with increased norepi and lack of dopamine or opioid

• All these chemical alterations create issues in the pre-frontal cortex regulating cognitive functions such as foresight and planning

Neurologic Changes

• Chronic use leads to dependence that leads to compulsive seeking behaviors

• Science has identified 2 models of habitual substance use producing changes in the brain

Neurologic Changes

• “Changed Set Point” model• Alterations in the baseline levels of dopamine & norepi to accommodate for

opioid use or withdrawal state

• Cognitive deficits model• A compromised communication system between the prefrontal cortex and

the mesolimbic reward system

• Reduced ability to use judgment & restrain their impulses and are now predisposed to compulsive drug taking behaviors• This model is also consistent with stimulant drug use as well

Neurologic Changes

• Cognitive deficits model• In contrast to stimulants, heroin damages the PFC but not the fronto-striatal

loop.

• Therefore, individuals who become heroin addicts may have some PFC damage that is independent of their opioid abuse, either inherited genetically or caused by some other factor or event in their lives.

• This preexisting PFC damage predisposes these individuals to impulsivity and lack of control, and the additional PFC damage from chronic repeated heroin abuse increases the severity of these problems (Kosten, 1998).

Addiction as a Disease

• Research and medications have changed over decades

• Drug use has also changed

• We have a much better understanding of what drives people to use opioids (prescription or illicit)

• Any disease can create change in the body

Addiction as a Disease

• Neurologic diseases or events that causes lasting behavioral changes• Alzheimer's

• Dementia

• Seizures

• Cancer

• Stroke

• Anoxic injury

• TBI

• OUD

• SUD

Stop the Stigma

• STIGMA• When people are labeled primarily because of their addiction, they are being

negatively stereotyped. Biased, hurtful words, attitudes, and behavior represent prejudices against people with SUD, and often lead to discrimination and social exclusion.

• This stigma whether personal, social, or institutional is a leading reason those with OUD/SUD avoid seeking treatment• Personal self disgust and shame at one's own appearance, behavior, lifestyle or condition

with feelings of being unworthy of help or recovery• Social negative perceptions, labels, and actions from friends and family leading to

isolation or rejection• Institutional, negative treatment and attitudes from healthcare providers, LE,

employment, or media

Stop the Stigma

• Its time to change our way of thinking and what terms we use• Abuser, seeker, junkie, addict, druggie ect.

• SUD / OUD• Substance Use Disorder / Opioid Use Disorder

Stop the Stigma

• As EMS providers we must look at change within our selves and our systems to stop the stigma

• Drug use has been a part of EMS for decades• 1980’s Cocaine

• 1990’s Crack

• 2000’s Meth

• 2010’s Opioid Prescription Pain Medications

• Heroin has been a part of the overdose scene for decades

Stop the Stigma

• Compassionate Care• Motivational interviewing

• Patient centric care

• Acceptance of their OUD

• Family interaction / education

• Meet them where they are

• Warm hand-off

Stop the Stigma

• EMS can make the profound difference in patient outcomes• How do we treat the patient & their family with each interaction

• Not everyone will seek help the first time

• Breakthrough moment

• It takes a teamwork• EMS, Fire, LE, ED, SW, Treatment centers

Rome wasn’t built in a day!!!

Questions?

Anthony Pantaleo

Paramedic I/C, BAS

EMS Opioid Outreach Coordinator

Division of EMS and Trauma

Bureau of EMS, Trauma, and Preparedness

Michigan Department of Health and Human Services

PantaleoA@michigan.gov

Phone: 517-241-3026

Mobile: 517-614-7792

References

• Kosten & George: The Neurobiology of Opioid Dependence: Implications for Treatment, 2002

• ASAM Public Policy Statement: 2011

• 2018 CDC Surveillance Report of Drug Related Risks and Outcomes

• Haydon, How opioids reshape your brain, and what scientists are learning about addiction, 2018

• 2017 Michigan EMS Protocols

MCRH EMS SUD Webinar CE Quiz and Evaluation• Please complete the quiz/evaluation within two weeks of attendance

to receive your CE.

• You must complete the quiz/evaluation with a score of 80% to receive your CE credit.

• Please allow up to 30 days for CE distribution via e-mail.

• CE Quiz/Evaluation web-link: https://msu.co1.qualtrics.com/jfe/form/SV_8fi588BhDOAsygt