N.J. Paramedics Get the OK to Administer Buprenorphine

The Philadelphia Inquirer

Last year, paramedics in Camden posed a question to their supervisors: What more could they do to help the dozens of overdose victims they were reviving?

Medics were rescuing patients with the overdose-reversal drug naloxone—but that lifesaving drug can also send an overdose victim into intense withdrawal, with nausea, vomiting, cramps, and craving, after they wake up.

It was difficult for paramedics to persuade patients in such pain to go to the emergency room, or think about entering treatment. Instead, to relieve the agony of withdrawal, some patients’ only thought was to find another dose of heroin—putting themselves at risk for another overdose.

On Monday, New Jersey’s health commissioner signed an executive order aimed at easing those symptoms in the field, and hopefully helping more patients seek medical help.

It allows paramedics around the state to dispense the medication-assisted treatment drug buprenorphine to overdose victims, and state health officials believe it’s the first program of its kind in the country.

“We’re taking this step to bring something that would, hopefully, allow a patient to be free of withdrawal symptoms, be clear-headed enough to go to the emergency room, and proceed with recovery care from there,” said Shereef Elnahal, the state health commissioner.

As the national overdose crisis has worsened, health officials around the country have turned to naloxone as a crucial tool in the fight to save lives. In Philadelphia, where 1,116 people died of overdoses in 2018, city officials have been encouraging everyone from paramedics to ordinary residents to carry the drug, just in case. Last week in New Jersey—where more than 3,100 people died in 2018—pharmacies handed out more than 32,000 doses of the drug to residents for free.

But no public health measures, to Elnahal’s knowledge, have tried to help paramedics persuade patients to enter treatment by addressing the immediate withdrawal symptoms that can come after a dose of naloxone.

Buprenorphine is one of several opioid-based medications that are considered the gold standard of addiction treatment: Studies have shown that taking it gives people a better shot at lasting recovery. In the short term, it’s useful for helping people endure withdrawal; in the long term, it helps patients stabilize in recovery by curbing opioid cravings.

It’s also protection against overdoses in the immediate future, said Rachel Haroz, an assistant professor of emergency medicine and medical toxicology at Cooper Medical School, who helps run the health system’s addiction clinic.

“It takes people right out of withdrawal, and it binds to the opioid receptors in the brain—staying on that receptor, and not allowing heroin to bind to it,” she said. “It’ll be there for 24 to 36 hours, and you’ll be adequately protected from overdose.”

Cooper physicians and EMS officials came up with the idea after Camden paramedics asked for help. (Cooper runs the city’s emergency medical services.)

“There certainly is a level of frustration, day in and day out, treating the same patient multiple times,” said Rick Rohrbach, the hospital’s EMS director. “You get the feeling that that’s all you’re doing, and you’re not solving the root cause."

So, about a year ago, Rohrbach and the paramedics spoke with Cooper’s emergency and addiction-medicine departments about how they could help the hospital’s addiction treatment programs. “We’re on the front lines,” Rohrbach said. “We should really be a part of that.”

The new program is voluntary, and it will be some time before it gets off the ground in New Jersey. To dispense the drug, paramedics will still have to receive approval on the scene of an overdose from their medical command—doctors employed by EMS systems who are on-call to consult on medical decisions. (Buprenorphine is not as heavily regulated as methadone, another opioid-based medication-assisted treatment drug, but doctors still can’t prescribe it without a special waiver from the federal government.)

Elnahal said he’s been fielding calls from around the country since signing the executive order. Concern about overdose victims’ reluctance to seek treatment, he said, has been increasingly common among the state’s paramedics.

Indeed, it’s a familiar story around the country, and one that’s prompted some draconian proposals: In 2017, an Ohio city councilman sparked a national controversy when he proposed that paramedics stop reviving people who had overdosed more than twice. (He later dropped the idea.)

Elnahal said he hopes treating overdose victims’ withdrawal symptoms will help remove what, in many cases, is a significant barrier to treatment.

“The ethical approach,” Elnahal said, “is to provide treatment. It’s a good way to solve the problem without proposals to deny care.”