Director’s Commentary: When First Aid Gets Confused with Last Resorts

by Howard Weissman, Executive Director

In 2004 the Federal Aviation Administration mandated that all large U.S. passenger planes carry Automated External Defibrillators (AEDs) along with personnel trained in their use. This decision has undoubtedly saved lives, but no one would argue that it has reduced the incidence or prevalence of heart attacks among airline passengers.

America and the St. Louis region remain in the grip of the worst drug epidemic in history. More (mostly young) people will die this year from a fatal overdose than were killed during the entire Vietnam War. The heroin epidemic has morphed into a fentanyl epidemic, and the fentanyl epidemic is becoming an epidemic of fentanyl variations that are so strong and generally unfit for human consumption that even the minutest amounts are killing people, and scaring first responders into wearing hazmat suits and approaching overdose victims as if they’re radioactive.

Solutions are in short supply.

To slow the death rate, a number of harm reduction strategies are being employed. These range from the strictly sensible to the controversial. Many millions of federal dollars are being spent to equip all police and fire departments with a ready supply of naloxone, the emergency overdose reversal medication. Naloxone (sometimes referred to by its trade name, Narcan) is now also found in high school nurses’ offices, jail infirmaries, and home medicine cabinets. It’s saving lives, but more and more is needed to revive those who have ingested fentanyl and its derivatives. Needle exchange programs, available in many cities around the country, now including St. Louis, are another harm reduction tool, as they reduce the spread of hepatitis C, HIV, and other infections.

However, the public tolerance for the rise in overdose deaths is reaching its already narrow limit. So the more radical harm reduction proposals, like “safe injection sites,” where users can be offered opioids of known dosage, potency and purity, or “heroin assisted” treatment, are unlikely to become widely accepted. And in places where prejudice and misunderstanding around addiction predominate, harm reduction is unpopular.

In Ohio, for example, Butler County Sheriff Richard Jones stubbornly refuses to allow his deputies to carry Narcan based on specious “safety concerns” of revived overdose victims becoming violent. His stance prevails despite record numbers of overdose deaths in his small county. This is the same Ohio county where a city councilman named Dan Picard drew national attention with his outrageous suggestion that emergency crews should stop responding to people who repeatedly overdose. Clearly, Butler County, Ohio is in the throes of two serious epidemics: opioids, and rampant stupidity among its elected officials.

While these Ohioans have responded to the opioid epidemic with ignorance and cruelty, their frustration is easy to understand. Sometimes the same person overdoses and is revived on multiple occasions before either dying or, less often, accepting treatment and finding recovery. Narcan is expensive, as is the price of dispatching an ambulance, fire truck or police cruiser. First responders don’t appreciate repeated calls to the same address for the same problem, and community resources are depleted by the varied social costs surrounding addiction.

Some critics of harm reduction go so far as to say that “Making Narcan available just gives people license to use heroin and other opioids because they know we’ll be able to revive them.” This is preposterous. There is little evidence to suggest that the availability of naloxone makes overdose more likely. And consider this: In the history of commercial aviation no one has said, “Well, once you put AEDs in airplanes, you’re just inviting high risk heart patients to fly, because they’ll know all they have to do is wait for someone shock them back to life.”

No one in their right mind believes that the opportunity for emergency resuscitation makes any high risk behavior more likely. The availability of lifeguards does not increase the chance of people testing themselves against riptides. The availability of epi-pens does not increase the chance of people testing themselves against killer bees.

Addiction seems different because people do continue to put themselves in harm’s way. This is not because they’re tempting fate, it’s because they’re in the throes of a disease that makes the compulsion to use utterly overwhelming. They throw caution to the wind in a desperate attempt to stave off withdrawal or satisfy a craving that is as primal as a drowning person’s craving for oxygen.

It’s important to remember that harm reduction measures, like the broad availability of Narcan, do nothing to solve the opioid problem. They are stopgap measures—finger-in-the-dike tactics occurring after the flood has over-topped it. Harm reduction, in other words, does nothing to stem the tide of new users from becoming addicted. Harm reduction, while necessary, is woefully insufficient. And though harm reduction does save lives and, as the name implies, reduce harm, it is only the equivalent of first aid. Just as AEDs on airplanes won’t make Americans eat better, get more exercise, lose weight, stop smoking, or become less likely to suffer a heart attack, naloxone in the school nurse’s office is not going to stop teenagers from experimenting with opioids.

The way forward—the way out—must involve a greater investment in prevention and education. We must intervene in the lives of our children long before they’ll ever be tempted to find pain relief in a pipe, a pill, or a syringe.

This is doable. We’ve brought cigarette smoking to historic lows through public education and prevention. It took a huge investment of money that was financed, in part, by the tobacco settlement. Though lawsuits are being filed against Big Pharma, they’ll never pay as much as Big Tobacco did, so we have to come together as a community to all dig into our pockets. When it comes to prevention, everybody pays to play.

If you own a profitable business, have access to a foundation or have access to government funds: we need your help. If you were born into wealth or inherited it later in life: we need your help.

With an additional $5 million per year we could provide our ridiculously effective prevention programming to all kids in the greater St. Louis area. We’re already spending $2-$3 million on these curricula and serving 80,000 students, but it isn’t enough. To effect meaningful regionwide change, we must do more.

We have the will. We have the knowledge. We will commit the time and talent…and that’s the hard part. The easier part should be finding the money…but when the forest is on fire, nobody’s thinking about how Smokey the Bear can help you prevent forest fires.

Without your help, this conflagration will continue to burn. If we can’t extinguish the flames through law enforcement or through treatment, let’s gain control of the fire by slowing the number of new users. And let’s prevent new fires from breaking out.

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