The Future of Emergency Medicine Response to Substance Use Disorder

When I became certified as an emergency medical technician (EMT), I didn’t quite anticipate the range of responsibilities I was taking on. I was prepared for the flashing lights, the sirens, the quick thinking, and the CPR. What I did not expect were the interfacility transports and lift assists. I did not expect to be holding a young girl’s hand on a non-medical mental health call, or chatting with an elderly woman who called 911 just because she was lonely.

While emergency medical services, EMS, will undoubtedly always remain just that—an emergency service—it is difficult to deny that it branches into other aspects of the community as well. EMTs and Paramedics frequently provide services which fall beyond the realm of emergency medicine, and this seems to be true more than ever in recent years. In the time since I began working, EMS agencies and providers have been working to envision new roles for EMS which extend beyond its named duty, emergency medicine, to fulfill its implicit duty, serving the public.

One new initiative in which I have taken a particular interest is the effort of EMS to provide better care for patients with substance-use disorder (SUD). Last year, I took a semester-long seminar entitled “Drugs and the Law” which explored perspectives of cognitive neuroscience, criminal justice, and society on drugs of abuse. I came away from the course with one resounding impression: that whatever we’re doing about addiction right now, it is not what we should be doing.

While taking this class and working as an EMT, I was interested to find that EMS is uniquely poised to help people suffering from addiction. In some situations, EMS providers may be the only contact between patients with SUDs and the medical system. Emerging new programs in EMS aim to capitalize on this point of contact in order to provide resources and assistance to people who may be experiencing addiction.

To explore these new solutions, I spoke with Captain Helen Tripp, the Community Paramedic program coordinator in Durham, North Carolina; and Joshua Schneider, Overdose Prevention Coordinator for the city of Pittsburgh, Pennsylvania, who has recently overseen the piloting of a new EMS-mediated buprenorphine treatment program.

Schneider explained to me that frequently, patients in a drug use crisis will refuse transport to the hospital once an emergency team has stabilized them. Data he worked with while creating the new program show that 30% of overdose patients in the City of Pittsburgh will refuse transport to the hospital. “Once we [EMS providers] leave the scene of a call, that’s it — they’re gone,” said Schneider. Even if they end up in the emergency room, they will probably be released once they have stabilized. Maybe they will receive flyers for SUD treatment counseling, and in a few places they may be given the option to begin on a medication-based treatment plan. But a lack of comprehensive treatment for SUD means that patients often end up discharged just to begin the cycle again. Patients with SUD who are discharged from the ER are more likely to return within the next 3 days than patients presenting to the ER without SUD.¹

Programs like community paramedicine are therefore essential to delivering resources and support to patients experiencing SUD. Community paramedicine is a relatively recent development in EMS which expands the roles of EMS providers to assist with public health, preventative services, and even primary healthcare for historically and intentionally excluded populations. The programs seek to improve access to care in their communities.² But, as Captain Tripp jokes, “If you’ve seen one Community Paramedic program … you’ve seen one.” Each program is designed to work within the needs and resources of the community it serves, so across the country (and even the world) they look quite different.

In Durham, North Carolina, the Community Paramedics program began in October of 2017. This program specially trains medics to provide additional support and resources for disinvested groups, including those with behavioral health issues, people experiencing substance-use disorder, and people who call 911 frequently. Community Paramedics (CPs) respond separately from the emergency ambulance, following up after 911 calls and referrals from community partners, such as behavioral healthcare centers and shelters for individuals experiencing homelessness. They provide resources and assistance, including referrals to treatment centers or for specialty medical equipment, information on Medicaid and social services, or connections with community outreach groups and behavioral health providers. CPs even began administering Covid-19 vaccinations to homebound individuals during the pandemic. A follow-up call is a “dig down” appointment, says Tripp, to get to the bottom of the reason the person has needed to call 911 and address the root issue.

If they are available, CPs will respond directly to 911 calls for opioid and substance use, as well as psychiatric calls. They can also follow up later on any of these calls. Strategies for responding to drug overdose calls include patient referrals to treatment programs and providing naloxone kits and information. Naloxone, or Narcan^®, is the life-saving medication that can reverse opioid overdoses.³ These naloxone kits are home kits left with the patients, not to be confused with the naloxone every ambulance carries to be administered by providers.

Durham EMS has recently added naloxone home kits to all of their ambulances so that every EMS crew can provide them to patients rather than waiting for CPs to locate patients after the call. Few patients experience an overdose at their own address or make their own 911 call, meaning that they can be impossible to find once EMS crews leave the call. Only around 11% of overdose calls in Durham were able to be traced later by the CPs, says Tripp, so adding naloxone kits to all EMS squads has significantly broadened their ability to deliver the kits.

The Community Paramedics program has also recently partnered with a community crisis center to send state-certified peer support specialists along on visits to patients who have experienced an overdose. All peer support specialists have experienced SUD and are in recovery, so they are able to speak with the patients on a much more direct and personal level about substance-use disorder and the recovery process. These specialists have had great success in motivating patients to seek treatment, and connecting them to places where they can receive it. Of several agencies who have partnered with the crisis center, Durham Country reports the highest rate of referrals and entries into treatment programs.

Another success story is happening right now in Pittsburgh, Pennsylvania, where Schneider has piloted a new EMS program over the past few years. When I heard Schneider speak at a national EMS conference last spring, I wondered why this program hadn’t already been expanded to the rest of the country.

The foundation of the program operates on the same principle as Community Paramedics—the idea that EMS is a unique point of contact with at-risk populations, and the attempt to leverage this precious time with a patient. Under this program, medics are specially trained in the use of buprenorphine. Buprenorphine is used to treat opioid addiction and relieve withdrawal symptoms, and is effective in treating opioid addiction over the long term.⁴ It’s not an emergency medicine; it is prescribed over months or years. But in Pittsburg, if patients consent, the first dose can be given right on the scene of a 911 call. Patients are eligible for this treatment if they have suffered an overdose, been given naloxone, and are now in withdrawal; or if they called 911 when their withdrawal symptoms became too much to tolerate or manage. This situation is not uncommon, with around five to twelve 911 calls per month in the city of Pittsburgh for withdrawal symptoms.

After receiving buprenorphine, even if the patient refuses to be transported to the hospital, they can agree to allow EMS to contact a telemedicine bridge clinic (or contact it themselves) where they can be prescribed more buprenorphine. Buprenorphine relieves withdrawal symptoms quickly. With the first dose of relief administered on scene and the immediate proof that it is effective, patients are incentivized to pursue recovery, says Schneider. The bridge clinic then offers what is known as “low threshold” treatment. Unlike many buprenorphine programs, this type of treatment has very few barriers to care (such as time requirements, multiple appointments, or prior authorization). A certified peer support specialist also works with the bridge clinic team to help the patient navigate the process. As Schneider says, “These patients need help now. If they have to wait a week, they may just keep using drugs … and that next injection could be the one to kill them.”

Schneider says despite still being in the pilot stages and initially only training a few medics, this program has shown success in many patients choosing to attend their bridge clinic appointments and fill buprenorphine prescriptions. So far, only around a dozen patients have gone through the program, but as more medics are trained, he is hopeful that this program will continue to expand its reach. Either way, he says that if the program can put even one person on the path to recovery, it is worth it to the community. Although similar programs only currently exist in a few agencies, he hopes to see it across the country soon. “Anyone can be an advocate for this type of program…and EMS will be a stronger field when we have everyday providers being advocates for their patients and for this type of work.”

And programs like these are already spreading. In fact, between the time of the initial interview and the final edits to this paper, the Durham CP program received two grants, one from SAMHSA and one from NC DHHS, that will allow them to initiate a similar program to the one in Pittsburgh. The program will begin providing medication assisted treatment (MAT) of buprenorphine in early 2023. Their goal is to have CPs or specially trained MAT-paramedics to provide the first dose of buprenorphine after an overdose if the patient refuses transport. Then the CP will follow up with the patient up to 7 days to provide additional buprenorphine doses while getting the patient connected to one of several SUD providers in Durham County that can continue the treatment and provide additional support services for recovery.

As the scope of these programs grows, developing support and enthusiasm among providers becomes increasingly more important. According to both program coordinators, providers do not seem to mind the additional responsibilities; in fact, many are clamoring to be a part of these new programs. Schneider pointed out that EMS providers tend to seek out additional qualifications, something I have found true in my experience as well. Providers, in general, want to be able to help patients at the highest possible level. There’s absolutely no worse feeling than watching a patient decline and knowing that if someone else were there, they could be doing more for them.

Being trained in the buprenorphine administration program has been self-incentivizing for many providers. Schenider explains that by making the training optional at the beginning of the pilot program, only the most excited providers took part in it. Once they used that excitement to tell everyone else how effective it was, the number of trained medics increased from eight, trained the first time the training was offered, to 36, the second time.

In Durham, the Community Paramedic program uses a different approach to ensure enthusiasm for this training, as this program is completely separate from the Durham EMS ambulances. CPs apply for the program and choose to take on a different manner of work. They demonstrate commitment and competence through stringent requirements which include an interview, case study preparation, and skills evaluation. They must also pass the IBSC CP-C exam (a Community Paramedic certification) within 18 months of being hired into the position. Although Community Paramedics will respond to the scenes of drug overdoses and other crises within their range of response if they are available, they no longer ride an ambulance as part of the primary crew. The CPs respond as their own unit, either during a 911 call or in a later follow-up call.

Even if providers are happy to take part in these programs, the issues of time and resources remain. These programs can be hard to justify if they take providers and equipment away from other essential services, but there is significant hope that they will eventually act to reduce the overall strain on the EMS system. Although there are not yet definite statistics on reduction in drug-related calls, there are indications that these programs can make a difference. The Durham Community Paramedic program initially focused a lot of their time on patients who frequently call 911, and they found a 27% reduction in 911 calls from this population after they began to visit and help—evidence that the CPs are definitely able to make an impact on their patients. And while the buprenorphine program is still in its pilot stages and has not yet collected significant data, it stands to reason that getting people who use drugs the treatment they need will reduce their calls to 911 and emergency room visits. Schneider says that Johns Hopkins University is helping the buprenorphine program conduct a retrospective analysis, which will compare a range of patient outcomes and data to evaluate the effectiveness of the program. And while he knows that this type of peer-reviewed evidence is certainly necessary and important, he says that what has really impacted him are anecdotal stories from medics and patients who have seen the life-changing effects this program can have. “Setting even that one person on the path to recovery … more than anything to me illustrates the power of this [program].”

As an EMS provider who was initially skeptical of these emerging programs, I find myself now wholly in support of them. Emergency services are known to gravitate towards “the way it is always done” — but this is not necessarily the right way. Fully addressing the drug use crisis will require dismantling deep-harbored stigmas, changing worldviews, and re-envisioning entire systems of care. But it starts with a few more people, on a few more ambulances, with a few more resources to help.

Disclaimer: The views and opinions outlined in this article are solely the author’s and do not reflect the views and opinions of AMWA Carolinas.

About the Author

Amy Fulton is a sophomore at Duke University studying Neuroscience and Global Health. She is certified as an EMT-A and Firefighter-II and currently volunteers with Duke University EMS and Lebanon Volunteer Fire Department. She is originally from Ohio and has previously worked and volunteered with multiple EMS agencies in Ohio. When at home, she now works as a Clinical Technician at Cleveland Clinic. She is involved in research with Duke Global Neurosurgery & Neurology as well as the Duke Department of Neurosurgery. She is also involved with several health and wellness clubs on Duke’s campus, including her role as Co-President of Duke Women’s Wellness Club. She is an officer for two martial art sport clubs at Duke, and her other interests include powerlifting, scuba diving, and car mechanics.

She wants to give a huge thank you to Joshua Schneider and Captain Helen Tripp for taking the time to speak with her and agreeing to be quoted in this article.

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