A major issue presenting across Canada is the number of opioid related deaths. Since 2003, the number of deaths has increased 136 per cent with more than 850 deaths in Ontario from opioid-related causes in 2016 (Public Health Ontario, 2018). The key concerns with this issue are the alarming rising numbers of users and related overdose deaths and that users are not getting the necessary help or support to overcome the addiction.
Niagara EMS has recognized the need to take action and help protect the public in a new and unprecedented way. They have been working on initiatives that re-evaluate the traditional approach and transform the healthcare system to better address the changing behaviours, pressures and care needs of those calling 911 in the community. These initiatives include; creating a specialty response unit and focusing resources towards Consumption and Treatment Site (CTS) to provide safety and education.
Niagara Region Public Health and Emergency Services, Niagara EMS, local governments, emergency services and community agencies have teamed up to collaborate on ideas and initiatives in reducing the number of deaths and overdoses in Niagara Region. The formation of Overdose Prevention and Education Network of Niagara (OPENN) allows these local agencies to coordinate their efforts and tackle the increase in opioid drug use, overdose and death witnessed in the Region.
Having received funding for a CTS providing supervision for injections, community partner Streetworks Niagara contacted NEMS for assistance with medical supervision. It was clear to Niagara EMS that paramedics could and should be a part of this community initiative. Paramedics interact with many of the people suffering with addictions in our community and with the work already being performed by our Mental Health and Addictions Response Team (MHART) it was felt that the collaboration offered good synergy and an opportunity to forge trust relationships with clientele to gain better trust further. The primary role of paramedics in the CTS is to quickly recognize someone who overdoes and provide immediate intervention. However, the paramedics at the clinic will have the opportunity to work hand-in-hand with clinic staff, monitor clientele, offer clean supplies, educate on substance abuse and actively work to understand more of the reasons people become addicted to get to the core of the problem with the ultimate goal of providing a pathway to recovery.
Drug addiction and death from overdose impacts more than just the user; it greatly affects the health and well-being of the drug users’ family. In order to have the greatest impact on health and health equity of Niagara residents, one of the MHART tasks is to respond alongside ambulances when information from the communication center indicates an opioid overdose. The MHART role is to provide harm reduction when possible and utilize the ‘stages of change’ model to assess patient’s readiness to enter into recovery. Evidence suggests this period is when an individual suffering from drug addiction is most willing to accept outreach. This time frame is used to offer support, education and access to addiction services, but it is also the time where users are at greatest risk for overdose because the presence of Naloxone in their system and the urge to use. Through emergency calls and consent of a patient, paramedics can also make patient referrals to MHART and the team will provide the same outreach, support and education within 24 to 48 hours.
To further gain the trust of the user and their family and provide further safety, Niagara EMS MHART has also begun offering Naloxone kits through Niagara Region Public Health. Users or their families might not want to replenish their Naloxone kits after use because of the stigma surrounding drug addiction. While visiting a client who has overdosed, paramedics can replenish Naloxone kits, solidify relationships with clients and determine what other services may be needed. IV drug use can also cause significant wounds that require medical attention, so paramedics will work with a wound specialist to identify wounds and what should be used to treat them to help reduce sepsis and poor medical outcomes. Although these steps might not stop the escalating opioid use, it could help prevent death from occurring, improve health quality and provide an avenue for users to seek treatment when they are ready.
In order to have a better understanding of where the majority of overdoses are occurring in the Niagara Region or, times when there is an increase in overdoses, Niagara EMS uses FirstWatch. FirstWatch turns raw data into meaningful information to helping improve situational awareness and clinical patient outcomes in real-time (FirstWatch, 2019). This program is designed to flag overdose calls from paramedic electronic patient call reports and give a geographic area as to where they are happening. Niagara EMS, Streetworks and MHART are notified when a trigger is hit higher than two standard deviations above the average number of overdose calls in a defined area. MHART and Streetworks can proactively visit these areas or individuals involved in the events, providing greater safety, education and other resources needed in the community.
Funding from the Provincial government provided a permanent location for a CTS and it will allow paramedics to dedicate their hours at the CTS seven days a week. Since MHART members have a relationship with users through their work in the community, team members will cycle through the CTS for further interaction. Fentanyl test strips will also be available at the CTS to allow clientele to test their drugs if they wish.
Paramedics develop strong trust in their communities, and the idea is to build upon this dynamic in to provide more holistic resources with regard to mental health and addiction. Paramedics understand how social determinants of health impact overall wellbeing, and so it was decided to create that role in a new and different way to a specific cohort of individuals who could benefit from more holistic care. As part of a new, evidence-informed clinical response plan, MHART is one of the resources that is responding to calls where there is an obvious or expected death. Evidence gleaned through Niagara EMS data indicates that a traditional transport unit is not required as these calls do not result in transport to the ED. Rather than send a traditional transport unit, when available, MHART responds in order to provide mental health support to family and caregivers who may be struggling with the loss and who could benefit from connections to community grief counselling resources. This type of response thereby also extends holistic care to family, care providers or even bystanders if appropriate. MHART is one of a number of teams that have been developed with the collaboration of community stakeholders to achieve maximum benefit as Niagara EMS rapidly moves from a traditional treat-and-transport EMS system towards a true Mobile Integrated Healthcare system.
Opioid-related morbidity and mortality in Ontario. (2018, May 23). Retrieved August 19, 2018, from https://www.publichealthontario.ca/en/dataandanalytics/pages/opioid.aspx
Every Record. In Real Time. Automatically. (2019, March 12). Retrieved May 23, 2018, from https://www.firstwatch.net/.