IntroductionChances are, as an EMT in New

Jersey you’ve been exposed to the useof illicit drugs. Even if you’ve neverbeen on an overdose call, you canhardly escape the current mediafrenzy about our state’s “opiate epi-demic.” Thousands have died of over-doses of opiates such as heroin,Oxycodone or Oxycontin. I have per-sonally responded to more fatal over-doses than I care to recall, as you mayhave as well.

And the situation is not getting anybetter, at least not in New Jersey. Arecent study showed that, for the firsttime since the federal governmentdeclared the opioid crisis an epidemic

in 2011, the number ofdeaths in the entirecountry edged down-ward last year – while inNew Jersey overdosefatalities continue toclimb. (See Figure 1)

No GeographicBoundaries

It’s hardly news thatillicit drugs are notrestricted to our innercities. In fact, many drugabusers are from affluentNew Jersey neighbor-hoods, with prestigiousaddresses we would allrecognize as “well off.”The teens and youngadults living in thesecomfortable environs arejust as likely to be snaredin the world of drugs asurban youth. This is afact you should recognize; justbecause your response area is afflu-ent or rural does not exempt yoursquad from encountering a variety ofdrugs.

In this article our discussion will beinformed from a “front lines” per-spective, based on a series of conver-sations I’ve had with “Abigail,” a 29-year-old recovering opioid user. Likemany young adults in New Jersey,

Abigail has seen the drug world onthe streets and has managed tosurvive, although often just barely!You will find her life experiencesinsightful and perhaps a bit shocking.

In Q&A format, what follows is justa portion of those conversations. Myquestions are marked “DH.” Inter-spersed with our discussions are in-depth analyses of the topics thatAbigail and I touched upon.

Street Drugs As Used By ‘Abigail’ & Friends

by Douglas Havilandby Douglas Haviland

The Gold Cross CONTINUING EDUCATION SERIESThe Gold Cross CONTINUING EDUCATION SERIES

After reading this article, the EMT willbe able to:

• Identify various types of drugs thatalter mental consciousness, theirlegitimate uses (if any) and the formsin which they may be encountered.

• Describe how Narcan works and thecircumstances under which it should(or should not) be used.

• Display a familiarity with Naloxoneprotocols, including recent changes.

• List the multiple safety concernsassociated with an overdose scene.

After reading this article, the EMT willbe able to:

• Identify various types of drugs thatalter mental consciousness, theirlegitimate uses (if any) and the formsin which they may be encountered.

• Describe how Narcan works and thecircumstances under which it should(or should not) be used.

• Display a familiarity with Naloxoneprotocols, including recent changes.

• List the multiple safety concernsassociated with an overdose scene.

EMT ObjectivesEMT Objectives

2010

Note: Total for 2017 is pending; 2018 figure based on trends to date.

843

1026

1294 1336 1307

1587

2221

2620

3000+

2011 2012 2013 2014 2015 2016 2017 2018

Heroin/Opioids & Drug Fatality Trends

in New Jersey

Naloxone

Figure 1:

-continues on page 10

8 Fall 2018

DH: Abigail, how old were you when youfirst experienced opiates1?

Abigail: “Pills at 16, heroin via IV at18.”

DH: How long did it take for your use ofheroin2 to turn into a habit?

Abigail: “From the first dose to usingit every day took six months.”

DH: How many of your friends have diedfrom overdoses3?

Abigail: “Half, at least 10 a year foreight years.”

DH: How did you manage to avoid thissame fate?

Abigail: “Doing just enough not to‘get sick’4, and luck.”

DH: How many times have youbeen in rehab for heroin?Abigail: “Twice in rehab in10 years; five times in detoxand once as an outpatient.”DH: People recovering fromheroin often end up relying onother, legal forms of drugs toreplace heroin. Have you hadany experience with these?Abigail: “ Two common

CEU Article: Street Drugs-continued from page 8

10 Fall 2018

1. A Narcotic is a drug that producessleep or altered mental consciousness.The terms “opiate” and “opioid” areoften – and incorrectly – used inter-changeably. Opiates are drugs derivedfrom opium. Examples include heroin,morphine and codeine. At one time,“opioids” referred only to syntheticopiates (drugs created to emulateopium, but which are different chemi-cally). Some examples of syntheticopioids include the prescription pain-killers hydrocodone (Vicodin) and oxy-codone (OxyContin), as well as fentanyland methadone. Now the term “opioid”is used for the entire family of opiatesand analogues including natural, syn-thetic and semi-synthetic.

Whatever their composition, thesedrugs work by binding to the brain’sopioid receptors – the parts of the brainresponsible for controlling pain, rewardand addictive behaviors.

2. Heroin is the most popular opiate,and a Schedule I narcotic under U.S.Federal law (no medicinal purpose,highly abused). It is also known asdiamorphine and other street namesthat go in and out of fashion. Heroin isan opioid commonly used as a recre-ational drug for its euphoric effects.

3. Signs Of An Overdose - Anyoneusing opioids is at risk of overdose.Signs include: a clammy, pale face;cyanosis; hypoxia; deep snoring or gur-gling; bradycardia; no response to phys-ical stimuli.

4. “Getting Sick” – In speaking toAbigail I found that drug users have alingo unto themselves and use termsthat can seem confusing. “Getting sick”doesn’t literally mean the user is sick aswe commonly understand it; it meansthe user is experiencing the onset ofwithdrawal symptoms. What struck memost was the user’s assumption that Iinherently understood what she meant.Personally, I have never experiencedheroin nor withdrawal, but I can tell youit induces a dramatic shift in personal-ity. Users denied the drug when theywould normally use it can becomeextremely agitated and desperate.

6. Methadone - Methadone is a syn-thetic opiate that works at the samereceptors in the brain as heroin (the muopioid receptors). Unlike heroin, it has aslow onset and long duration of actionwhen taken as directed. Properly pre-scribed, methadone is not intoxicatingor sedating. It does effectively suppressopiate withdrawal and relieve the debili-tating craving that typically causespeople to relapse. However, there aredownsides. As an opioid, methadonecan be addictive. And because it’s sucha long-acting drug, it can build up in thebody and remain in the bloodstream fora long time. It is easy to overdose onmethadone due to its strength. Evenlegitimate use via a prescription canturn into abuse as tolerance develops.According to the CDC, in 2009, metha-done contributed to one in three pre-scription painkiller deaths. As metha-done has increasingly been used totreat pain and not just addiction, moreof this long-acting opiate has becomeavailable to people who abuse drugs.

5. Suboxone – Perhaps the most shock-ing thing I learned in researching thisarticle concerned the use and abuse ofSuboxone. I had never heard of Suboxone,much less understood it.

Suboxone has saved countless lives,lives that would have been lost to heroin,and that was why it was developed. How-ever, Suboxone has led a twisted medicaland legal existence.

Suboxone is a mixture of naloxone andbuprenorphine. It’s typically used in themanagement of opioid abuse and with-drawal. It can be given to people to facili-tate detox, withdrawal and the early stagesof opioid abuse recovery, as well as beused in the longer-term – as a mainte-nance medication to reduce the risk ofrelapse with more dangerous substances.

Buprenorphine is a partial opioidagonist. Its moderate activity at the brain’sopioid receptors can help to reduce theeffects of withdrawing from an opioid suchas heroin. As an opioid receptor antagonist,naloxone counteracts opioid overdose butalso serves to prevent more potent opioidsfrom fully delivering their euphoric effects.Suboxone is available in tablet form, aswell as a sublingual film that dissolvesupon insertion under the tongue.

Suboxone is a beneficial medication thataids in the treatment of opioid addiction.However, as an opioid drug, Suboxoneabuse and addiction can and does occur.People may buy, sel l , or trade theirSuboxone, take Suboxone that is not pre-scribed to them, or take inappropriatedoses of Suboxone.

Now the term ‘opioid’ isused for the entire family

of opiates includingnatural, synthetic and

semi-synthetic.

Now the term ‘opioid’ isused for the entire family

of opiates includingnatural, synthetic and

semi-synthetic.

drugs – Suboxone5 and metha-done6.”

DH: Have you ever been “Narcaned” for aoverdose?

Abigail: Yes, by the police. They saidI was out of control; they gave meNarcan7 (via the nasal route) inpolice headquarters.

DH: Are heroin users exclusive to thatdrug, or do they mix other drugs in theirroutine?

Abigail: “Mix – anything to get high,Xanax8 and cocaine9 are com-mon.”

GC: What is the current street cost ofheroin? How much would a typical usertake in a given day?

Abigail: “A ‘bag’ of heroin is $5.00 to$10.00. Its not unheard of to use50 bags in a day (that’s $250.00 to500.00 a day).

My initial reaction to Abigail’s “50 bags aday” remark was that it seemed ludicrous. Inspeaking to one law enforcement officer hesaid it was close to impossible. However, inspeaking to other users, I found a truth

CEU Article: Street Drugs-continued from page 10

11Fall 2018

8. Xanax - Xanax is the trade nameof the prescription drug alprazolam, andis in a category of medications known asbenzodiazepines. It comes in severaltablet forms and as a concentratedsolution. Xanax is typically prescribed totreat anxiety and panic disorders; it isthe single most prescribed psychiatricmedication in the U.S.

Xanax is especially addictive whenmisused (taken recreationally or otherthan as directed). It is commonly abusedby those taking it as a sedative. Over-users will appear lethargic, and lack themotivation to engage in normal activitiesor tasks requiring sustained attention.

9. Cocaine - Glamorized by popularculture and countless 1980s dramas, tomany cocaine is a drug of “Reagan era”America. This is misleading. Cocaineuse is widespread and drug users oftendrift between a variety of products suchas heroin and cocaine (or often combinethem). For this reason, many prehospitalpersonnel frequently confuse the drugs.

Cocaine is a stimulant, as opposed toheroin which is a CNS depressant. Beinga stimulant does not necessarily make itsafer. While heroin and its pharmacycousins are deadly due to their inordi-nate ability to depress vital functions,for certain populations the stimulanteffects of cocaine can have cardiaceffects that are just as deadly. Usersolder than 55 are especially in danger.

7. Narcan (naloxone) – Narcan is thebrand name for the drug naloxone. Unlikepartial agonists like buprenorphine, whichpartially blocks opioid effects while stillproviding its own, milder version of them,naloxone is a pure opioid antagonist. Thismeans that naloxone does not produce anyopioid effects and instead binds to thebrain’s opioid receptors (see Figure 2), ren-dering any opioid drugs in a person’ssystem essentially powerless.

While these properties give naloxone theability to reverse an overdose and savesomeone’s life, this sudden and completestoppage will initi-ate immediate andoften extremelypainful withdrawalsymptoms, so it isreserved strictly asan emergencymeasure.

Narcan can beeasily administered via the nasal route (asin Abigail ’s story) and via an “IM” orinjectable pen device similar to an epi-pen.Narcan can reverse the effects of not onlyprescription opioids, but also drugs likeheroin and even fentanyl. It binds to thebrain’s opioid receptors within two to threeminutes. Narcan has no effect on over-doses of substances other than opioids.

There is no such thing as a drug that hasno side effects. Side effects of Narcan mayinclude headache, nasal swelling, conges-tion, inflammation, dryness and increasedblood pressure.

However, the most unpleasant andpotentially dangerous of the Narcan sideeffects is a result of its intended use. Therapid reversal of an overdose shocks thebody into near immediate drug withdrawal.These withdrawal symptoms may includenausea, dyspnea, diarrhea, stomachcramps, tremors, tachycardia, diaphoresis,muscle aches, flu-like symptoms (fever,chills, weakness) and finally cardiac arrest.

At present, one of the glaring issues withNarcan is its overuse. As illustrated byAbigail’s story, Narcan can be given to con-scious patients with any opiate use or

overdose. However, prehospitaluse of Narcan should berestricted to unconsciouspatients who are not breath-ing.10 Narcan should not beused to gain control of unrulypatients! In fact, Narcan is bestused in the prehospital settingto block just enough opiate to

restore normal breathing, not to wake thepatient. Any care of patients with sus-pected opiate overdose should be focusedon the “A-B-Cs.” EMS should be first andforemost prepared to “bag” the patient(BVM administration with supplementaloxygen and airway control). Narcan is asecondary concern; breathing is primary!Be careful: In some instances, Narcan willnot just wake the patient but cause him toawake in an agitated state. Some patientsmay vomit and potentially lose airwaycontrol. Remember: Breathing is yourprimary concern, not waking the patient!

Any care of patients withsuspected opiate over-dose should be focused

on the ‘A-B-Cs.’ Narcan isa secondary concern;breathing is primary!

Any care of patients withsuspected opiate over-dose should be focused

on the ‘A-B-Cs.’ Narcan isa secondary concern;breathing is primary!

-continues on page 12

Figure 2:

Narcan ExplainedNarcan Explained

hidden in her remark that had escaped me.The reality is that one bag of heroin13 is notnecessarily equal to a single injection; userscan and will prepare and inject multiple bagsin one syringe delivery. Users will shoot up toten bags in one injection and doing the mathwe can see that could possibly be up to fiveindividual injections (in a given day).

CEU Article: Street Drugs-continued from page 11

12 Fall 2018

Figure 4:

NJDOH/Office of Emergency Medical Services - EMT Treatment ProtocolsNJDOH/Office of Emergency Medical Services - EMT Treatment Protocols

10. Protocols - All EMTs should befamiliar with current NJ State treatmentprotocols. The opiate overdose protocolreceived an update with a significantchange in September 2017 (see Figure 4).Also keep in mind that while NJ does allownaloxone use by EMTs, it requires medicaldirection and specific in-house agencytraining. Wording specific to the state pro-tocols are as follows: “Respiration depres-sion, secondary to an opiate overdose, isprimarily managed by continuous, attentive

airway care and ventilatory support. Ifavailable, reversal therapy with naloxonecan be secondarily considered after venti-latory support with the goal to increaserespiratory effort and increased respira-tions due to depression.”Other State Protocols for naloxone:

Age: No restrictions. However, the proto-cols do recommend that for patients underage five, medical direction should be con-sulted. Keep in mind children can get into

-continues on page 13 -continues on page 13

DH : When did you first experiencecocaine?

Abigail: “15” (years of age).DH: How is cocaine used on the street?Abigail: “Snorted, injected and

smoked (in a pipe).”DH: What should an EMT look out for in

treating a patient with sharps12 onboard?

CEU Article: Street Drugs-continued from page 12

13 Fall 2018

-continues on page 14

opiates – legal and illegal – in the home.(Do not underestimate an abuser’sability to be careless with drugs, evenwith small children in the house; parent-hood does not displace the desire to useheroin and other opioids.)

Indications: respiratory depression orarrest secondary to known or suspectedopiate overdose – pinpoint pupils,depressed mental status.

Contraindications: hypersensitivity,medication is discolored, cloudy, precipi-tated or expired. Use with caution withknown cardiac history, SVT arrhythmia,head trauma, brain tumor, or poly-sub-stance overdose.

Dose: The biggest change in the pro-tocols was the reference to Narcandoseage. Prior editions referenced anEMT level dose of a single 2mg (applica-tion) spread over both nares. Lawenforcement was allowed higher levels.The latest version makes no mention ofa specific dose. This may be due toreportedly higher resistance to Narcanby users consuming higher levels ofopioids, or more intense versions suchas fentanyl11. EMTs are now allowed toadminister multiple doses of 1mg pernare. To be clear the latest protocol isopen-ended with no specific maximumdose amount mentioned for EMTs.

Protocols (continued)

Are Those Drugs Real or Fake? EMTs should be aware that the drugs

they encounter at an overdose scenemight not be what they appear to be.

“Almost 100 per-cent of what’s beingsold out there iscounterfeit,” saidthe chief securityoffice for Pfizer, thecompany that makes prescription Xanax.“They’re putting whatever they want intoit: fentanyl, boric acid, whatever ingredi-ents are available they’ll put into it and sellit as Xanax. If the intent is to kill kids thenthey’re doing a good job of it.”

Most buyers simply don’t realize they’regetting something different than what theyintended to purchase, especially when the

counterfeit looks exactly like the real thing.Fake Xanax is a good example: it has the“XANAX” label, and has a similar size,

shape and color. Infact, the physicalcharacterist ics ofthese pi l ls are soexact, even forensicscientists can’t tell

they’re fake just by looking at them.More and more news reports are mirror-

ing one that came from the San Franciscoarea last year, where at least nine peoplefell prey to fake Xanax pills laced with fen-tanyl. Three suffered from heart attacks(one fatal) and one from heart failure,while others experienced a major hit torespiratory and nervous system function.

11. Fentanyl - Fentanyl is a syntheticopioid that is often used in conjunctionwith heroin; street mixtures of the twodrugs are common. Fentanyl is at least75 times more potent than morphine,and fentanyl analogs (such as carfen-tanil) may be as much as 10,000 timesmore potent than morphine. Fentanyland heroin appear identical, but even asmall dose of fentanyl can have dra-matic effects or can even be fatal.

In its purest form, fentanyl is a whitepowder or in grains similar in size tograins of salt. It only takes a very smallamount of fentanyl to cause a severe orpotentially deadly reaction; as little astwo milligrams isa lethal dose formost people (seephoto at right).Consequent l y,not only areusers exposed to danger, but also otherswho might encounter fentanyl such asfirst responders and police officers.

In 24 of the nation’s largest metro-politan areas, fentanyl-related overdosedeaths increased nearly 600 percentfrom 2014 to 2016, according to countyhealth departments. While many ofthose overdosing on fentanyl specificallysought to use the drug, officials sayoverdoses also occur among users whodidn’t know the powerful opioid was cutinto their heroin – or even their cocaine.

Fentanyl’s attractiveness lies in itsdirt cheap price. If a particular batch ofcounterfeit pills has two milligrams offentanyl per pill, approximately 500,000pills can be manufactured from onekilogram of pure fentanyl. On the street,these pills sell for $10 to $20 each.

In addition to powder, granular andpill form, fentanyl is also sold by pre-scription as a transdermal patch, com-monly under the brand name Duragesic.EMS personnel are well-advised to do athorough head-to-toe exam of suspectpatients to locate such patches (theremight be more than one). Extremecaution should be taken in removing apatch; gloves area must. Remem-ber: as long asany patch is lefton, the patient isstill being medi-cated. A Fentanyl patch

A Few Common TermsCDS: controlled dangerous substance.

Sharps: common medical term for needlesor diabetic lancets

Paraphernalia: items used for preparing andingesting drugs including needles,spoons, lighters, pipes and packets

Rehab: generally an inpatient stay, 24/7 withsupervision, especially for those withsevere substance abuse issues. Averagestay is 30 days.

Detox: medically supervised purging of theaddicts body of toxins (the drugs). Mostoften the first step in rehab.

IM: intermuscular injection

MAD: nasal applicator for Narcan

14 Fall 2018

Abigail: “Needles will be hidden in avariety of fashions: in clothing,shoes, sunglass cases and purses.Look for holes in clothes (as accessto hiding places). Any of thesecould contain sharps.”

DH: Any closing thoughts?Abigail: “I wish I knew what I know

now when I started!”

Catch And Release?One of the hottest debates of late is a

practice that’s often called “catch andrelease.” Specifically, this entailsadministering Narcan to an overdosepatient and – once it takes effect andthe patient is conscious – asking himor her if they wish to be transported tothe hospital. Almost without excep-tion, the patient will decline transportand sign off as an RMA . Certaindepartments and counties are counter-ing “catch and release” and enforcing a100% transport rule after administer-ing Narcan to patients who overdose.

Those in favor of transporting, withor without consent, point out thattransporting to the hospital will givethe drug user an opportunity to becounseled by someone at the health-care facility. Their hope is that theshocking experience of being trans-ported will bring some sense intothem and they will suddenly “see thelight” and the gravity of their situa-tion. The user will, with counseling,curtail his habit and be put on theroad to recovery.

Those against transporting willpoint out that all oriented patientshave “free will” to refuse, and if weignore their wishes we open ourselvesto potential litigation. We should allbe familiar with a patient’s right torefuse all or part of care, includingultimate transport.

The entire issue reveals a seriousfailing in the current climate of unre-strained prehospital use of Narcan bylaw enforcement and EMS. While

there’s no question that Narcan hassaved thousands of overdose victims,it has also created an aura of “conse-quence-free” IV drug use. Hardcore IVdrug users harbor little fear of death,at least none they will admit to openly.

From an EMS perspective I offer mystudents the following: If you’ve takenany patient to the point that you’veassisted or administered a drug –aspirin, glucose, nitro, epi-pen orNarcan – you have crossed over athreshold of patient involvement(care) beyond doing vitals and coun-seling them. My personal belief, espe-cially given the increased level oflethalness of opioids, is to do every-thing possible to get them to agree tohospital transport. The very real pos-sibility is that the drug – a heroin andfentanyl mix , for example – willremain in the patient’s body longerthan the Narcan is active in the blood-stream; this can result in anotherepisode of overdose within minutesor hours of your 9-1-1 visit!

Your best course of action mayseem odd: namely, don’t give Narcan

CEU Article: Street Drugs-continued from page 13

-continues on page 15

12. Sharps - Prehospital personnelshould know that drug users commonlyuse needles – “sharps” – to injectheroin and cocaine into their blood-streams. These sharps are not justcommon but were made legal in aneffort to prevent disease transmission.In interviewing Abigail she made pointedreference to the confusion over the legalavailability of needles in the pharmacy.

Like three million other Americans,Abigail has type 1 diabetes and usesneedles multiple times a day. In herteens, Abigail found out how popular hersupply of new and “sl ightly used”needles were. A diabetic who is a drugabuser – surrounded by other drugusers – will often recycle the sharps,even with several users. These well-used sharps may be strewn about care-lessly or, conversely, carefully hidden.

The New Jersey law decriminalizingneedle possession was enacted in2012. The law provides for the sale ofhypodermic syringes or needles inquantities of ten or fewer to anyone 18or older who presents valid photo identi-fication. The law also provides that ifsyringes are purchased for criminalintent or unlawful purpose, law enforce-ment intervention would be triggered.

I sought out several police officers toget their viewpoints on the law. Thispresented another occasion for me to beshocked. Even veteran officers seemedconfused at best at what the law actu-ally says. How law enforcement typicallytreats a needle possession incidentseemed to vary between officers I spokewith; some were unaware that needlescan be purchased without a script. Oneveteran officer offered the most conciseobservation: “The needle alone wouldmean little. Other evidence pointing todrug use would give police cause topursue action.”

The bottom line for EMS is to alwaysuse caution and be hyper aware of whatone might encounter. As Abigail warned:“needles may be hidden in clothing”and other areas. What I learned wasneedle sharing is very much alive andwell! IV drug users are numbed to thechances of disease transmission sincetheir singular focus is to obtain more ofthe drug they desire. To them, needlesare simply a reusable element withinthe big picture.

13. Heroin Packets - If you’ve everhad the misfortune of attending to aheroin overdose death, you may havenoticed the presence of the ubiquitousheroin packet. These packets are aboutthe size of a book of matches. The tech-nical name for the bag is “wax glassinebag.” Published internet data indicatesthey contain a single dose of heroin; thisdose seems to vary between 33.5 mg to50 mg or more.Typical ly theyare plain-lookingbut frequentlythey have a“brand” stamp.The brand stamping is particularlycommon from the Philadelphia areathrough New Jersey, New York and thenortheast. I clearly recall the first time Isaw one; it was embossed with a logoidentical to the familiar Garden StateParkway or “GSP” logo (the outline ofthe state inside a circle with text aroundthe circumference). The drug brandingis actually an attempt, as with all con-sumer products, to build loyalty amongusers to one’s brand.

Fentanyl is a syntheticopioid that is at

least 75 times morepotent than morphine.

Fentanyl is a syntheticopioid that is at

least 75 times morepotent than morphine.

15 Fall 2018

initially! If your OD victim is uncon-scious, your main role is to supportbreathing with a BVM. The BVM ven-tilation will maintain your patient’slife and your patient also will beunable to refuse the transport. Hos-pital staff can then make a call in thefacility to give the Narcan or not.

We have all heard of IV drug userswho have been “Narcaned” (hadNarcan administered on scene) byEMS two or three different times in agiven day or over the period of a week.Such stories should clearly illustratethe nature of the issues at stake. In thisauthor’s view, both extremes of the“catch and release” debate are playingmoral and political games on thebacks of severely ill drug addicts.

Scene Safety In a recent EMT class I was conduct-

ing, an astute student asked: “Whatshould we do if we arrive at the sceneof a heroin overdose and there are stilldrugs and paraphernalia layingaround?” My first thought was to saythat the priority is the overdose victim;the paraphernalia is not your concern.

However, the presence of that para-phernalia raises another issue that weas EMTs should keep foremost in ourminds when approaching an overdosecall. That is, we must be wary of theselfish and sometimes barbaric mind-set of many drug abusers.

Since your first EMT class, instruc-tors have drummed into your head theconcept of “scene safety.” I find the termis repeated so frequently, by rote, thatwe become numb to the meaning of it.And the danger of becoming numb isthat a CDS overdose scene is preciselynot the time to let your guard down!

Narcotics users frequently turn tocrime – ranging from robbery andcredit card fraud to prostitution – tosustain their habit. Criminal behavioris often accompanied by an aggressiveor violent mindset, and firearms andother weapons are not unheard of in adrug scene setting.

As Abigail alluded to in her inter-view, used needles are commonly leftstrewn about the scene or hiddenwithin clothing or personal posses-sions. IV drug users are often carriers

of various communicable – and some-times deadly – diseases.

When you combine all of thesefactors: fentanyl’s potency, diseasetransmission, the potential presence offirearms, criminal behavior, uncertainpatient response to Narcan, and unse-cured sharps, you can see the ubiqui-tous overdose is hardly an EMS run tobe treated lightly. Yes, the opioid/heroin overdose call is very common,and becoming moreso, but the under-

lying circumstances leading up to anytwo of them could be as different as dayand night. Always remain vigilant andapproach each scene with a heightenedsense of situational awareness!

Douglas Haviland has been involved inemergency services since 198 0 and a fullEMT instructor since 2005. He teaches forJersey Shore University Medical Center -Hackensack Meridian. He also trains newinstructors in AHA CPR.

CEU Article: Street Drugs-continued from page 14