First Responders Saving Lives Only for Them to Overdose Again
A man named Nicholas gets intendance in an ambulance after overdosing in San Francisco, Calif. Rachel Bujalski for NPR hide caption
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Rachel Bujalski for NPR
A homo named Nicholas gets intendance in an ambulance after overdosing in San Francisco, Calif.
Rachel Bujalski for NPR
It's a sun-filled, fall mean solar day and Nicholas is strapped to an ambulance gurney near eighth and Market streets in downtown San Francisco, dazed and barely conscious. Plastic IV tubes snake around his left mitt where L-O-5-E is tattooed simply beneath his knuckles.
"Nicholas, endeavour to wake upward a niggling bit for me, come on," paramedic Paula Fartash coaxes, as she unsuccessfully tries to rouse him from his drug-induced stupor.
Nicholas (we're non using his concluding proper noun because of the stigma of addiction) tells Fartash that when he started getting high in nearby U.N. Plaza park, he assumed he was smoking his drug of selection.
"This admirer thought that he was doing meth," the veteran San Francisco Burn down Department paramedic says. "And turned out he was actually doing fentanyl likewise," the constructed opioid many times more powerful than heroin. "Then he walked over to someone and they gave him some Narcan."
That'due south the brand proper name for naloxone, the emergency nasal spray drug used to try to reverse an otherwise potentially fatal overdose. That someone who administered life-saving antidote was a nearby volunteer and street cleaner carrying Narcan. It'due south function of a city-supported programme.
San Francisco has amongst the highest per capita drug overdose death rates of whatsoever city in the U.S.
Faced with a stunning rise in drug overdose deaths the concluding few years, the vast bulk tied to fentanyl, San Francisco has launched mobile teams made upwards of paramedics and nurses. The new Street Overdose Response Teams (SORT), a collaboration between the city's health and fire departments, aim to evangelize a broad range of back up and care directly post-obit an overdose.
"Fentanyl is a game-changer," Dr. Hillary Kunins, the city's director of behavioral and mental wellness services, says of the opioid that'south 80 to 100 times stronger than morphine. "Information technology requires a new way of thinking and resourcing." It as well, she says, "requires people to learn to piece of work beyond disciplines and sometimes beyond organizations."
San Francisco Department of Public Wellness nurses with the Street Overdose Response Team paw out Narcan as part of a broader endeavor to contact and help those who take recently overdosed. Rachel Bujalski for NPR hide caption
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Rachel Bujalski for NPR
Registered nurse Louise Bisby is part of the city'due south mobile outreach team that aims to help people who recently overdosed with a broad range of support services, from treatment to housing. Rachel Bujalski for NPR hibernate caption
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Rachel Bujalski for NPR
Dr. Kunins previously led New York City'southward response to its overdose and substance abuse crunch. She concedes they aren't certain what combination of tools, ultimately, will piece of work best here to not merely reduce fentanyl and other drug-related deaths simply also heave treatment success rates.
And then the street overdose airplane pilot project is part of a broad and ambitious strategy of interventions across city agencies.
"There is no unmarried approach that's going to solve this complex trouble," Kunins says. "What's heady and important about the work is that it is really part of a movement across the land to rethink how we address people who are at risk of overdose, who have ongoing other challenges: mental wellness, housing, food. And we must do this work to scale."
Fentanyl forced city officials to modify how they approached harm reduction
Capt. Michael Mason, a paramedic, is the burn department'southward point person on the new plan. As he races to the call for Nicholas' overdose, he's simultaneously coordinating with other paramedics.
"So starting direct at the scene of this overdose, we can start trying to straight this guy's care in the best management possible," Stonemason says.
That direct appointment could include helping to find a shelter bed, reaching out to friends or a doctor, helping with food or, most importantly, seeing if a person wants to showtime treatment with buprenorphine or suboxone, a medicated-assisted therapy for opioid dependence.
"Get this individual suboxone, stabilize him at the [emergency department], by that afternoon they can exist in a treatment program," Mason says, "All in the context of a 911 incident."
For many years San Francisco has championed a damage reduction public health approach to lowering drug deaths and injury. The city, known for its relative tolerance of illicit drug utilize, was a pioneer of clean syringe admission, distribution of life-saving naloxone kits, as well equally boosting admission to the treatment drugs methadone and buprenorphine.
But when fentanyl hit difficult here starting a few years ago, the overdose crunch spiraled and the metropolis was forced to rethink its approach. Free Narcan and syringes weren't enough.
San Francisco Department of Public Wellness nurses with the city's new mobile outreach teams say following upwards with people who've recently survived a drug overdose is a key part of the plan. Rachel Bujalski for NPR hide caption
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Rachel Bujalski for NPR
"If fentanyl is in the drugs that you lot're using, your hazard of overdose triples," Capt. Mason says, adding that the drug is at present tainting about every street narcotic hither: Meth, cocaine, heroin and fake opioid pills.
The new street response teams bring the clinic to the patients
Pandemic isolation and lockdowns — people using solitary with no ane to administer life-saving Narcan — only partially explain the historic rise in overdose deaths here.
The drug death rate, in fact, had been trending college well earlier that, city medical examiner data show. In mid-2018 the numbers began to skyrocket, reaching 441 deaths in 2019. And in 2020, a whopping 712 people fatally overdosed, more than double the number of people here who died from COVID-xix during that same period.
The vast bulk of those deaths – almost three-quarters –involved fentanyl.
The death price would have been fifty-fifty college if not for the wide availability of Narcan here. Well over 3,000 people reported using Narcan in the city in 2020, a self-reported effigy. Officials say the real effigy is probably far higher.
But health and burn department officials here, Mason says, noticed something else important: nigh one-half of all who died of an overdose were treated or revived by a paramedic crew in the days or weeks before their death, a big signal they were headed for repeat trouble.
"Surviving a nonfatal overdose is one of the best predictors of future mortality. Anyone who survives a not-fatal overdose is a huge crimson flag for us, and that is what this plan is almost," he says.
A key goal is trying to bring the clinic to the patients: rapid, contiguous follow-upward outreach on the street.
"We get out, we look for them, we say, 'Hey, let'south talk well-nigh yesterday,'" says city wellness department nurse practitioner Kevin Lagor, equally he drives through the Tenderloin neighborhood, where many of his clients live. He's a program pb with SORT's outreach arm.
The goal is to accomplish back out inside 24 to 72 hours of an overdose to try to assist the person with everything from housing to treatment.
"That could be providing medical intendance to address their mental illness. Maybe they're out of their meds, or maybe they want to start something to accost their substance employ disorder," he says. "Only kind of, basically, meeting them where they are and seeing what they need and how we can help them."
Just to run across them where they are, the nurse teams first have to find them.
It's a huge challenge. Many of them are homeless, living in tents on the street or in and out of shelters.
The overdose and substance abuse crisis is directly linked to the city's epic struggles with homelessness and related challenges including mental illness. Almost thirty% of all overdose deaths here are among the unhoused or people "with no stock-still address." SORT collaborates closely with the city's other programs, including street medicine and new mental health and homeless street crisis response units.
Neil, nosotros're not using his total name because of his illegal drug use, is homeless and living in the city's Tenderloin commune. He says he smokes the powerful opioid fentanyl to deal with depression and chronic breadbasket pain. Rachel Bujalski for NPR hide caption
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Rachel Bujalski for NPR
Homeless people living in tents line a side street in the Tenderloin district. More 40% of all drug overdoses are in the Tenderloin and neighboring SOMA commune, co-ordinate to city data. Rachel Bujalski for NPR hide caption
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Rachel Bujalski for NPR
Metropolis data show that men were almost 4-times more than likely to die of an adventitious overdose than women. And the homeless, older San Franciscans and minority communities were disproportionately affected by the death rate. Almost quarter of all overdose deaths are amid Black San Franciscans who make up but under half dozen% of the city'south population.
More than than 40% of all overdose deaths in the terminal year have been concentrated in 2 neighborhoods: the Southward of Market area and the Tenderloin, according to information from the metropolis and county chief medical examiner's office. Those areas make up just 7% of the metropolis's population.
While drug deaths hit every sector of order, many who overdosed were found in city-funded hotel rooms for the homeless and in depression-income flat buildings.
"We have to remember that this is a social crisis at the intersection, particularly in San Francisco, of a housing crunch, of a mental health crisis, of people living at the margins of society," says Dr. Dan Ciccarone, a professor and researcher at University of California, San Francisco.
Open air drug use and dealing in the Tenderloin, an area long challenged by poverty, homelessness and addiction crises, has simply worsened during the pandemic. It's mutual, day or night, to see people smoking or shooting up opioids or nodding out from drug use.
1 32-year-old man named Neil says he's been homeless and living on the streets, mainly in the Tenderloin, for 3 years at present. Nosotros're not using his last name because of the stigma of addiction.
He says he uses fentanyl "to take the edge off" off of his depression and chronic breadbasket pain. He occasionally sells drugs, he says, to go money to support his habit. He presently crushes a small-scale corporeality of fentanyl into a piece of tinfoil and begins to smoke the drug.
Follow-up work by nurses is full of challenges
On a contempo day, nurse Lagor has half a dozen clients listed on his clipboard. He can't observe a single person.
"So we'll merely kind of keep following up with the staff at the shelter," he says in the lobby of one facility, having been unable to observe a client.
The same happens at a makeshift tent encampment behind a local Best Buy.
Outside some other shelter, Lagor and his squad strike out again trying to detect a young man they thought they were making progress with. They'd recently written him a prescription for a supply of buprenorphine.
"He hasn't been here in a couple of days," Lagor says, disappointed.
"It is a bad sign. Sometimes folks disappear for a couple days and then resurface," he says. "Then they disappear, or it merely falls autonomously."
And when it all falls apart, information technology can hitting Lagor and the remainder of his team hard.
"It's a lot of death and they're not strangers. Yous know, we've had a couple of deaths this week and we've, nosotros shed tears together," Lagor says. "Information technology'southward hard not to intendance most someone when you're actually trying to help them."
Addiction and public health experts say these mobile, non-police teams marker a much-needed pivot for the metropolis.
"Information technology'due south bold and it'southward innovative. I similar it," says Dr. Ciccarone, a professor of medicine at UC San Francisco and a leading expert on drug use, drug users and heroin. "We need to bring in some innovations here because fentanyl is a wild card and it has caught the states all past surprise. That's what we need to practise in a crisis situation: Think creatively."
City public health section nurses Kevin Lagor and Louise Bisby, part of new mobile outreach teams, get supplies out of their SUV to bring to people who accept recently survived a drug overdose. Rachel Bujalski for NPR hibernate explanation
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Rachel Bujalski for NPR
Simply Dr. Ciccarone cautions that the ravages of fentanyl and its circuitous stew of related challenges hateful the city needs to calibration-up this new street overdose response program and keep to try to break down obstacles to treatment that include bureaucratic silos, turf battles and funding woes.
"It's definitely non enough," he says. "We have to make sure that harm reduction is adequately funded, that our mental wellness system, our substance treatment system, our housing systems are adequately funded."
So far, just two months since the program'due south launch, ten% of those encountered by the SORT teams who've overdosed are now getting medicated assisted treatment for opioid utilize disorder. That includes buprenorphine or suboxone in collaboration with urban center'southward street medicine nurses.
"I'1000 proud of that number," Capt. Bricklayer says, "and I very much look forward to increasing that."
To get that number even college, the fire department has applied to the land Ems agency to allow paramedics to more than easily administer and prescribe those treatment drugs direct in the field.
Despite a recent slight drib in monthly fatalities the city looks to end 2021 with more than than 700 overdose deaths for the second year in a row. Unfortunately, Dr. Kunins, the city's managing director of behavioral health services, says San Francisco is "on rail to go along this really tragic loss of life."
Paramedics on the team look for minor victories
Back on the street, another call comes in from the 911 dispatcher for a possible overdose. A middle-anile woman has been found slumped over in a McDonald's bathroom across town in the Fillmore district.
Capt. Mason's occasional staccato siren squawks aren't working on a scattering of indifferent drivers and pedestrians in heavy rush-hour traffic. And so he hits his fire truck'southward lights sirens full diameter.
When they arrive, the adult female tells the paramedics she has relapsed after several months of sobriety.
The heroin she bought, Bricklayer says, was probable laced with fentanyl. Narcan saved her.
Inside the ambulance, Stonemason says the woman handed paramedics a crumpled, greasy chocolate-brown fast-nutrient bag and asks that they get rid of it.
"In that location were some clean syringes in there and what appeared to be small bags of heroin."
Paramedic Capt. Michael Mason, of the San Francisco Fire Department, takes a pocketbook of drugs and paraphernalia to a nearby police force station for disposal. The drugs were from a woman who'd simply overdosed in a nearby fast food restaurant. Rachel Bujalski hide caption
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Rachel Bujalski
Fire Department Capt. Michael Stonemason with the urban center's Street Overdose Response Squad arrives at the scene of a reported drug overdose in downtown San Francisco. Rachel Bujalski for NPR hide explanation
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Rachel Bujalski for NPR
Bricklayer finds out she was already part of a medicated-assisted treatment programme using suboxone. He says she told them that she wants to go sober once more.
"She was feeling extreme shame from experiencing a relapse," he says. "Substance apply disorder impacts millions of Americans. At that place'due south no shame in having a relapse."
He hopes she restarts her suboxone treatment apace.
"As for today," Mason says, "and as for surrendering those items and requesting they be disposed of, my hat's off to her."
The paramedics and nurses involved in this pilot project are defended to this difficult work. But all say working beyond multiple metropolis agencies, treatment centers, health providers and non-profits can be exhausting.
"Information technology's complicated," Bricklayer says with a sigh, "it takes work from dozens of folks in a single come across."
How does he handle the strain of 12-hour shifts filled racing from overdose to overdose, including to some who seemingly don't want help and others who don't survive?
"For my ain mental health, I have to kind of remain an optimistic warrior," he says, driving his fire section pick-up through rush hour traffic. "There's a quote in the Talmud that says, I won't become it exactly right, but essentially says, "You lot don't have to end this work, but you exercise have to start it.'"
And the adult female who overdosed in the McDonald'southward bathroom who wants help once again? It'south a small victory.
Maybe.
It'southward a outset.
Source: https://www.npr.org/2021/11/03/1049637659/drug-overdose-deaths-san-francisco-mobile-response
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