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'Over and over and over.' How Lancaster County EMTs see the opioid crisis

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This is what 2mg of fentanyl looks like. That's enough to kill you. And this synthetic opioid is in a swell of street-made drugs fueling an escalating opioid crisis. Not shown is the derivative carfentanyl, which is 100 times stronger.

Opioid users are smart enough to go public.

“They go to Walmart parking lots, because they know somebody’s going to drive by and see them unconscious and call 911,” says Lancaster County EMT Greg Brasington.

Shoppers, passers-by, police officers on patrol – someone will find them if they sit in the car in a well-traveled place, turning blue and playing cat-and-mouse with death itself. First responders show up with naloxone – most commonly referred to by its main brand name, Narcan – and spray it up the nose of someone dying in the front seat.

The users don’t remember anything once they’re under.

“All they know is, they take the drug, the feel good, and the next thing they know, the medics are there,” Brasington says. “They don’t remember throwing up or not breathing or turning blue.”

Some users bypass relying on first responders altogether.

“They have their buddy stand by with their resurrection drug,” he says. “As soon as they go out they know their buddy’s going to give them this antidote so they can wake back up and do this over and over and over.”

How it happened

Over and over and over. That’s the rhythm Lancaster County’s paramedics have to work with, in a heightened version of what was already a nightmare. Opioids flooded the streets about a decade ago as an offshoot of overprescribed painkillers. When federal legislation and the Trump administration put their weight behind fighting the opioid problem, it was 2018 – a decade into what had become a national epidemic of overdoses and deaths.

Rural South Carolina took the hardest hit. Data from the state Department of Alcohol and Other Drug Abuse Services (DAODAS) starting in 2015 charts the administration rates of naloxone through 2020. The spikes on the graph read like the quickening pulse on a hospital monitor: Up. Down. Way up. A little down. Way, way up. Fairfield County’s pulse in particular is a sprinter among joggers.

Lancaster’s pulse looks like everyone else’s and hovers near the top of the field of counties spraying resurrection up someone’s nose. And like almost all other counties in South Carolina, its pulse took a big dip in 2018 – when the number of pharmaceutical opioids going home with patients had dropped for the sixth straight year, nationwide, according to the CDC, and Lancaster’s rate of naloxone administration was half (1.09 doses per 1,000 residents) of what it had been the year before, according to DAODAS.

Then came 2019, when the national rate of prescribed opioids dropped again, but Lancaster’s rate of naloxone administrations shot to its highest level yet (2.43 per 1,000 residents). The reason has much to do with the presence of opioids made not in legitimate drug labs, but in underground labs; pills made from pressing powders together and selling them as brand name drugs like Xanax and Percocet.

According to the U.S. Department of Justice, the main ingredient in these knockoff pills is the synthetic opioid fentanyl, which the U.S. Drug Enforcement Agency states is 800 to 1,000 times stronger than morphine, the main narcotic in heroin (for which demand spiked following years of overprescription and abuse of doctor-distributed opioids).

With less of a market for selling prescription-grade opioids, illicitly made, cheaper-than-heroin synthetic opioids started showing up to fill the void. A 2017 report from the National Institutes of Health explains: “An economic incentive exists for trafficking organizations to ‘extend’ heroin with fentanyl or to sell fentanyl outright.”

The problem is that fentanyl is so toxic that as little as 2mg can be fatal, according to the DEA. Its increasingly prevalent derivative carfentanyl is, according to DOJ, 100 times stronger than fentanyl (and 10,000 times stronger than morphine). These substances are real painkillers used for surgeries (carfentanyl on large animals like horses and bears), but when they end up as powders in underground pill presses and are packed into bars and tablets, dosages vary, says Brasington; and the results can be lethal.

When the pandemic hit in 2020, all progress took a hit, and Lancaster County’s pulse spiked even higher, closing the year at almost three doses of naloxone given per 1,000 residents (of which there are around 96,000).

How Lancaster’s first responders COAP with reality

Although Lancaster’s opioid numbers climbed again in 2019 – from 14 deaths in 2018 to 35 the following year, according to a June, 2021, report by the South Carolina Association of Counties (SCAC) – “our numbers were looking good,” says Holly Furr of the Lancaster County Sheriff’s Office. “Or, at least better” heading into 2020.

The reason things were starting to look manageable was the county’s Comprehensive Opioid Abuse Program (COAP), for which Furr is the project coordinator. COAP, made possible through a 2019 DOJ grant, was the first of its kind in South Carolina. It funds a Community Response Team (CRT) of EMS and law enforcement personnel whose task when finding opioid users is to steer them towards treatment, rather than jail.

“We now know that we’re not going to be able to arrest ourselves out of this opioid crisis,” Lancaster Sheriff Barry Faile told the SCAC. “We also know that we’re making a positive difference, a significant impact by going out, helping these folks and trying to get them immediate treatment.”

In a Facebook posting in September of 2020, the Sheriff’s Office touted COAP’s early successes, saying, “Clients have gotten into treatment programs, reunited with their families, gotten jobs, and genuinely improved their lives while being in close contact with a case manager.”

But COAP’s success, like anything else, is not total. First responders have lost people – some, Brasington says, whom EMTs found with needles still in their arms, some whom first responders found “in the woods” or in their homes days after they died, because no one was around to find revive them with naloxone.

“Those are the ones that break our hearts because we know we could have fixed it,” he says.

It doesn’t help when family members are involved, which Brasington says he’s run into. It also doesn’t help when children are involved, as was the case in October, when an 11-month-old baby was found dead in her crib amid bottles of Narcan. The girl’s mother and grandmother were charged in her death, the cause of which was determined to be fentanyl overdose.

Moments like this weigh heavily on first responders. So, members of the CRT say, do the calls taken by dispatchers, who didn’t always get to find out how it went. COAP changed that, by including the dispatchers in reports on how a call played out.

That’s the other part of the program – the attention to the emotional health of first responders who dig the rush of their work, but not the losses.

“It does take a toll,” Furr says.

For Helen Gordon, a member of the CRT and a 44-year veteran paramedic, staying professional is the key to emotionally surviving the tough cases.

“You have to compartmentalize,” Gordon says. “You have to hold yourself at a distance and remember that it’s a professional relationship. But then, there are heartstrings that get tugged.”

Furr adds: “You can’t take this home and keep replaying it. You’ve got to do a lot of self-care and keep those boundaries.”

But first responders are people. They will take it home with them from time to time. Gordon says she has a “get out of jail” card that she tacks up on the refrigerator when she needs time to decompress. Her family knows to give her time to let go of some bad feelings, and she knows not to try to cope with those feelings through angry outbursts and heavy drinking – or drugs – which plagues first responders.

“There are methods that we employ,” says Gordon, who spent several years as a professional peer debriefer using critical incident stress management. “First and foremost is to remember [to] take care of yourself very well, especially after a difficult call. Feed yourself. Stay well hydrated. Relax and do something nice for yourself. Rest. Talk to people who you know and trust. Talk to a counselor.”

Furr says COAP has funded a counselor at the Sheriff’s Office, who is around twice a week for first responders of all stripes. She’s hoping to expand the four-year grant to, among other things, create more time for the counselor to be around.

Something the CRT has learned is to approach tough situations without judgment. That holds for their colleagues as much as the people they try to make their clients – those with whom CRT members establish regular contact as they navigate treatment for their sickness. Lancaster’s first responders say they have no use for the old-school “suck it up, buttercup” approach to just getting over the stresses of a job on which you frequently see your neighbors and relatives hoping to cheat death with a well-timed shot of naloxone, and that they understand that people in the grip of synthetic opioids have a medical problem – ironically, often, spurred by a different medical problem that exposed them to addictive pills.

But emotional trauma is not the only thing that puts first responders in jeopardy of poor health and worse coping choices. When law enforcement officers “kick in doors,” Gordon says, they are met with drug sellers and makers who do not want to get arrested on drug charges. They often throw powder into officers’ faces, and those often have unknown amounts or fentanyl and derivatives in the mix.

If these synthetic opioids are absorbed into the skin or eyes, “you go out,” she says, unless someone is right there with naloxone. The environment has gotten so dangerous that Gordon has modified her wardrobe with a vest that carries enough naloxone for any patients and the crew she answers a call with.

It’s a reminder that the opioid crisis, in Lancaster County or in the country in general, has more potential victims than the ones who know enough to go blue in their driver’s seats in public, betting that someone will find them before their systems shut off and can never be switched back on.