Ohio official: Don’t send medics for third overdose

An Ohio city councilman has suggested a controversial solution to the growing opioid problem in his town: If an addict keeps overdosing, the city won’t dispatch anyone to save their life.

Middletown City Council member Dan Picard is proposing to give drug users two chances. Paramedics would respond to an overdose twice, and each time the addict would receive a summons and be required to do community service after being treated.

But if they don’t show up in court, don’t complete the service and then overdose a third time? That’s it. No one will come to help them.

Prescription and illegal opioids are commonly abused because they are so addictive.

Opioid medications bind to the areas of the brain that control pain and emotions, driving up levels of the feel-good hormone dopamine in the brain's reward areas and producing an intense feeling of euphoria.

As the brain becomes used to the feelings, it often takes more and more of the drug to produce the same levels of pain relief and well-being, leading to dependence and, later, addiction.

Oxymorphone hydrochloride —

Oxymorphone hydrochloride, under the name Opana ER, was at the center of an HIV outbreak in Indiana in 2015. Some addicts began injecting and shared needles increased the spread of HIV.

In June, the Food and Drug Administration requested that Opana ER manufacturer Endo Pharmaceuticals pull the drug from the market. It was the first time the agency has asked that a opioid pain medication be pulled "due to the public health consequences of abuse." Endo announced in July that it would pull the drug.

Codeine —

Codeine is one of the weakest opioids, often given when painkillers such as acetaminophen or ibuprofen fail to work. Because it decreases activity in the part of the brain that controls coughing, it's frequently mixed with other liquids to develop cough syrups for colds and flu. It has frequently been used for pain relief after removal of tonsils and adenoids in children.

After an investigation, the FDA restricted the use of codeine and tramadol in children under 12 and recommend against their use in children between 12 and 18 years of age. Additionally, the FDA has warned breastfeeding mothers not to take these medications due to the risk of serious adverse reactions in breastfed infants.

Heroin —

You can't get heroin by prescription, but many heroin users start off abusing prescription opioids, then turn to this illegal opioid.

CNN's Chief Medical Correspondent Dr. Sanjay Gupta has reported on recent research that shows today's typical heroin addict starts using at 23, is more likely to live in affluent suburbs and was likely unwittingly led to heroin through painkillers prescribed by his or her doctor.

According to the CDC, deaths from overdoses of prescription drugs and heroin continue to be the leading cause of unintentional death for Americans, rising 14% from 2013 to 2014.

Fentanyl —

Fentanyl citrate, pictured here, is a Class II controlled substance and one of the most powerful opioids on the market. It's often administered via injection or transdermal patch, or in lozenge form for pain after surgery, for difficult-to-manage chronic pain and for people who have developed a tolerance to other opioids.

The type of fentanyl usually associated with overdoses is bought on the street in powder or pill form and is often mixed with heroin in a clandestine lab to increase the high it produces. Street names include Apache, China girl, goodfella, jackpot, murder 8, TNT and Tango and Cash.

Hydrocodone —

These pills are a more powerful form of codeine, called hydrocodone, and are often mixed with acetaminophen. Hydrocodone is the most frequently prescribed opioid painkiller, according to the U.S. Food and Drug Administration, and the most abused. An overdose of hydrocodone can cause "cold and clammy skin, severely constricted pupils, and slow breathing that can lead to a loss of consciousness and death."

Oxycodone —

Oxycodone is a powerful narcotic pain reliever prescribed for moderate to high pain relief. It's often given in an extended-release formula for patients who will need to be on pain medications for long periods of time.

Patients are warned not to break, chew, crush or dissolve extended-release tablets because the rush of oxycodone into the system could cause serious health problems, including overdose and death.

Though highly addictive, oxycodone is not thought to be as frequently abused as hydrocodone. OxyContin, Percocet, Percodan and Tylox are some trade-name oxycodone products.

Morphine —

Morphine is another powerful opioid often administered via syringe for severe pain. It can come in pill form, usually as extended-release tablets and capsules, and is prescribed only to relieve difficult, chronic pain that cannot be controlled by the use of other pain medications.

As with most opioids, mixing medications, drinking alcohol or taking other meds that contain alcohol, or using street drugs while taking morphine, increases the risk of breathing problems or other serious, life-threatening side effects.

Meperidine —

Meperidine is another narcotic analgesic, similar to morphine. It's often used to help put people to sleep before an operation and to provide pain relief after childbirth.

The most common brand name is Demerol, which comes in both tablet and liquid forms. It is usually taken with or without food every three or four hours as needed for pain.

As with all opioids, meperidine can cause drowsiness, so never drive a car or operate machinery after taking it until you know how you will react.

Hydromorphone —

Hydromorphone is another highly potent prescription painkiller. It's most commonly known by the brand names Dilaudid, pictured here, and Exalgo.

Liquid hydromorphone holds the dubious honor of being frequently mistaken for morphine in hospital "wrong drug" medication errors because of the similarity of the names and appearances.

Methadone —

Though methadone is used to relieve severe chronic pain, it's most commonly known for preventing withdrawal symptoms in patients who were addicted to opioid drugs, as a part of their recovery process.

Methadone has many of the same side effects as other opioids, including weakness, headache, nausea and vomiting, stomach pain, sweating, difficulty urinating, mood changes and vision problems, and difficulty falling asleep or staying asleep.

Buprenorphine —

Buprenorphine is a opioid used as an alternative to methadone to help addicts recovering from heroin use. Buprenorphine is different from other opioids because it's a "partial opioid agonist," which means that when taken in proper prescribed doses, it should produce less euphoria and physical dependence, and therefore a lower potential for misuse. It's also supposed to have a relatively mild withdrawal profile.

However, if abused by crushing and snorting or injecting, it can suppress breathing and cause dizziness, confusion, unconsciousness and death.

Subutex, the brand name for buprenorphine, is taken as a tablet placed under the tongue and allowed to dissolve.

The brand Suboxone is a combination of buprenorphine and naloxone, an opioid antagonist. Antagonists block the opiate receptors in the brain, keeping the narcotic from creating the high abusers crave.

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So far, the proposal is only that – a proposal. Picard said the city manager is still looking into the legality of the plan before the council can move forward.

Picard said his proposal isn’t meant to be a solution to opioid abuse. He’s concerned that Middletown simply doesn’t have the money to keep treating overdoses.

According to the Middletown Fire Department, EMS units responded to 535 opiate overdoses in 2016, 77 of which resulted in death.

Picard said the city spent over $1.2 million responding to those calls. This year, the Middletown city manager estimates that cost will exceed $2 million.

NORWICH, CT - MARCH 23: Oxycodone pain pills prescribed for a patient with chronic pain lie on display on March 23, 2016 in Norwich, CT. Communities nationwide are struggling with the unprecidented opioid pain pill and heroin addiction epidemic. On March 15, the U.S. Centers for Disease Control (CDC), announced guidelines for doctors to reduce the amount of opioid painkillers prescribed, in an effort to curb the epidemic. The CDC estimates that most new heroin addicts first became hooked on prescription pain medication before graduating to heroin, which is stronger and cheaper. (Photo by John Moore/Getty Images)

Opioid addiction rates continue to skyrocket

At that rate, Picard said, it’s inevitable the city will not have sufficient funds to keep responding. He hasn’t calculated the cost of implementing his proposal, which would require keeping records of repeat offenders.

“Either we go down the road with my plan, or we don’t, and we run out of money,” Picard said. “In either scenario, they’re not going to get treatment.”

Opioid use is on the rise across the country, and overdose deaths are becoming more common in Ohio. In 2014, the state had the second-largest number of opioid-related deaths in the country. It had the fifth-highest rate of overdose. And the next year, overdose deaths in the state rose 11%.

One Ohio coroner’s office barely had room for the 145 overdose-related victims it processed in January of this year. And in September, 21 people in Akron overdosed in a single night.

‘I was trying to scare people’

Butler County, where part of Middletown lies, has the fourth-highest overdose death rate in the state. Even though the intention of the plan isn’t to lower the number of overdoses, Picard hopes it will still have that effect.

“I was trying to scare people,” he said. “I want the drug users out there to know that if you come to Middletown and you overdose, there’s a possibility that we’re not going to come.”

An EMT's view from the front lines of America's heroin crisis 

Truth Pharm, a national advocacy group focusing on substance addiction and drug policy, wrote an open letter to Picard on the organization’s website criticizing his approach.

“To suggest that you withhold emergency medical response to overdose patients is manslaughter at best and premeditated murder at worse,” the letter read.

Truth Pharm wrote in the letter that it would provide information for people to sue Picard and “the entire town government” if the policy moves forward. Picard has acknowledged that he’s considered people may try to take legal action if the plan moves forward.

Picard said there have been a lot of misconceptions about the details of his proposal – more specifically, the details about exactly when the city would leave an overdosed user without aid.

He said that an EMS squad dispatched to the scene of an overdose would never leave a victim to die. Under Picard’s rules, if a user overdoses for a third time, the city won’t send someone again. If EMS workers are dispatched, he said, they are obligated to treat the patient they were called to help.