CITY STAND ON HEROIN ANTIDOTE RISKS LIVES

The drug combats overdoses, but experts say the proper dose isn't
being given. And the antidote isn't readily available to all patients.

Two months ago, as scores of drug users in the city began dying of
heroin overdoses, two city paramedics discovered something alarming.
Narcan, a powerful drug that could almost instantly revive a patient,
wasn't working.

In the following weeks, an apparent culprit would be unmasked: Heroin
dealers were adding fentanyl to their product, an opioid up to 100
times as powerful. More than 500 people across the country have died
of the tainted heroin - a number that is sure to climb.

But as the concerns of the two paramedics made their way up the Fire
Department's bureaucracy, the city did not make key changes in how it
treated people dying of a fentanyl overdose - though experts say that
simply increasing the dosage of the antidote would counteract the fentanyl.

Fire Department officials say that this year, using the current
Narcan dosage guidelines, they used the antidote to treat at least 88
fentanyl-related overdose patients who later died.

To make matters worse, many people suffering from overdoses didn't
receive Narcan because they lived in areas where the number of
emergency medical personnel who could administer the drug had been cut.

"We're losing people every day that don't need to die," said Casey
Cook, executive director of Prevention Point Philadelphia, a
nonprofit that runs the city's needle-exchange program.

An Inquirer investigation has found that:

City and health officials are at odds over whether current dosages of
Narcan are high enough to counteract fentanyl-laced heroin.

The city's chief paramedic, whom top fire officials referred to as an
expert during an interview, did not know that Narcan worked as an
antidote to fentanyl.

Because of a shuffling of resources, the neighborhoods hardest hit by
heroin-related deaths are not specifically served by paramedic units
that can administer the antidote.

Unclear On Treatment

Even though the fentanyl-poisoned heroin had been on Philadelphia
streets for eight months, Philadelphia rescue officials seemed
uncertain last week of the proper emergency treatment.

In interviews, fire paramedic-operations chief Daniel T. Parrish
first said he didn't believe that Narcan had an effect on fentanyl.

A few days later, he changed his mind and said the city needed to
increase the dose and would change its protocols. "My feeling is that
fentanyl needs a much higher dosage," said Parrish.

"Unfortunately, some individuals could not be privileged to the
change, and we lost some human beings," he said Thursday. "We will do
the best we can to help other individuals [and keep them] from losing
their lives."

Experts who study opioids such as heroin and fentanyl caution that
emergency cases are complicated by many unknowns, but that unless a
patient is brain-dead when paramedics arrive, Narcan can keep them alive.

"They just need to give more of the drug," said Charles P. O'Brien,
director of the Charles P. O'Brien Center for Studies in Addiction at
the University of Pennsylvania Health System. O'Brien has developed
medications to treat alcohol, opioid and cocaine dependence.

But C. Crawford Mechem, medical director of EMS, said Philadelphia's
protocol for treating fentanyl-laced heroin overdoses was sufficient,
and typical of those in most cities.

"The policy we have in place is perfectly adequate," said Mechem, who
is also an attending physician at the Hospital of the University of
Pennsylvania's emergency room.

The Fire Department's Parrish said that after his interview with The
Inquirer, he discussed the issue with Mechem, and Mechem told him he
wanted to review the city's protocol for using Narcan.

Mechem, who oversees Parrish and makes all medical decisions for EMS,
said he did not tell Parrish he would reevaluate the policy. Upon
hearing Mechem's comments, Parrish said he himself must have been
mistaken. "I'm in a chain-of-command situation here, and whatever he
said is what it is."

Mechem said paramedics gave 0.4 milligrams of Narcan and continued to
administer the drug up to 2 milligrams. After that, they must get
permission from a doctor to give more.

When asked whether more Narcan was needed to reverse a fentanyl
overdose, Mechem replied: "It may, but there is little literature to
support it."

But at least two paramedics whom the city will not identify became
concerned when patients did not respond to Narcan.

In a videotaped interview recorded for a White House-sponsored
fentanyl conference in Philadelphia last month, one of the paramedics
said he began to suspect bad heroin when he saw users with needles
still in their arms. He said he could not revive many of the victims
because they were too far gone, but he did manage to save two people.

"The treatment of the two people I did have a chance to save, the big
difference with that was the protocol," he said. He said he was going
to administer a few milligrams of Narcan, but because he suspected
fentanyl-laced heroin, he asked to use more.

"We had to use, we had to call... contact base command and our
doctors to... give a little more Narcan."

Not Just Philadelphia

The spread of fentanyl-laced heroin is a deadly problem that
Philadelphia, Chicago, Detroit and other major cities have struggled
to deal with. Camden also has seen dozens of deaths. In a large swath
of Philadelphia that includes areas where paramedics were removed,
fire officials said 137 people had died this year of heroin-related
overdoses. An overdose of fentanyl, a powerful painkiller, can kill
quickly because it binds to receptors in the brain stem that control
breathing, said Bertha Madras, a neurochemistry and psychobiology
expert in the White House Office of National Drug Control Policy.

Narcan, which is the brand name of the drug naloxone, is an opioid
antagonist that also binds to receptors in the brain. If there are
equal numbers of naloxone and fentanyl molecules, naloxone will
prevent the fentanyl from binding because it binds more efficiently.

This makes naloxone very effective at reversing the sedation,
respiratory depression and low blood pressure that result from an
opioid overdose. Some people dying of an overdose will get up and
walk away after getting the drug. Further, Narcan is safe, even in
large quantities, because it has no effect on people who are not
overdosing, experts say.

No Narcan

In Philadelphia, some drug users dying of overdoses didn't get Narcan.

Before the rash of fentanyl overdoses became apparent, a shortage of
paramedics prompted the city to swap them for EMTs, emergency medical
technicians. EMTs cannot administer the drug, and the change was made
in the very neighborhoods that would be hardest hit by the poisoned drug.

Fire Commissioner Lloyd Ayers said he took the paramedics from places
where coverage overlapped and most calls were not medically urgent.

"This is another example of a real crisis we are experiencing in
providing our citizens with fast and effective emergency medical
services, especially in view of our unprecedented demand," said City
Council President Anna C. Verna, who expressed concerns about the
moves when Ayers told City Council about them this summer.

Exactly how many drug users who overdosed went without Narcan is hard
to say, but during the fentanyl conference, Capt. Richard Bossert,
the EMS official in charge of quality assurance for the city, said
that if the paramedics hadn't been redeployed, the city would have
given Narcan to twice as many people.

As of last month, city paramedics had administered Narcan to 630
people this year, compared with 655 patients in all of 2005.

"That number is skewed low," Bossert told the audience, because EMT
units "do not give Narcan."

Deputy Fire Commissioner Ernest F. Hargett later dismissed Bossert's
remarks as being "off the cuff."

"I think he was speculating," said Hargett, adding that the numbers
would have been lower.

Ayers said that shuffling of city paramedics was a tough choice, but
that ultimately it had had little impact on the quality of service.

"I look at every firefighter and every paramedic and I can tell you
the quality of care is the highest that's available," said Ayers.

Douglas L. McGee, the past president of the Pennsylvania chapter of
the American College of Emergency Physicians, empathizes with Ayers.

"Tainted heroin is not a regular occurrence, so you could redeploy
resources only to see the problem go away."

EMS medical director Mechem said that although it is tragic that so
many have died, their deaths are not related to whether they received
Narcan or how much. He said they represented a relatively small
number of patients compared with what the system handles.

It makes no difference, he said, whether an overdosed patient gets
treated by a paramedic or an EMT. He said either they're too far gone
when EMS arrives or an EMT can keep them alive until they reach one
of the city's many hospitals.

"While the ultimate reversal agent for narcotic overdose is naloxone,
I don't think the fact that they can't administer naloxone is why
these people are dying," said Mechem.

"Ventilating the patient will also keep them alive until they get to
the hospital," he said, adding that respiratory depression is what
kills most overdose patients.

Mechem said EMTs use a mask with an inflatable bag attached to drive
oxygen into the lungs, a practice commonly referred to as bagging.

Dave Kearney, a Philadelphia paramedic for 11 years, said bagging was
not practical.

"Can you imagine trying to hold a mask on someone's face, squeeze a
bag, all while carrying them on a stretcher down several flights of
stairs? It doesn't work," said Kearney, who is the recording
secretary for the local firefighters' union and a frequent critic of
the city's EMS system.

"Why do that when we can give them a shot?"

Other doctors who have studied fentanyl said that although much
depends on the circumstances, bagging is often difficult and can lead
to vomiting and aspiration, which can be fatal.

"In theory, there is no doubt that the best treatment is earlier
administration of naloxone, because the patient may be near death
already and so you want to reverse all the effects," said Paul M.
Paris, a nationally recognized expert on emergency medical care and
the chairman of the department of emergency medicine at the
University of Pittsburgh School of Medicine.

"It's not so simple as providing oxygen."

Paris proposes that Pennsylvania adds naloxone to a list of drugs
that EMTs can give patients.

That's exactly what some states have done. New Mexico passed a law
allowing police officers to give it.

In Maine, state EMS medical director Steven E. Diaz said the state
allowed EMTs to deliver Narcan after a rash of opiate overdoses three
or four years ago.

"This is something we did to save lives, and it worked," said Diaz, a
former paramedic who has written two books on emergency medicine.