We respond for the “overdose.” In a lot that is littered with wax bags and other drug paraphernalia, a Spanish man is sitting alone in a row of three portable chairs in the sun. His eyes are closed, his mouth is open. He is as still as a dead man.
While my partner pulls the stretcher, I stimulate him. “Hey Buddy!” I rub my knuckles on his chest. I do this three times before he opens his eyes. I block the sun so I can get a good look at his pupils. Pinpoint. “He’s okay,” I say to my partner. When I turn back to him, his eyes are closed again and he is nodding forward.
I shake him again. “Hey!”
He reopens his eyes and he gives me a big smile. “Okay,” he says.
We check his vital signs. BP is 124/70. Heart rate 44. Respiratory rate 12 with a saturation of 95%. The heart rate is a low, but we are seeing more and more patients with slower heart rates lately. Likely due to the adulteration of the fentanyl supply with medetomidine, an animal tranquilizer that has bradycardia (slowed heart rate) as a side effect.
“You know why we’re here?”
He shakes his head.
“Someone called 911. They thought you were overdosed.”
He shrugs.
He does not want to go to the hospital. A guy from down the street comes over to check on him. “He did three bags of fentanyl. He gets like this. I’ll keep an eye on him.”
“We can take you to the hospital,” I say to the man in the chair.
“I’m good,” he says.
I get the computer out and type in his name and pull up the refusal form, which I have him sign after telling him three times (I am required to do this on every refusal) he should go. Several other bystanders have come over now. They know him and say they will also keep an eye on him, as well. I leave a naloxone kit with them. The patient’s eyes are closed again and he is nodding off. I shake him one last time and he opens his eyes and smiles.
“We get called again, we’re taking you,” my partner says.
A couple hours later I see our patient standing in front of the nearby bodega smoking a cigarette.
Was this a drug overdose? Was it a drug intoxication? Or was it just a pleasant stupor, the intended effects of the fentanyl? How different was this from having a couple of beers on a hot summer day and enjoying a nap in the sun? (Other than the fact that a badly mixed bag of fentanyl can kill you on the spot if no one gives you naloxone after you stop breathing.)
I wrote about the categories Massachsetts uses to define opioid related EMS calls. Under their criteria, someone on the nod is classified not as an Acute Overdose, but as an Opioid Intoxication.
I like their categories. I think it is important that “overdoses” are well-defined. I was once asked to review a paper for a harm reduction journal and my main comment was asking for the authors to define what they meant by an overdose. The journal never asked me to review another paper.
Today I read an interesting 2018 article that redeems my comment.
In Drug Overdose: What Is It and Why Does It Matter?, the authors argue that it is important to define just what an overdose is so that data can be effectively compared and understood. They said people talk all the time about overdoses, and “there is an assumption that everyone understands the meaning in the same way,” but when they searched for definitions they found confusion and inconsistencies.
They cite these and other definitions to demonstrate the multiple views out there:.
Google Dictionary – An excessive and dangerous dose of a drug
Dictionary.com – To take an excessive dose or give an excessive dose to (v); an excessive dose (n)
Merriam Webster – Too great a dose; a lethal or toxic amount (as of a drug); an excessive quantity or amount
Wikipedia – The ingestion or application of a drug or other substance in quantities greater than are recommended or generally practiced
WebMD – When a person takes more than the medically recommended dose
They settle on this definition from the Harm Reduction Coalition‘s Guide to developing and managing
overdose prevention and take-home Naloxone kits.
“Opioid overdose occurs when the level of opioids, or combination of opioids and other drugs in the body render a person unresponsive to stimulation or cause their breathing to become inadequate.”
In my forthcoming book, The Friends and Family Guide to the Opioid Overdose Epidemic: Including How to Recognize and Treat an Overdose, I define opioid overdose as: “when the drug exceeds its intended effects and impairs consciousness and breathing.” I further define it as when a person who has taken opioids is “breathing inadequately despite stimulation.”
When that happens, they need naloxone.
On this day, the man in the chair was just on the nod. Dosed.