Paramedics and the Moral Dilemma of Overdose Prevention Sites

11 Jun Paramedics and the Moral Dilemma of Overdose Prevention Sites

Deborah Cooper is Primary Care paramedic with Frontenac Paramedic Services (FPS). In April, Frontenac County Council approved FPS participation in a six-month pilot project to establish an Overdose Prevention Site in Kingston.

Much conversation has been generated with the Ontario government’s announcement in January 2018 of the application for overdose prevention sites, similar to safe injection sites [5].  Overdose prevention sites are temporary locations operating for up to six months whereas safe injection sites are permanent locations.  Overdose prevention sites are temporary sites that allow for supervised use of drugs, harm reduction supplies (clean needles) and naloxone [1] as well as an opportunity for addictions workers to make contact with users and offer support.

Opioid agonist treatment and harm reduction are currently the standards of care and the interventions with the best evidence for long term patient safety, social wellness and physical health benefits for the treatment of opioid addiction [2].   It’s hard to accept this as frontline paramedics as we see our patients when they are in crisis and we miss out on the success cases.  Our concept of an addict is still clouded by the notion of addiction as a character flaw rather than the complex bio-psycho-social issue that it is.  Before we pass judgement we should examine the processes of addiction and its neuro-biological complexity.

As we think of addiction, we grapple with one of the oldest and most fundamental questions of philosophy: do people always do what they think (and know) is best?  When someone with addiction chooses to take drugs, do they show us what they really care about [3]?  Fortunately (and unfortunately) their brain is much more complex than this.  We can see this directly in the action-consequence model.  The addict knows that by using drugs they risk death, incarceration, loss of family, etc., and yet they still use.  So we know something stronger than knowing right from wrong and consequences must be at play.  Addiction is an example of the true pull of different parts of the brain.  The “wanting” system of the brain is responsible for cravings for things like food, sex and drugs by using the neurotransmitter dopamine [3].  This system is strong, and insensitive to the long-term consequences of the person’s actions.  The addict is on a constant struggle with this powerful part of their mind pushing them toward behaviours that they do not actually want to do.  The person understands the consequences of their behaviours and are likely reminded of them constantly, but are unable to use this to control their behaviour [3].  The best treatment to control the “wanting” system of the brain is to use of opioid agonists, which allow the addict to make decisions without the overwhelming pull of this part of their brain.

Methadone and buprenorphine treatments are considered the best medication treatment for opioid addictions [2], but the use of opioid agonists is one of “the most highly debated, regulated and controlled interventions in addiction treatment” [2].  It seems to be easier to prescribe narcotics than methadone.  By allowing overdose prevention sites we bring the addict into an environment where their addiction and recovery is considered safe conversation.  Discussions about methadone can occur and the person can be referred to an addictions specific trained doctor who is able to prescribe and willing to support methadone therapy.

Another concept that we as paramedics must consider is that health (and access to health) is a human right.  The World Health Organisation states “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” [4].  This statement means that the human rights of opioid dependent individuals need to be respected.  If we choose to disregard this statement on the grounds of the immorality of addictions then we push our own moral compass on the individual and disregard the neuro-biological basis of addiction.  We must also examine our own biases, prejudices and bigotry.

Addiction occurs across all races and classes.  But within the context on the opioid crisis, social determinants of health such as poverty, trauma, mental health and social exclusion are considered as underlying health problems associated with opioid use [2].  More than 50% of individuals (up to 87% in some studies) with opioid addiction have a concurrent mental health disorder and almost 35% of addicts live within the lowest 1% of income class [2].  Socioeconomic position is a risk factor for mental illness and also a factor in receiving medical care.  It is difficult for someone in a lower socioeconomic position to get a family doctor and is hard for them to attend appointments if they are working a job that gives little flexibility in hours, as many minimum wage jobs do.  Even if addicts are able to connect with a doctor, they often lack extended health benefits for medications.  It’s not surprising then to see the connection between socioeconomic position, mental health and opioid (and other drug) addiction.

Paramedics work in a field where we see people at their worst.  It skews our concept of what the general public is and clouds our thoughts with biases.  It’s easy as a paramedic to get into the habit of black and white thinking, especially for something like drug use and addictions.  We have to remember that the repeat customers that we see and treat with Narcan are the exception to the rule.  There are many people living out there struggling with substance dependence who use regularly and also hold down jobs and try to contribute to society.  Some may not be able access support or care for their addiction and underlying mental illness.  Some may be too ashamed of their addiction to reach out for support, or don’t know where to start.  By supporting and allowing Overdose Prevention Sites in our communities, we bring the addict to a source of support for themselves and their families and potential for treatment for their addiction.

  1. Ministry of Health. (n.d.). Health Bulletins. Retrieved from http://www.health.gov.on.ca/en/news/bulletin/2018/hb_20180111.aspx
  2. Morin, K. A., Eibl, J. K., Franklyn, A. M., & Marsh, D. C. (2017). The opioid crisis: Past, present and future policy climate in Ontario, Canada. Substance Abuse Treatment, Prevention, and Policy,12(1). doi:10.1186/s13011-017-0130-5
  3. Kenessey, B. D. (2018, March 05). People are dying because we misunderstand how those with addiction think. Retrieved from https://www.vox.com/the-big-idea/2018/3/5/17080470/addiction-opioids-moral-blame-choices-medication-crutches-philosophy
  4. Ghebreyesus, T. A. (2017, December 12). Health is a fundamental human right. Retrieved from http://www.who.int/mediacentre/news/statements/fundamental-human-right/en/
  5. Ministry of Health. (n.d.). Health Bulletins. Retrieved from http://www.health.gov.on.ca/en/news/bulletin/2018/hb_20180111.aspx