State opioids order sparks funding concerns for first responders
It was among the most-discussed proposals made by Gov. Tom Wolf and his cabinet when they declared a state of emergency over Pennsylvania's worsening opioid abuse crisis: Allowing first responders to leave behind kits of the life-saving drug naloxone at the scenes of overdoses.
"We want patients who are resuscitated by naloxone to go to the emergency department because we then want to link them with treatment," Secretary of Health Dr. Rachel Levine said at a press conference Wednesday. "But at times, they don’t. And first responders have been asking us, EMS have been asking the Department of Health for the ability to leave behind a kit of naloxone to have their friends and family save their life if they overdose again."
But according to several EMS services in the area, the proposal ignores the funding situation faced by first responders.
EMS services are usually the ones paying for the naloxone kits, which cost about $40.
Insurance might cover the cost but only if the overdosing patient is transported to a hospital, said Jason Campbell, CEO and chief of South Central EMS, which serves Lower Paxton, East Hanover, West Hanover, and South Hanover townships.
Insurance won't cover the cost of naloxone kits left behind to prevent deaths from future overdoses, Campbell said. One alternative is to send the bill to the overdose patient. But those are likely to go unpaid, leaving EMS to bear the burden.
"I can tell you that someone who is overdosing or someone that’s an addict is not going to pay that bill, generally speaking," said Campbell. "And now, since we can’t even recoup the cost of the initial treatment, they want us to leave Narcan on the scene with them, which is an additional expense? Not going to happen."
But the state's idea is not without merit said Nathan Harig, assistant chief of administration for Cumberland Goodwill, a Carlisle-based squad serving a wide swath of southwestern Cumberland County.
"The idea is really beneficial for those patients that would be high risk for overdosing," said Harig. "Maybe they overdosed in the past, so that’s really encouraging from a harm reduction standpoint."
But, like Campbell, Harig is concerned with who will pay for these kits.
In October, the Wolf administration unveiled a $5 million program to distribute free naloxone kits to first responders. The kits were distributed by the Pennsylvania Commission on Crime and Delinquency, known as PCCD.
"Unfortunately, we were told that if we leave behind a second dose for the patients, that’s not going to be covered under these grants," said Harig. "So really the biggest concern is who is going to pay if we leave these behind?”
PCCD designated centralized coordinating entities - first responders or government officials in charge of fielding requests for naloxone and distributing them to agencies. If an EMS squad, fire department, or police department wants free naloxone, they apply for it through their coordinating entity.
For Dauphin County, the coordinator is Jason Campbell. For Cumberland and Perry counties, that person is Duane Nieves, director of operations for Holy Spirit EMS, a Geisinger affiliate.
"Literally, I’m just the pass-through," said Nieves who said he was given a supply of naloxone kits by PCCD in November.
Along with accepting requests for naloxone, Nieves also receives quarterly reports from agencies stating how many kits they used in that quarter. Nieves then reports that information back to PCCD, which uses it to determine how many kits a region needs in the next quarter.
Because of this, said Nieves, he can’t "in good conscience" hand out kits he might not be able to replace.
"We only have 312 kits," said Nieves. "That's barely enough, if it's enough."
Just hours after the governor announced the drop-off program, Nieves sent an email to all the EMS squads in Cumberland and Perry counties letting them know he does not have kits enough to replace ones left behind as the governor has suggested.
"If an EMS agency responds to an OD, administered one naloxone dose to one patient and leaves a second dose with the family to use if the need arises," Nieves told first responders, "Cumberland County is NOT going to get the second dose replenished from the state."
According to the email, kits supplied to the county are restocked based on usage statistics from the previous quarter. If ambulances begin leaving kits behind as the governor has proposed, it means squads will have to replace those kits themselves.
"We barely have enough to deploy a kit everywhere we need them in the county," wrote Nieves, "so if we hand them out at scenes for future use, we will not be restocked from the program for those doses."
The governor's declaration made no mention of future funding plans for more kits. Neither PCCD nor the governor's office responded to requests for comment.
The announcement was greeted warmly by some EMS stations who don’t question the wisdom of the proposal - just the manner in which it will be carried out.
So says Lori Shenk, community outreach manager for Northwest EMS, serving a 200 square-mile area of Lancaster, Dauphin, and Lebanon counties.
"I have a lot of questions," said Shenk. "Primarily what comes to mind is the question of where does EMS get the kits? How do we distribute them? Do we just leave them behind? Do we need to report to our licensing agency that we’ve left them there? Are there some parameters to who gets a kit and who doesn’t get a kit?"
Shenk, like everyone else spoken to for this article, received no advanced notice of the details of the declaration other than what was in early media reports.
Alongside the naloxone kits is the issue of data reporting. In his proclamation, Wolf announced the start of a command center within the Pennsylvania Emergency Management Agency that would collect data from first responders.
"If this is a 90-day window and the clock started ticking yesterday, we want to know exactly how we should implement this and how we should participate," she said. "The data collection that PEMA is going to do will be skewed or be subjective if we’re spending two weeks playing catch up."
As others have theorized, Shenk believes the 90-day window is meant to test policies that may then be prolonged.
"I think the 90 days is the determining factor of what works and what doesn’t work," said Shenk. "I think that’s why there’s this command center: For PEMA to collect the data and look at it and if they see successes, they can extend that regulation."