Sunday, July 16, 2017

A Junkie's Guide To Thwarting the Middletown City Council's Plan

Recently the Washington Post published a couple of articles describing a plan in the works by the Middetown, Ohio city council to limit the number of EMS responses a person overdosing on opioids may receive.

While I am a die-hard libertarian, and I don't necessarily disagree with what the city council is attempting to accomplish in the face of rising (and staggering) costs associated with treating junkies who don't pay taxes or medical bills, their plan won't work. It's just not realistic in our current system, and here is why:

  1. Junkies (who the articles describe as already being aware of the city's proposal) will become clever and begin lying to dispatchers about the actual nature of the call. Only then when EMS responders are on scene will it become apparent that the patient overdosed. By that time the responder will have established a patient/provider relationship and risk becoming guilty of abandonment by not seeing the call through. 
  2. Junkies will become clever and begin dragging their half-dead friends to public areas like parks before calling 911. Where it might be easy to limit EMS responses to residences, it would be impossible to restrict responses to public places. 
  3. Junkies will become clever and begin dumping their half-deadies at ER entrances. In this case the EMS system is saved, but the problem is transplanted into the hospital's budget. Depending on how the hospital is funded, and the projected economic fallout of a hospital shutting down its emergency department, the city would only succeed in kicking the can down the road.
  4. The city will likely meet the legal criteria for negligence based on their breach of duty to respond. Their breach of duty will then become the cause of any damage done which could have been avoided by an EMS response. Pretty simple chapter 1 EMT-Basic textbook stuff here. An argument could potentially be made that - force majeure - the city doesn't have enough money to meet the need, but this might be difficult to defend if the city hasn't exhausted every opportunity to reduce costs including shopping for alternative sources of naloxone (the prices one article quoted from "officials" are certainly not the lowest on the market) or embraced treatment approaches which allow for naloxone to be withheld from patients who are oxygenating adequately as measured by waveform capnography combined with pulse oximetry. I've also recently noticed a number of federal grants posted specifically addressing the rising costs of treating and preventing opioid overdoses.
  5. In order for this type of plan to work, a database containing HIPAA protected data will have to be established, which can then be accessed by dispatchers. This presents immediate patient privacy concerns which I don't think can be resolved to the satisfaction of the city council for the same reason that dispatchers can no longer (as well they shouldn't!) keep databases of people with AIDS, a practice which only went out of style disturbingly recently in my part of the country. A system would also have to be in place to somehow determine if a patient is an indigent chronic junkie or perhaps a cancer patient who has a difficult time managing their pain medications. In that case the city would be cracking open a whole ethical can of worms in determining who is worthy of naloxone and who isn't, and the city would potentially open itself to lawsuit as well as justice department investigation based on violations of the U.S. Constitution's equal protections clause, especially if service is denied to a disparate number of racial minorities. 
In the end, even if this plan is enacted, I doubt it will save an appreciable amount of money. But I do see a small win for the city here in forcing a conversation. It will be interesting to see if this is dead in the water, or if it actually goes somewhere.

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