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It was at least 10 minutes from the time a housekeeper pushed into a bathroom on the Brockton VA campus and found a man on the floor to the time paramedics arrived.
They used naloxone, common brand name Narcan, to reverse the man's opioid overdose. Brain damage can begin after just five minutes without oxygen.
Pam Bellino, patient safety manager for VA Boston, which includes Brockton, read the incident report back in December 2015 with alarm.
"That was the tipping point for us to say, 'We need to get this naloxone immediately available, without out locking it up,' " she said.
The easiest way to make naloxone immediately available, Bellino reasoned, would be to add the drug to AED cabinets — those metal boxes on the walls of VA cafeterias, gyms, warehouses, clinic waiting rooms and some rehab housing.
The Boston VA was already training patients addicted to an opioid to use naloxone, as well as the staff who treat them and VA police. Stocking AED boxes would mean everyone, from veterans to the general public, could reach for naloxone if needed to reverse an overdose at a VA facility in Jamaica Plain, West Roxbury and Brockton.
Bellino started with one AED cabinet in 2016, and kept adding. Now 41 of 50 defibrillator boxes on all three VA campuses include naloxone. The kits have been used to reverse two overdoses so far.
Giving naloxone to someone who has not overdosed is not harmful, but it is a prescribed drug. So Bellino says the VA had to persuade the accrediting agency The Joint Commission to approve guidelines for the AED naloxone project.
The cabinets must be sealed and alarmed so staff can tell if they've been opened. They must be checked daily and refilled when the naloxone kits expire. The commission did not agree to let the VA paste the words "naloxone" or "Narcan" on the cabinets doors to alert the public that the drug is inside, but did allow the VA to paste the letter "N."
In December, the project will expand nationwide, as VA hospitals across the country will add naloxone to their AED cabinets.
"The overwhelming evidence is that it just saves lives," said Dr. Ryan Vega with the VA's Center for Innovation. "We're hopeful that other health systems take notice and think about doing the same."
Bellino says that's critical for veterans. Citing 2005 death data, Amy Bohnert, an investigator with the Ann Arbor VA, says vets have nearly twice the risk of overdose, compared with civilians. She says it isn’t clear why veterans are more likely to OD, but many do have complex medical conditions.
"Some of that’s related to combat exposure," Bohnert said. "They’ve got mental health treatment needs. They may have injuries that result in them being more likely to be prescribed opioids than your average person. And all of these things can impact their risk of overdose."
A smattering of schools, airports, churches and employers around the country have added naloxone to their AED cabinets.
Some are stocking other lifesaving tools as well: tourniquets to stop bleeding after a shooting; EpiPens to keep airways open; and even injectors to treat diabetic shock.
Dr. Jeremy Cushman leads a project at the University of Rochester that has placed both tourniquets and naloxone in 80 AED cabinets across that campus as of July.
"This system is already in place," Cushman said. "The question is, how can we leverage it to save more lives?"
Cushman says there are challenges to turning AED cabinets into mini emergency medical stations. Medicines can't be left outside during extreme temperatures. They are expensive and expire.
Those are all challenges Dr. Scott Weiner has encountered while developing street-level dispensing stations for naloxone.
And then there's the belief among some that naloxone enables drug use by offering an assurance of life after an overdose. Weiner says that attitude is waning and as it does, the public may be more open to other controversial, lifesaving measures.
“Naloxone is kind of the lowest barrier for people to understand, where someone has already overdosed and we’re going to give them the antidote,” said Weiner, who is president of the Massachusetts College of Emergency Physicians. “The leap to giving them needles [through a needle exchange] or allowing them to inject in a safe space, that’s just another level of acceptance that people will have to get to.”
The VA's Bellino has a quick response for naloxone skeptics.
"Think of this as you would a seat belt or an airbag," she said. "It by no means fixes the problem, but what it does is save a life."
Her hope is that AED manufacturers will start selling cabinets that fit the new hospital accreditation standards. In Boston, the VA drilled holes in its AED cabinets and uses a plastic tie to create the required tamper-proof seal.
Zoll Medical, which sells the cabinets used by the Boston VA, declined comment about whether it plans to roll out an AED cabinet equipped with naloxone, tourniquets or other items.
Elijah White, the VP for marketing, says the company knows its boxes are becoming repositories for other lifesaving equipment and has no objections.
“Anything that increases the utility of those cabinets so that people who invest in them can get more out of it, anything that increases visibility and the importance of being prepared for an emergency is good for everybody,” White said.
So if you see an overdose and are near an AED cabinet that includes naloxone, here's the instruction sheet you'll find inside.
If you'd rather prepare by watching a video, this is what the VA offers.
The Boston VA counts 132 lives saved through all three parts of its naloxone project: training high risk veterans, equipping police and the AED cabinets.
This segment aired on September 19, 2018.
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