These paramedics are for more than just emergencies in N.C. communities
By Vibhav Nandagiri
On a street corner east of Durham’s downtown, Cheryl Riley spotted a woman sitting on a ledge outside a grocery store, her upper body bobbing back and forth.
Riley, a Durham County paramedic, pulled over her Ford Expedition with bright blue and yellow markings and asked the woman if she could take her vitals. After getting a go-ahead, Riley checked her blood pressure and oxygen levels.
This was not a stop in response to a 911 call. Riley criss-crosses the city as part of the county’s special Community Paramedics program, and she sometimes focuses on areas where drug users congregate.
“We do not judge,” Riley told the woman after removing the blood pressure cuff and pulse oximeter. “But can you tell me what you took?”
“Fentanyl,” the woman responded.
“Do you trust your dealer?” Riley probed further.
“I don’t trust nobody,” her patient responded.
Worried about a potential overdose, Riley gave the woman some water and asked if she could call for an ambulance. After initial resistance about being stuck with a big medical bill, the woman acquiesced when Riley comforted her and promised to check on her later.
Cheryl Riley, a Durham County community paramedic, checks a woman’s blood pressure while on her rounds. Credit: Vibhav Nandagiri / NC Health News
“That usually doesn’t happen,” Riley told NC Health News. Often, Riley said, the people she encounters in nonemergency situations on her usual routes are wary of being taken to the hospital.
Riley is one of two community paramedics in Durham County. The program began in 2017 to serve people with substance use issues, mental illnesses and chronic medical conditions through home visits, community check-ins and their professional connections with health care centers.
The goal is to cut down on emergency department visits, provide follow-up care after hospital stays and take essential information and medications to patients that some refer to as “frequent flyers” for their numerous ER visits. These specially trained paramedics serve as bridges to clinics, detox centers and other facilities that provide nonurgent care. They also help the elderly, disabled and others make their homes safer, such as pointing out measures they can take to better prevent falls, and help organize transportation to medical appointments.
In recent years, community paramedics have made it a priority to distribute naloxone kits and share recovery resources for people with substance use disorder.
“It’s this many-armed approach that combines both health care with social health and community outreach,” said Riley, who’s been in her current role in Durham for two years and worked in Orange County emergency management before that.
NC Health News joined Riley in early July for part of her rounds and agreed not to disclose identities of the people she stopped to check on.
A statewide effort
Durham County is not the only North Carolina entity with a community paramedic program.
McDowell County touted itself as one of the earlier programs in the country and among the first in rural NC after launching in 2013 with funding from the Kate B. Reynolds Charitable Trust.
Others have launched more recently with some of the $750 million allocated to the state as part of the $26 billion multi-state settlement with pharmaceutical manufacturers and distributors accused of stoking the opioid crisis.
Edgecombe County started a program in 2023. Onslow County, home to Camp Lejeune and Jacksonville, has a large community paramedic team with slots for eight full-time workers. The Johnston County Emergency Medical Services Division has a community paramedic program, as do Davie County, Caldwell County, Orange County, Yancey County.
Nash UNC Health Care realized that it could cut down on some of its repeat emergency department visits by sending community paramedics out for home visits with blood sugar monitors to help people with diabetes, bring medication information and help them navigate medical issues outside a physician’s direct care as vulnerable patients recuperate from a hospitalization. Cape Fear Valley Health did the same thing.
What distinguishes community paramedics from traditional paramedics and emergency medical technicians is their ability to follow up with patients and help them find longer-term treatment options for such problems as substance use disorder, a process they call “bridging.”
Over the past year, they’ve started using medications for opioid use disorder as part of treatment. These synthetic opioid medications like buprenorphine and methadone help people manage withdrawal symptoms and start on the pathway to recovery, research shows.
Many of the people working in harm reduction and health care, Riley included, believe these medications are a key part of treating addiction as a chronic disease.
A fourth wave
Deaths due to opioid overdoses have been rising in North Carolina, including in Durham County, where opioid-related deaths tripled from 2019 to 2022. NC Health News has reported extensively on the opioid epidemic, its impact on North Carolinians and how counties are responding to the crisis.
Public health officials have described opioid deaths as happening in three waves, with the third and most recent wave associated with a decade-long increase in overdose deaths from synthetic opioids, most notably fentanyl.
Anjni Joiner, medical director of Durham County Emergency Medical Services and a physician at Duke Health, is part of a growing group of experts observing what they describe as “a fourth wave” from fentanyl being consumed with other drugs — cocaine, methamphetamines and marijuana — often unknowingly.
“People who are not even trying to take opioids … are overdosing,” Joiner said.
One such case serves as a cautionary tale for Riley. She had just started her job in Durham and encountered a woman who had been smoking marijuana to relieve symptoms from the chemotherapy she was getting while battling breast cancer. Unbeknownst to the woman, the marijuana was laced with fentanyl, and she overdosed. While paramedics were able to revive her, Riley believes it underscores the risks inherent to the drug supply from the streets.
“We’re seeing a lot more of that — where people think they know what they are taking, but their drugs are contaminated,” Riley said.
Durham data underscores that trend. Joiner said that before the proliferation of fentanyl in recent years, they were seeing, on average, 40 to 60 overdoses per month. Now that monthly average is 80 to 100 overdoses with peaks in the summer months. In July 2023, Durham County emergency medical services responded to a record 102 opioid overdoses — which Joiner and others within county emergency medical services attributed to fentanyl contamination.
Meeting people where they are
When paramedics respond to a suspected opioid overdose after a 911 call, their first step is to administer naloxone, which is known by its brand name, Narcan. Opioids cause the slowing and shallowing of breathing — which can lead to respiratory failure. Naloxone reverses these effects, but it also produces withdrawal symptoms.
These symptoms such as sweating, anxiety, diarrhea and vomiting can be serious, according to Riley. Given that, she disputes the narrative that people with opioid dependence can simply quit “cold turkey.”
Medications like buprenorphine help manage withdrawal symptoms and, if administered regularly, have been shown to improve people’s chances of recovery. Durham County paramedics began administering buprenorphine in June 2023. In the ensuing 12 months, 36 people have been started on buprenorphine out of 818 overdose-related calls, according to data shared with NC Health News.
An informational sheet on buprenorphine distributed by Durham County community paramedics. Credit: Vibhav Nandagiri / NC Health News
Treatment for ten of those people began in June 2024, the most in a single month. Joiner sees that as a positive sign that Durham emergency service providers are making treatment more available. “It just takes time to really get integrated in the community,” she said.
The slow start is also a reflection of program capacity. When the program began, only community paramedics and paramedics who volunteered to get special training were allowed to administer buprenorphine. As of March, all Durham County paramedics have been trained. Each ambulance is now stocked with the medication, according to Joiner, allowing for administration of buprenorphine whenever emergency services responds to a call.
Joiner said the emergency teams have had the most success with getting people on buprenorphine a few days after an overdose.
“They’re pretty overwhelmed. It’s a near-death experience, and so we find that when we follow up with them in the next couple of days, [people] are more open to starting on the medication,” she said.
While the goal is to get people into long-term care where they can receive medications regularly, that doesn’t always happen right away. During those lags, community paramedics can provide follow-up care and daily administration of buprenorphine for up to seven days. Often, they call their patients ahead of time and schedule a set meeting point and time to administer buprenorphine.
“I think we’re really innovative in that respect,” Joiner said.
Expanding funding and access
Over the past five years, North Carolina has been investing more in medications for opioid use disorder. Through its Bridge MAT program — MAT being the old acronym for medication-assisted treatment for substance use disorders — the state Department of Health and Human Services funds county emergency medical services to use buprenorphine to treat opioid use disorder.
The first two counties in the Bridge MAT program were Onslow and Stanly, which received grant funding in 2019. In 2023, the funding was expanded to eight more counties, including Durham. Recipients of these grants, crucially, must invest in a community paramedics workforce to administer buprenorphine.
“People are interested in what we’re doing. They like the idea that there’s something out there that’s supportive, someone that they can call,” said Helen Tripp, program director of the community paramedics program. The Bridge MAT grant has helped sustain Durham County’s community paramedics program and keep it accessible for all residents.
“They don’t have to worry about getting a bill because we don’t charge for what we do,” Tripp said.
Cheryl Riley monitors dispatches and appointments from inside her community paramedic vehicle. Credit: Vibhav Nandagiri / NC Health News
The program is about to grow. Tripp said two more community paramedics will be added in Durham County, bringing the total to four. There also are plans to tap into another grant to hire peer support specialists — trained staff who have lived through managing substance use disorder and can dispense their wisdom.
Riley believes the new personnel will help them keep up with the high demand for their services. Between active dispatches and follow-up visits, her 12-hour shifts tend to be very busy.
“We are health care…but we’re also filling in this home care position. We’re doing a little bit of social work, we’re doing a little bit of case management, we’re working on the opioid overdose problem,” Riley told NC Health News.
But she also appreciates the freedom offered by the community paramedics program. Driving between appointments, Riley checks in on familiar faces — many of them unhoused — as she hands out water, food and naloxone kits. Some of them recognize her from previous visits.
Riley sees this “combination of medicine and helping better your community” as central to community paramedics team missions.
“Durham has clinics, Durham has resources, Durham has opioid response … but the problem is getting those resources to the people who need them,” Riley said.
The post These paramedics are for more than just emergencies in N.C. communities appeared first on North Carolina Health News.
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