Afghanistan has historically been a dominant producer of opium, contributing significantly to the global heroin supply. In 2007, the United Nations Office on Drugs and Crime (UNODC) reported that Afghanistan accounted for over 90% of the world's illicit opium production (UNODC, 2007). This extensive role in the opium trade has profoundly influenced global drug markets and posed significant challenges to public health systems, including emergency medical services.
In April 2022, the Taliban, following their return to power, announced a comprehensive ban on opium poppy cultivation. This policy was implemented to address societal harms associated with opium production and in alignment with religious principles. By 2023, Afghanistan's opium cultivation had decreased by over 95%, leading to a significant contraction in the global opium supply (UNODC, 2023).
While this reduction in heroin availability may appear beneficial at first glance, it has critical implications for global drug markets, healthcare systems, and paramedic practice. As heroin availability declines, the use of synthetic opioids, such as fentanyl and nitazenes, is increasing. These substances are significantly more potent than heroin and are associated with a higher risk of overdose and death. The UK has already seen a concerning rise in opioid-related fatalities, with synthetic opioids playing an increasing role in this trend. In 2022, England and Wales recorded 4907 drug poisoning deaths – the highest number since records began in 1993 – with a significant proportion involving opioids (Office for National Statistics, 2023). Between June 2023 and May 2024, 179 deaths in England involved nitazenes, a group of synthetic opioids with potency far exceeding that of traditional opioids (Office for Health Improvement & Disparities, 2024).
Complexity of the opioid crisis
These trends underscore the growing complexity of the opioid crisis and the need for paramedics to adapt to the changing landscape of drug use. The potency and rapid onset of synthetic opioids challenge traditional overdose-response strategies, requiring enhanced training and resources for prehospital care providers. Paramedics play a pivotal role in managing opioid overdoses, but the complexity of synthetic opioids demands a reassessment of traditional approaches. Naloxone, the standard treatment for opioid overdoses, may be less effective against synthetic opioids because of their high potency and prolonged receptor-binding effects. This can result in rebound toxicity, or the need for repeated doses of naloxone, complicating prehospital care (Wampler et al, 2019).
Post-overdose mortality rates further highlight the challenges faced by paramedics. Research shows that 6.5% of patients treated with naloxone in out-of-hospital settings die within 12 hours, and over 15% die within a year, often owing to inadequate follow-up care and support (Weiner et al, 2021). These statistics underscore the importance of integrating paramedics into harm-reduction and long-term care strategies. Barriers to seeking and completing treatment during hospitalisation are significant challenges for people who use opioids. Fear of withdrawal symptoms, stigma, and inadequate pain management often deter individuals from engaging with healthcare services. Many patients self-discharge or leave wards intermittently to procure opioids, further disrupting their care (University College London Hospitals (UCLH), 2022).
Hospital discharge is another critical period for patients who use opioids. Reduced tolerance, coupled with insufficient opioid substitution therapy (OST) during admission, increases the risk of fatal overdoses after discharge. These risks are exacerbated by the use of additional sedatives to manage acute symptoms during hospitalisation (Harris et al, 2022).
What is (and is not) being done?
OST, involving methadone or buprenorphine, is a proven intervention for managing opioid dependence and withdrawal symptoms. Effective OST provision not only reduces withdrawal-related self-discharge but also improves treatment adherence for coexisting medical conditions (Department of Health and Social Care (DHSC), 2017). National guidelines emphasise the importance of local hospital protocols to facilitate timely OST provision and ensure continuity of care after discharge. However, procedural barriers such as limited out-of-hours prescription verification and inconsistent hospital policies undermine the effectiveness of these interventions (Wickremsinhe et al, 2024).
Innovative projects such as the Improving Hospital-based Opioid Substitution Therapy (iHOST) initiative have sought to address these challenges. The iHOST project incorporates patient-held cards for prescription verification, staff training, clinical guidelines, and designated hospital ‘champions’ to advocate for OST management (Lewer et al, 2024). These measures aim to enhance OST provision and mitigate the risks associated with opioid withdrawal and self-discharge. Despite these advances, ambulance services are rarely included as stakeholders in OST-specific initiatives. This omission represents a missed opportunity to leverage paramedics' unique position within the healthcare continuum.
The role of paramedics
Ambulance services already play a critical role in public health promotion and are well placed to identify patients requiring substance misuse interventions (Crabtree and James, 2021).
Paramedics could be instrumental in bridging gaps between prehospital and hospital care. Their involvement in harm-reduction strategies, such as distributing naloxone kits and initiating referrals to long-term care or social support services, could significantly improve patient outcomes. Additionally, paramedics could collaborate with hospital teams to develop joint protocols for OST provision, ensuring seamless transitions between prehospital and inpatient care. The evolving opioid crisis demands a coordinated, multifaceted response. While the reduction in Afghanistan's opium production has disrupted global heroin markets, the rise of synthetic opioids presents new challenges for paramedics and healthcare systems. Paramedics, as frontline healthcare providers, are uniquely positioned to address these challenges by engaging in harm reduction, supporting OST provision, and bridging gaps in care.
To maximise their impact, paramedics must be integrated into broader healthcare strategies, including collaborative efforts with hospitals and public health agencies. Strengthening these partnerships could pave the way for standardised protocols that address the complexities of synthetic opioids, ultimately improving outcomes for individuals experiencing opioid-related harm.
Education and training
Expanding paramedic training to encompass the specific challenges of synthetic opioid toxicity is essential in responding effectively to the evolving drug crisis. The unprecedented potency of synthetic opioids such as fentanyl and nitazenes requires paramedics to be adept in recognising overdose symptoms that may present more rapidly and severely than those caused by traditional opioids. A systematic review by the Agency for Healthcare Research and Quality (AHRQ) highlights the increasing need for emergency medical services (EMS) personnel to be trained in various naloxone administration routes, optimal dosing strategies, and the titration of naloxone to achieve sufficient spontaneous respiratory effort (Chou et al, 2017). Given that synthetic opioids often exhibit prolonged receptor binding, a single dose of naloxone may not be sufficient, necessitating further training on managing prolonged overdose effects, including rebound toxicity and respiratory complications in prehospital settings.
In addition to naloxone administration, paramedic education should incorporate training on the broader implications of synthetic opioid exposure, including personal safety concerns and the management of withdrawal symptoms in patients following overdose reversal. A study published in the International Journal of Drug Policy examined a training programme aimed at reducing emergency responders' perceived risk of overdose from incidental fentanyl contact. The findings demonstrated that targeted training can significantly alleviate misconceptions and provide responders with the necessary knowledge to handle opioid-related incidents more effectively (Beletsky et al, 2020). Integrating such evidence-based approaches into paramedic education could enhance both patient care and responder safety, equipping paramedics with the skills to navigate the complexities of synthetic opioid toxicity. Ensuring that ambulance services are equipped, not only with sufficient naloxone supplies but also with updated clinical protocols and training, will be crucial in mitigating the rising mortality rates linked to synthetic opioids.
Conclusion
To address this crisis, paramedic education must evolve in tandem with the changing drug landscape. Comprehensive training on synthetic opioid toxicity, including evidence-based naloxone administration protocols, overdose recognition, and harm-reduction strategies, should become a core component of paramedic curricula. Moreover, greater collaboration between ambulance services, hospitals, and public health agencies is essential to bridge gaps in patient care, from initial overdose management to long-term treatment referrals.
Without these critical adaptations, paramedics risk being underprepared for the escalating opioid crisis, ultimately compromising patient outcomes. As the frontline responders to opioid overdoses, paramedics hold the power to save lives – not only in the moment of crisis, but also by guiding patients towards sustained recovery. The time to act is now.