Distance
The distance first responders must travel to service calls and to administer naloxone emerged as the most consistent theme among interview participants in Montana’s rural and populated counties. For example, one rural EMS provider states: “Distance. Yeah. We are such a rural county; we have one ambulance station, and we cover about 2000 square miles. So, time and distance to be able to get to a patient is sometimes very difficult.” This theme was present among all types of first responders; for example, a county deputy recounts: “Law enforcement, our agency, we are very far from a lot of our calls. It's not uncommon for us to have a 30-minute, 40-minute runtime to our location. We are, by far, the quickest and fastest unit, but we're spread out.” Distance in a frontier and remote setting presents other challenges for first responders, such as which calls to prioritize:
I would say probably for us, obviously distance. We are the sole ambulance for the county and it's like 12,000 people and almost 4,000 square miles. Depending on the road, if you get off the pavement even on nice high grade county roads, it might take us two or three hours to reach the edge of our county, depending on how you're getting there. [. . . ] Often the helicopter coming out of Billings can beat us. [. . .] I would say for overdoses, it's the access to law enforcement. We don't have that much law enforcement and we don't have enough staff and they're so busy and often understaffed that they're not truly able to go to every call like that before us and clear all of those.
This participant describes a vast service area that an emergency helicopter out of Billings can cover quicker than ‘local’ first responders. In addition, first responders rank the most urgent calls, only responding to a select few due to distance and travel time for service.
First responders in Montana’s most densely populated areas were not exempt from difficult routes and long travel times for service. For instance, one urban EMS provider recounts: “And just because of the highways and the distances in Montana, we respond to some really faraway places that are probably... We call them ‘dead zones’ where there's just not a lot of responders available.” Based on our interviews with first responders, much of Montana could be classified as a ‘dead zone’: a geographically isolated area with a persistent lack of services. Further complicating their job, Montana’s emergency responders are assigned large coverage areas that strain their modest crews. One rural EMS participant states: “On our normal shifts we have a four-man crew, but sometimes faced with vacation and comp and that kind of stuff. We may have a three-man crew and running a three-man crew on an unresponsive [overdose] patient … you need more people.” Emergency responders in Montana report covering large swaths of the state, often understaffed to deal with the challenges they face.
Lack of Resources
The large service coverage areas that first responders patrol interrelates with the overall lack of available resources across Montana’s vast landscape. For instance, Montana lacks treatment and recovery programs in rural areas which forces residents to travel long distances for services. One rural county’s EMS director stated: “Access to substance abuse treatment and mental health…I mean, we don't have resources here. The only behavioral health unit close by is often full.” Montana’s frontier and remote counties lack vital services and rely on those offered in Montana’s, often distant, more densely populated areas. Figure 2 displays the number of MOUD providers by county in Montana, noting that 42 of Montana’s 56 counties have 2 or fewer waivered providers for prescribing Buprenorphine.
A law enforcement officer in one rural county notes:
I don't know if you could ever have enough [treatment] resources. But being a small community where there's not a ton of resources, I know the clinic has kind of a MOUD program. We do have drug court here through district court that the sheriff sits on. So we try to do things, but like AA has fallen off a lot. You don't see the AA meetings or the NA meetings as much. I think we went from three or four meetings every week to having trouble finding one meeting in our area every week. So stuff like that's fallen off. I think just when you're in a smaller community, there's just not ever going to be enough resources to get people in to, and they're going to have to travel to bigger areas. Like for us, it would be Great Falls or Kalispell where there's going to be more resources available.
Participants in rural counties rely on urban centers that have more available resources, but those resources are often unable to handle the demand within and across counties. A law enforcement officer in an urban county states:
You could interview officers daily who, somebody is on drugs and they want to get treatment right now. And we all know that if you have an addict who needs treatment or wants it, right now, when they're willing is the best thing in the world. And our guys will call up there and they're like, "Yeah, we don't have any beds." And so, we got nowhere to take them.
A firefighter working in an urban and wealthy county states:
We have a lack of social services in [Name] County. To include what you're asking, also mental health, those prevention programs and things like that, I don't think we're a big enough community yet to have all the resources that we need, and that's going to continue to be a bigger and bigger problem as the county grows as fast as it is, and we see it all the time in different scenarios, not just drug abuse, but mental health is another one. Our geriatric patients or our older patients, we just lack social services, and our homeless community, there aren't a lot of resources, and we don't even have a homeless shelter that's open year-round. We don't have a homeless shelter that's open 24 hours a day. I mean, we're just not there yet. There's a lot of services that we need that we just don't have yet. So, I guess just as a citizen, I would say no. There's probably not enough resources for drug abusers.
Montana’s emergency responders, regardless of their service area’s population density, describe a lack of mental health and treatment resources. The dearth of services contributes to first responders’ support for training laypersons in naloxone administration.
Community Training
This study’s interviewer asked emergency responders whether they supported or opposed training community members in naloxone administration. Only one of the twenty-two participants outright objected to training and providing naloxone to community members, while some supported training certain community members, and others supported training every willing resident. A rural law enforcement officer states: “I think it would have to be selective. Some providers, that would benefit from the Narcan training [would be] mental health people that we have here in town because that's, like I said before, it kind of coincides with some mental health issues.” An EMS director in another rural county agreed: “When we have a person that we've identified as being at risk of overdose, having some key people that are frequently around that patient or person, I think [the targeted training] would be the best use of resources.” Some respondents felt training individuals closest to those at risk of overdosing was the most efficient way to ensure naloxone was within reach of an overdose victim; however, other participants questioned this tactic, especially in rural areas where community members would be unwilling to identify as drug users or individuals with high-risk contacts. One rural law enforcement officer captures this sentiment: “I just don't think that there would be a big turnout for the people that would be the most at risk because they wouldn't want to put themselves out there.” This participant alludes to the stigma associated with identifying oneself as high-risk in rural communities in Montana, suggesting that the targeted approach recommended by previous participants might not work in some areas.
To circumvent the challenges with training select community members, respondents viewed the pandemic, and the distances emergency first responders need to cover as a justification for training laypersons who lack a direct connection to drug abusers. A member of the Montana Department of Justice states:
[Narcan] should just be available to all walks of life because... Not only to people that can afford it since... But all the way down to people that are struggling, that they could have an opportunity to be administered or given Narcan so that they could use it because they have family members and loved ones that could be and are addicted to opioids. And it could be lifesaving for them at some point as well.
The previous respondent describes that training laypeople in a rural state like Montana, where first responders are faced with vast coverage areas and lengthy response times, can save lives. Other first responders who support training community members equate naloxone administration training to other forms of first aid trainings, such as CPR and AED training. For example, one rural law enforcement officer states: “It never hurts. It's the same thing as giving them CPR training, AED training. You hope they never have to use it, but if they did, at least they'd be confident in using it.” An urban firefighter echoed the previous participant: “I teach CPR classes [to the] general public. My opinion on the matter is yes, and whether it's stop-the-bleed classes, or CPR, or Naloxone, or anything like that. I think there's always a benefit there.” The distances emergency first responders cover in Montana and the lack of resources within communities affects participants’ attitudes toward the potential for training and administering naloxone among laypersons. Some may argue that the need for basic first aid training and naloxone administration in rural areas far exceeds the need in more densely populated areas with access to resources; however, participants in this study regard all of Montana as underserved and layperson training would benefit residents throughout the state.