Editor鈥檚 note: This first appeared on and is republished here under a .
By Lauren DeLaunay Miller,
As the opioid epidemic has spread over the past decade, fueled by the availability of synthetic opioids like fentanyl, no corner of California has escaped unscathed. Even in the rural Eastern Sierra, on the edge of the state鈥檚 border with Nevada, rates of opioid use disorder have risen. Here, where it routinely takes ambulances up to 30 minutes to cover large distances between small towns, emergency responders know that when they get a call for a suspected overdose, the clock will be working against them.
鈥淵ou can鈥檛 cheat time,鈥� said Phil Wesseler, a paramedic in Mono County who has witnessed the devastating impact of opioid use disorder over the last seven years of work in the Eastern Sierra. But he鈥檚 also seen a solution that works: communities being equipped with naloxone. Commonly referred to by its brand name, Narcan, naloxone can rapidly reverse the symptoms of opioid overdose by stimulating the respiratory system. Often given as a nasal spray, Wesseler said that today, on most of the overdose calls his team responds to, bystanders have already used naloxone on the patients, drastically improving their chances of survival. Mono County has a free naloxone distribution program.
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Comparing urban and rural rates of drug overdose deaths across the country. Image from the National Center for Health StatisticsCalifornia is one of just five states in which the rate of death from drug overdoses is higher in rural areas than urban ones, according to data from the Centers for Disease Control and Prevention. The latest data from the California Department of Public Health shows that statewide, more than 7,800 people died from opioid overdoses in 2023, the most recent year statistics are available. While Los Angeles County recorded the highest total number of opioid-related overdose deaths in 2023 at 7,847, when adjusted for population size, Alpine and Sierra counties had the highest rates, though this data is less stable given the counties鈥� small total population size.
Because rural EMS units often rely on volunteer crews and face geographic barriers that force them to cover large distances in more varied terrain, response times are typically slower, according to the federal Centers for Disease Control and Prevention. In California, urban EMS providers also tend to receive more funding, resulting in a higher quality of care, according to the CDC. But across the state, emergency responders in rural regions are finding solutions tailored to their communities. Driven by a desire to help patients find long-term help for drug use, emergency providers are partnering with local organizations to connect patients with mental health care and treatment programs, as well as equip communities to distribute overdose-reversal medication.
Eureka is the most populous city on the California coast north of the Bay Area, but with 27,000 residents, it isn鈥檛 exactly urban. The opioid overdose death rate in Humboldt County, where Eureka is located, is five times the state average, and as the county seat, Eureka sees the brunt of overdoses, according to Jacob Rosen, managing mental health clinician with Crisis Alternative Response of Eureka (CARE). The city started the program in response to a request from the police department, and it now works to integrate mental health services into emergency response protocols citywide.
鈥淚t鈥檚 not the traditional response of a municipal government to have its own mental health team,鈥� Rosen said. 鈥淲e鈥檙e fortunate our community really wanted that.鈥�
CARE works with the Eureka police department to respond to emergency calls that require mental health intervention. The program鈥檚 team of clinicians and case managers can respond alongside police officers or, in nonviolent cases, on their own to both de-escalate the present emergency and offer support for long-term care. Rosen says that the majority of mental health calls they receive are related to or exacerbated by substance use, and by sending his team to respond to such calls, patients can be immediately connected to social services, mental health care and substance-use treatment.
Rosen largely credits the police department for CARE鈥檚 inception, explaining that, over time, law enforcement has become the 鈥渄e facto鈥� mental health response in cities across the country, yet 鈥渢hey don鈥檛 necessarily get training that鈥檚 equivalent to that,鈥� he said. Before CARE, Rosen said people experiencing a mental health crisis were often brought by police to the local emergency room, but that system was routinely overburdened. This left law enforcement officers ill-equipped to help patients find a long-term plan to address the root causes of patients鈥� crises. Now the goal, Rosen said, is to find a way to proactively intervene before patients reach the hospital.
After the initial emergency has been resolved, Rosen鈥檚 team tries to establish a follow-up meeting with patients to connect them to resources and local agencies. Some patients, Rosen said, might even get daily follow-up care, depending on the team鈥檚 evaluation of their risk level.
In 2024, CARE responded to 234 patients, more than 60 percent more than the program had helped the previous year. In 2024, the program responded jointly with the Eureka Police Department to more than 200 of those 234 patients.
鈥淎s long as everyone鈥檚 patient and collaborative, we can do some incredible things,鈥� Rosen said.
Long-term treatment, from the ambulance
Sometimes, the long-term care that patients need includes mental health treatment; other times, it鈥檚 more directly related to substance use. For patients with opioid use disorder, medications, such as methadone and buprenorphine, can be an important tool. These medications, opiates themselves, mimic the effects of opioids to help prevent withdrawal symptoms without giving the patient a sense of 鈥渉igh.鈥� Usually distributed under the care of a physician in a clinic or hospital, some EMS units are finding ways to start that treatment before patients even reach the hospital.
Following an overdose, many patients refuse to be transferred to a hospital, or they leave the hospital before a long-term care plan can be established, according to EMS Bridge, a program within California Bridge to Treatment, which works to use EMS services to advance community health. Either way, surviving an overdose can trigger painful withdrawal symptoms that have historically been difficult for medics to treat. But in the last few years, some EMS units across the state and country have experimented with providing medications that help withdrawal symptoms in the ambulance before patients even reach the hospital.
In 2019, clinicians at Cooper University Health in Camden, New Jersey, began a groundbreaking experiment. They trained paramedics to begin treatment with buprenorphine in the ambulance, a practice that had historically been limited to physicians in a clinic. It was a massive success: patients who were offered methadone or buprenorphine pre-hospital were six times as likely to use it, vastly increasing their chances of long-term treatment. Clinicians in California began wondering if they could bring the same success to their communities.
Beginning with a small pilot project in Contra Costa County in 2020, EMS Bridge, a program of the Public Health Institute鈥檚 Bridge Center, began a program to train EMS professionals to administer buprenorphine through funding from the CARESTAR Foundation. 鈥淚f you have an overdose and survive it, you have a 10 percent change of dying within a year,鈥� said Dr. Gene Hern, medical director for EMS Bridge and associate clinical professor of emergency medicine at UCSF. But treatment with buprenorphine can lower that mortality rate by 70 percent鈥攁 success that Hern said is unparalleled within emergency medicine.
According to the Department of Health Care Services, 1,300 paramedics across 13 California counties have been trained to administer buprenorphine in the ambulance, and with new funding, Stanislaus County will be next. Hern said that adoption in rural California can be limited because patients will need a reliable, accessible place to continue getting medication once transferred. But he sees some strengths in rural areas as well. Longer transport times can mean that medics have more time to connect with their patients, establishing a trusting relationship in which a patient may be more open to starting buprenorphine.
Being able to help patients find long-term care helps medics, too, said Vanessa Lara, EMS Bridge Program Manager. While quantitative data is difficult to collect, she said their surveys indicate that being able to watch a patient transform before their eyes helps medics feel more satisfaction in their work, as does knowing that they helped put them on a path toward long-term healing.
Training overdose responders within the community
Many rural California regions are now training community members to be naloxone overdose responders outside of the medical system, helping to administer the medication before EMS services arrive.
Savannah O鈥橬eill, an Oakland-based consultant who has worked on harm reduction initiatives for more than a decade, said that the idea of getting naloxone into lay people鈥檚 hands has been around since the 1990s, even if it is only now gaining momentum 鈥� and, importantly, funding 鈥� in many rural or conservative communities.
In 2016, when O鈥橬eill created the Overdose Prevention and Education Naloxone Distribution Project in Alameda County, she said she still faced a lot of pushback. But now, she said, distributing naloxone is built into many EMS and treatment protocols.
鈥淧eople who use drugs reverse more overdoses than ambulances,鈥� said O鈥橬eill, highlighting a statistic that, for some policymakers, has helped curb caution about programs that primarily entrust substance users. In rural communities, O鈥橬eill said that a reliance on personal relationships and longstanding trust can help organizations reach the people that need naloxone the most, whether that鈥檚 opioid users themselves or their family, friends and neighbors.
In the remote Eastern Sierra, for example, Crossroads Recovery Center has worked to distribute naloxone widely to members of the Bishop Paiute Tribe who suffer from disproportionate rates of substance abuse disorder. Dr. Annie Goshgarian, medical director for Inyo County Substance Use Service and emergency room physician and addiction specialist at Bishop鈥檚 Northern Inyo Hospital, explained that finding realistic crisis intervention that people will use is a critical first step in finding them long-term solutions.
鈥淧atients only have the opportunity to find sobriety if they are still alive,鈥� Goshgarian said.
