In a first for Long Beach, fire department paramedics have recently begun helping police subdue people they believe are potentially violent or combative, sometimes by administering a powerful sedative to the person being detained.

Over the past four months, LBFD paramedics have used the drug midazolam on more than three dozen people as part of a new pilot program meant to bolster coordination between the police and fire department, city officials recently announced.

Nearly 1,000 police and fire personnel, including more than 60 dispatchers, have received training on how to recognize the symptoms of a person exhibiting what city officials call “agitated delirium” as well as coordinate a combined response, according to an Aug. 20 statement from the city.

But the pilot program, which city officials say was designed to reduce the levels of force officers could use in these situations, is controversial among medical professionals because it can involve the use of midazolam in a non-healthcare setting without a doctor present.

In two high profile cases in other cities, individuals died after being restrained and then injected with a sedative, though the exact role the sedative played, if any, in the deaths is debated.

For police chief Robert Luna, the new program is being done “in the spirit of doing things better. … We’re trying to eliminate the use of force as many times as we can.”

Luna added that the program provides “another tool” for officers following the department’s decision last year to suspend use of the controversial carotid restraint, which cuts off blood flow to the brain by putting pressure on a person’s neck.

Though the pilot program was introduced at the beginning of the year, police and fire began training for it in April, said Long Beach fire Battalion Chief Joshua Hogan.

“Police and fire talking to each other so they can coordinate where they meet—we never had that before in Long Beach,” said Hogan.

The goal of the program, Hogan said, is to decrease response times, and improve time for medical intervention. “We’re getting treatment to the patient quicker,” he said.

City officials say they’ve used the new coordinated response 137 times, and administered a sedative in 31% of the incidents (roughly 42 times).

Under the program, dispatchers have been trained to ask callers a series of questions to determine if they’re dealing with a 647V—an “intoxicated person potentially violent.”

Police and fire officials call this “agitated delirium,” and say it can be the result of alcohol intoxication, drug use, mental illness, uncontrolled anger, or combination of all four.

If the 647V criteria is met, dispatchers would then route both police and paramedics to the scene. There, paramedics would assess the level of “medical management” they would need to use on the person, which could include administering midazolam. The sedative can be administered by nasal spray or injection, say city officials.

Hogan, who was part of the working group that developed the pilot program, said paramedics are authorized to give patients two 5mg doses of midazolam spaced five minutes apart. If that doesn’t sufficiently calm the person, then paramedics will call St. Mary Medical Center.

After consulting with a nurse there who’s authorized to assist them, they may give another two 5mg doses of midazolam, again spaced five minutes apart, if necessary, for a total of 20mg.

Aili Malm, a Cal State Long Beach professor of criminology and criminal justice, said the training of so many dispatchers in this is a promising sign toward deescalating police encounters like this. “It has a lot of potential,” she said.

Other cities nationwide have implemented similar programs, and generated controversy as well. At least three professional medical associations—the American Psychiatric Association, American College of Emergency Physicians and the American Society of Anesthesiologists—have publicly denounced the practice of paramedics administering sedatives for law enforcement purposes.

“The American Society of Anesthesiologists firmly opposes the use of ketamine or any other sedative/hypnotic agent to chemically incapacitate someone for a law enforcement purpose and not for a legitimate medical reason,” reads a statement from that organization.

The reason is that sedatives like midazolam or ketamine (which is used by paramedics in some cities) can “can elevate blood pressure and heart rate, and can lead to confusion, agitation, delirium, and hallucinations,” according to the Anesthesiologists statement. When “administered in a non-health care setting without appropriately trained medical personnel,” these effects can result in death, according to the statement.

Paramedics administered sedatives in two high profile cases of individuals dying while being arrested in the last few years, though it’s unclear how much, if at all, the sedative contributed to the deaths.

In 2016 in Dallas, Tony Timpa, 32, called police, saying he was off his schizophrenia and depression medication and was scared. Police cuffed him, then pinned him to the ground for nearly 14 minutes before paramedics injected him with midazolam.

Timpa died a few minutes later. The coroner listed the cause of death as “sudden cardiac death” caused by “the toxic effects of cocaine and physiological stress associated with physical restraint,” according to CBS News.

Three years later in Aurora, Colorado, Elijah McClain, 23, went into cardiac arrest after paramedics injected him with ketamine. Colorado Public Radio reported that police said he was exhibiting signs of “excited delirium.”

Outcry following McClain’s death led to Colorado Gov. Jared Polis signing a bill in July that banned law enforcement from directing paramedics to administer ketamine for law enforcement purposes, according to the Denver Post.

Dr. Paul S. Appelbaum, a professor of psychiatry at Columbia University and former president of American Psychiatric Association who has criticized similar programs in other cities, also finds fault with Long Beach officials’ use of the term “agitated delirium,” which he says is not a legitimate medical diagnosis.

“Delirium is a specific medical syndrome, with a clear definition,” he said. “Most of the agitated people encountered by police are not delirious. They are drunk. Or high. Or manic. Or just angry. Use of a term like ‘agitated delirium’ for this entire category of persons encourages overuse of medical interventions.”

For their part, city officials insist that their pilot program is designed to lessen the probability that officers will rely on physical restraint of violent suspects.

“If you want to reduce the application of force, how else do you do it?” asked Luna. “You have to look for alternatives that make somebody safer.”

“The longer a patient is physically restrained, the poorer the outcome,” said Hogan. “Our goal is to decrease the time the patient is restrained.”

A police spokesperson said officials are still evaluating how the pilot program is progressing, and couldn’t say how long it would last.

Editor’s note: This story originally mischaracterized Chief Luna’s statement about the need to look for alternatives to physical restraint, and has been corrected.