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To Stop an Overdose: Heroin, Narcan and the New Public Policies That Are Saving Lives

Friday, 11 April 2014 10:59 By Mike Ludwig, Truthout | News Analysis
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2014 0411ludwig(Image: Addiction via Shutterstock)I'm lying on the floor in my friend's kitchen. A dozen people are gathered around me. Maria grinds her knuckles across my sternum, but the sensation on the sensitive pressure point does not cause me to react. She rolls me on my side, turns my face to the side and brings one of my knees up toward my chest. Putting me in this "recovery position" will prevent me from choking if I vomit.

Maria pulls out a thick-gauged intramuscular syringe and a vial of naloxone hydrochloride, a drug known commonly by the brand name Narcan. She shows the people gathered around me how to draw up 1 cubic centimeter of naloxone into the syringe. "You want to inject it into fleshy areas, the upper arm muscle, thigh or butt," she says. "If there is not response in a few minutes, try administering one more cc of naloxone. Paramedics will give up to 3 cc's."

Naloxone is a nonaddictive prescription drug that reverses the effects of opiates. A person who takes a fatal dose of heroin or other opiate-based drug and stops breathing can often quickly be brought back if a friend, family member or medical professional has naloxone on hand and knows how to use it.

"Take a deep breath to stay calm, and insert the needle directly into the muscle at a 90 degree angle," I tell the group as I sit up from recovery position. I have not actually overdosed. We're holding a training workshop. We've already discussed calling 911, which we always recommend in the event of a life-threatening situation. Outside a few dozen people are skateboarding in an empty pool, sharing drinks and dancing to a local band on a wet night in New Orleans.

Learning how to administer an opiate antidote may seem like a strange thing to do during a party on a Saturday night, but it makes perfect sense to everyone gathered in the kitchen. Some of us have never used opiates and some of us have. But we all know that it's been a scary winter. We've all heard of, or personally known, someone who has died of an overdose in recent months. Many of us also know someone who has been saved by a vial of naloxone and a friend or family member who knew how to use it. We've heard the whispers among our friends and neighbors: That Narcan you gave us, it got used.

A National Overdose Crisis

The number of opiate-related overdoses has skyrocketed  in our local area, and we're not alone. From Phillip Seymour Hoffman's death in New York City to Cleveland, Ohio, where a record-breaking 195 people died of heroin-related overdoses last year, headlines from across the country are telling the grim story of a national uptick in opiate use and related deaths.

Nationally, drug overdose death rates have more than tripled since 1990, according to the Center for Disease Control (CDC). The CDC defines a drug as any chemical used for the diagnosis or treatment of a disease or injury, for relieving pain, or for the feeling it causes. An overdose occurs when a drug is taken in excessive amounts and causes bodily injury. Drug overdoses killed more than 38,000 people in 2010 alone, surpassing traffic accidents as the number-one accidental killer of adult Americans. Prescription painkillers and other prescription drugs cause a majority of overdoses, but law enforcement crackdowns on prescription painkillers have led many users to switch to street drugs like heroin. Between 2006 and 2010, heroin overdoses in the United States increased by 45 percent, according to the Department of Justice.

In response to the crisis, drug policy reformers and harm reduction activists have been pushing to make naloxone more widely available. Harm-reduction groups employ a spectrum of practical strategies to reduce the negative consequences of drug use and advocate for social justice. A 2010 CDC report credited 48 naloxone distribution and training programs run by harm-reduction groups in 15 states with 10,171 overdose reversals since 1996. At our naloxone training, we hand out overdose kits containing naloxone, clean needles, alcohol pads and instruction booklets. Our friends will keep them handy at home or pass them off to people who could potentially witness an overdose.

Policy makers are also paying attention. Naloxone has been part of the White House's National Drug Control Strategy since 2012. Attorney General Eric Holder recently called on states to pass laws expanding access to naloxone and urged first responders to carry the drug. Last week, the Food and Drug Administration issued an expedited approval of Evzio, a handheld naloxone auto-injector that can be easily used by family members and caregivers outside a medical setting. When activated, the Evzio injector gives verbal instructions out loud on how to safely deliver the antidote. The FDA, however, recommends that caregivers and family members becoming familiar with using the device before it is needed. FDA officials said Evzio would save lives by allowing caregivers and family members of drug users to quickly administer the antidote in an emergency, but they will have to get a prescription first. 

Expanding Narcan Access

Naloxone is not a controlled substance, but, like the new Evzio product, it is a prescription drug. In many states, naloxone is only available by prescription and must otherwise be administered by a doctor or medical professional. That can be a problem for drug users and the people who may be around them during an emergency, especially those who can't afford healthcare services or fear discussing their drug use with physicians.

"There are so many reasons why people are hesitant or unable to see physicians," says Meghan Ralston, a harm-reduction specialist with the Drug Policy Alliance (DPA).

Social stigma against drug use, for example, deters people from discussing drug problems with doctors, Ralston says. A patient may not want to admit to a doctor that they use opiates out of fear that friends or family could find out.

Drug users can face tough criminal penalties and get wrapped up in the legal system for years, so fear of law enforcement can also deter users from seeking help. 

Without legal protections that only exist in a few states, physicians may also be reluctant to prescribe naloxone to an opiate user. Naloxone is typically administered by someone witnessing an overdose, not the drug user themselves, so Ralston says that doctors need to be assured that they will not be held liable when the drug they prescribe to someone is administered by a friend or family member.

Naloxone's status as a prescription drug leaves informal distribution and training efforts like ours in a legal grey area, but without reforms to state law that would allow pharmacists and harm-reduction groups to distribute the drug with legal cover, there will be no official naloxone and overdose prevention services in New Orleans and other cities across the country. In the meantime, we're left to tackle the threat of overdoses in our community, with help from a loose networks of activists who operate in a do-it-yourself and essentially underground manner. But this could soon change in Louisiana - and has already changed in states across the country.

The Slow March Toward Reform

Seventeen states and the District of Columbia have amended their laws to expand access to naloxone in recent years. Some reforms allow doctors to prescribe naloxone to third parties, such as friends and family members of drug users, who may witness an overdose. Others helped put naloxone in the hands of first responders and allow doctors to issue "standing orders" authorizing harm reduction groups, such as syringe exchange programs, to distribute naloxone to those in need. The Justice Department reports that these state efforts have resulted in 10,000 overdose reversals since 2001.

Similar initiatives are currently being considered in Louisiana, where a scourge of heroin-related deaths has also prompted lawmakers to buck the national trend and pass a bill establishing a mandatory minimum sentence of two years in prison for anyone caught with heroin despite a growing body of evidence that mandatory minimums don't reduce crime. But a bill known as a 911 Good Samaritan initiative has also been introduced, which would provide legal immunity from drug possession charges to people who call 911 to save someone from an overdose.

The Justice Department recently announced its support for 911 Good Samaritan laws, and with good reason. The most common reason overdose witnesses cite for not calling 911 is fear of police involvement, according to the DPA, and the threat of prison time would only exacerbate this fear among drug users in Louisiana. Such laws have been passed in 14 states across the country, including Washington, where 88 percent of opiate users told researchers that they were more likely, and less afraid, to call 911 in the event of a future overdose, according to the Drug Policy Alliance.

New York recently approved a program allowing every law enforcement officer in the state to carry naloxone. States such as New Mexico, Washington and Rhode Island have allowed pharmacists to sell naloxone to anyone who thinks they may witness an overdose "essentially upon request," according to Ralston. California lawmakers are currently considering such a measure, and California Gov. Jerry Brown signed a law in January protecting doctors who prescribe naloxone and laypeople who administer naloxone to others from legal liabilities.

While drug policy reforms and harm reduction activists are cheering this patchwork of state reforms, the slow pace of legislation continues to be frustrating. Some politicians are still wary of naloxone due to the misconception that it encourages drug users to be reckless, despite research to the contrary and broad support for the drug among major health organizations.

Politicians, however, often support reforms after seeing the facts. A bigger problem, Ralston says, is that sensible overdose prevention policies often fall on the legislative back burner.

"It’s not that state legislatures are opposed to these kind of polices," Ralston says. "It's just an issue that gets forgotten about."

Ralston and the DPA are encouraged by the Obama administration's recent support of state initiatives to expand naloxone access among first responders, but they hope that the administration will clarify its position and support naloxone access to anyone who might be the first person to discover someone in the throws of an overdose, not just cops, paramedics and firefighters. Activists are also calling on lawmakers to adopt more comprehensive overdose prevention policies that get to the root of the problem.

"This includes improving access to effective, noncoercive drug treatment for everyone who wants it, as well as improving access to medication-assisted treatments such as methadone and buprenorphine,” says Ralston, who told Truthout that the "NIMBYism" and stigma against opiate replacement programs and facilities is "shameful."

America's attitude toward drug treatment is changing, however. A recent poll by the Pew Research Center found that more than two-thirds of Americans now say that drug users need access to treatment instead of facing jail time. Two-thirds also support initiatives in some states to throw out mandatory minimum sentences for minor drug crimes, up from less than 50 percent in 2001.

Ralston says that providing young people with better access to mental healthcare and education on drug safety would also have a big impact.

"There are so many steps along the way that we can intervene in the lives of young people before they are lying on the floor of the bathroom while someone panics and calls 911," says Ralston. "How are we teaching young people about drugs?"

As the Pew researchers pointed out, the American public "appears ready for a truce in the long-running war on drugs." There is even a bipartisan effort in Congress to reform mandatory minimum sentencing laws for federal drug offenses. After decades of trying - and failing - to stomp out illicit drug use, voters and policymakers are slowly moving toward the types of reforms that advocates and medical professionals have said for years would save lives and reduce the harm that drugs cause to individuals and society.

But we still have a long way to go. In the meantime, my friends and I will continue sharing skills that can help us keep each other alive, healthy and safe, and, if possible, keeping some naloxone around in case anyone feels the need to take it home and put it on their bathroom shelf.

Learn the steps to recognizing and responding to an overdose and administering naloxone from the detailed guides provided by the Harm Reduction Coalition:

"Recognizing an Overdose: Assessment and Stimulation"

"Overdose Response: Recovery Position and Calling 911"

"Performing Rescue Breathing"

"Administering Naloxone"

"Aftercare: Addressing Withdrawal and Re-overdose Risk

Correction: This article originally stated that laws passed in New Mexico and other states allow pharmacists to "give" naloxone to people in need of the drug. Naloxone is not given away for free; it is sold by pharamcies like any other drug. This article also stated that California is considering a bill that would provide legal cover for doctors who prescribe naloxone and laypeople who administer it to others. That bill, AB 635, was passed by the California legislature and signed into law on January 1 2014. 

Copyright, Truthout. May not be reprinted without permission.

Mike Ludwig

Mike Ludwig is an investigative reporter at Truthout and a contributor to the Truthout anthology, Who Do You Serve, Who Do You Protect? Follow him on Twitter: @ludwig_mike.


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To Stop an Overdose: Heroin, Narcan and the New Public Policies That Are Saving Lives

Friday, 11 April 2014 10:59 By Mike Ludwig, Truthout | News Analysis
  • font size decrease font size decrease font size increase font size increase font size
  • Print

2014 0411ludwig(Image: Addiction via Shutterstock)I'm lying on the floor in my friend's kitchen. A dozen people are gathered around me. Maria grinds her knuckles across my sternum, but the sensation on the sensitive pressure point does not cause me to react. She rolls me on my side, turns my face to the side and brings one of my knees up toward my chest. Putting me in this "recovery position" will prevent me from choking if I vomit.

Maria pulls out a thick-gauged intramuscular syringe and a vial of naloxone hydrochloride, a drug known commonly by the brand name Narcan. She shows the people gathered around me how to draw up 1 cubic centimeter of naloxone into the syringe. "You want to inject it into fleshy areas, the upper arm muscle, thigh or butt," she says. "If there is not response in a few minutes, try administering one more cc of naloxone. Paramedics will give up to 3 cc's."

Naloxone is a nonaddictive prescription drug that reverses the effects of opiates. A person who takes a fatal dose of heroin or other opiate-based drug and stops breathing can often quickly be brought back if a friend, family member or medical professional has naloxone on hand and knows how to use it.

"Take a deep breath to stay calm, and insert the needle directly into the muscle at a 90 degree angle," I tell the group as I sit up from recovery position. I have not actually overdosed. We're holding a training workshop. We've already discussed calling 911, which we always recommend in the event of a life-threatening situation. Outside a few dozen people are skateboarding in an empty pool, sharing drinks and dancing to a local band on a wet night in New Orleans.

Learning how to administer an opiate antidote may seem like a strange thing to do during a party on a Saturday night, but it makes perfect sense to everyone gathered in the kitchen. Some of us have never used opiates and some of us have. But we all know that it's been a scary winter. We've all heard of, or personally known, someone who has died of an overdose in recent months. Many of us also know someone who has been saved by a vial of naloxone and a friend or family member who knew how to use it. We've heard the whispers among our friends and neighbors: That Narcan you gave us, it got used.

A National Overdose Crisis

The number of opiate-related overdoses has skyrocketed  in our local area, and we're not alone. From Phillip Seymour Hoffman's death in New York City to Cleveland, Ohio, where a record-breaking 195 people died of heroin-related overdoses last year, headlines from across the country are telling the grim story of a national uptick in opiate use and related deaths.

Nationally, drug overdose death rates have more than tripled since 1990, according to the Center for Disease Control (CDC). The CDC defines a drug as any chemical used for the diagnosis or treatment of a disease or injury, for relieving pain, or for the feeling it causes. An overdose occurs when a drug is taken in excessive amounts and causes bodily injury. Drug overdoses killed more than 38,000 people in 2010 alone, surpassing traffic accidents as the number-one accidental killer of adult Americans. Prescription painkillers and other prescription drugs cause a majority of overdoses, but law enforcement crackdowns on prescription painkillers have led many users to switch to street drugs like heroin. Between 2006 and 2010, heroin overdoses in the United States increased by 45 percent, according to the Department of Justice.

In response to the crisis, drug policy reformers and harm reduction activists have been pushing to make naloxone more widely available. Harm-reduction groups employ a spectrum of practical strategies to reduce the negative consequences of drug use and advocate for social justice. A 2010 CDC report credited 48 naloxone distribution and training programs run by harm-reduction groups in 15 states with 10,171 overdose reversals since 1996. At our naloxone training, we hand out overdose kits containing naloxone, clean needles, alcohol pads and instruction booklets. Our friends will keep them handy at home or pass them off to people who could potentially witness an overdose.

Policy makers are also paying attention. Naloxone has been part of the White House's National Drug Control Strategy since 2012. Attorney General Eric Holder recently called on states to pass laws expanding access to naloxone and urged first responders to carry the drug. Last week, the Food and Drug Administration issued an expedited approval of Evzio, a handheld naloxone auto-injector that can be easily used by family members and caregivers outside a medical setting. When activated, the Evzio injector gives verbal instructions out loud on how to safely deliver the antidote. The FDA, however, recommends that caregivers and family members becoming familiar with using the device before it is needed. FDA officials said Evzio would save lives by allowing caregivers and family members of drug users to quickly administer the antidote in an emergency, but they will have to get a prescription first. 

Expanding Narcan Access

Naloxone is not a controlled substance, but, like the new Evzio product, it is a prescription drug. In many states, naloxone is only available by prescription and must otherwise be administered by a doctor or medical professional. That can be a problem for drug users and the people who may be around them during an emergency, especially those who can't afford healthcare services or fear discussing their drug use with physicians.

"There are so many reasons why people are hesitant or unable to see physicians," says Meghan Ralston, a harm-reduction specialist with the Drug Policy Alliance (DPA).

Social stigma against drug use, for example, deters people from discussing drug problems with doctors, Ralston says. A patient may not want to admit to a doctor that they use opiates out of fear that friends or family could find out.

Drug users can face tough criminal penalties and get wrapped up in the legal system for years, so fear of law enforcement can also deter users from seeking help. 

Without legal protections that only exist in a few states, physicians may also be reluctant to prescribe naloxone to an opiate user. Naloxone is typically administered by someone witnessing an overdose, not the drug user themselves, so Ralston says that doctors need to be assured that they will not be held liable when the drug they prescribe to someone is administered by a friend or family member.

Naloxone's status as a prescription drug leaves informal distribution and training efforts like ours in a legal grey area, but without reforms to state law that would allow pharmacists and harm-reduction groups to distribute the drug with legal cover, there will be no official naloxone and overdose prevention services in New Orleans and other cities across the country. In the meantime, we're left to tackle the threat of overdoses in our community, with help from a loose networks of activists who operate in a do-it-yourself and essentially underground manner. But this could soon change in Louisiana - and has already changed in states across the country.

The Slow March Toward Reform

Seventeen states and the District of Columbia have amended their laws to expand access to naloxone in recent years. Some reforms allow doctors to prescribe naloxone to third parties, such as friends and family members of drug users, who may witness an overdose. Others helped put naloxone in the hands of first responders and allow doctors to issue "standing orders" authorizing harm reduction groups, such as syringe exchange programs, to distribute naloxone to those in need. The Justice Department reports that these state efforts have resulted in 10,000 overdose reversals since 2001.

Similar initiatives are currently being considered in Louisiana, where a scourge of heroin-related deaths has also prompted lawmakers to buck the national trend and pass a bill establishing a mandatory minimum sentence of two years in prison for anyone caught with heroin despite a growing body of evidence that mandatory minimums don't reduce crime. But a bill known as a 911 Good Samaritan initiative has also been introduced, which would provide legal immunity from drug possession charges to people who call 911 to save someone from an overdose.

The Justice Department recently announced its support for 911 Good Samaritan laws, and with good reason. The most common reason overdose witnesses cite for not calling 911 is fear of police involvement, according to the DPA, and the threat of prison time would only exacerbate this fear among drug users in Louisiana. Such laws have been passed in 14 states across the country, including Washington, where 88 percent of opiate users told researchers that they were more likely, and less afraid, to call 911 in the event of a future overdose, according to the Drug Policy Alliance.

New York recently approved a program allowing every law enforcement officer in the state to carry naloxone. States such as New Mexico, Washington and Rhode Island have allowed pharmacists to sell naloxone to anyone who thinks they may witness an overdose "essentially upon request," according to Ralston. California lawmakers are currently considering such a measure, and California Gov. Jerry Brown signed a law in January protecting doctors who prescribe naloxone and laypeople who administer naloxone to others from legal liabilities.

While drug policy reforms and harm reduction activists are cheering this patchwork of state reforms, the slow pace of legislation continues to be frustrating. Some politicians are still wary of naloxone due to the misconception that it encourages drug users to be reckless, despite research to the contrary and broad support for the drug among major health organizations.

Politicians, however, often support reforms after seeing the facts. A bigger problem, Ralston says, is that sensible overdose prevention policies often fall on the legislative back burner.

"It’s not that state legislatures are opposed to these kind of polices," Ralston says. "It's just an issue that gets forgotten about."

Ralston and the DPA are encouraged by the Obama administration's recent support of state initiatives to expand naloxone access among first responders, but they hope that the administration will clarify its position and support naloxone access to anyone who might be the first person to discover someone in the throws of an overdose, not just cops, paramedics and firefighters. Activists are also calling on lawmakers to adopt more comprehensive overdose prevention policies that get to the root of the problem.

"This includes improving access to effective, noncoercive drug treatment for everyone who wants it, as well as improving access to medication-assisted treatments such as methadone and buprenorphine,” says Ralston, who told Truthout that the "NIMBYism" and stigma against opiate replacement programs and facilities is "shameful."

America's attitude toward drug treatment is changing, however. A recent poll by the Pew Research Center found that more than two-thirds of Americans now say that drug users need access to treatment instead of facing jail time. Two-thirds also support initiatives in some states to throw out mandatory minimum sentences for minor drug crimes, up from less than 50 percent in 2001.

Ralston says that providing young people with better access to mental healthcare and education on drug safety would also have a big impact.

"There are so many steps along the way that we can intervene in the lives of young people before they are lying on the floor of the bathroom while someone panics and calls 911," says Ralston. "How are we teaching young people about drugs?"

As the Pew researchers pointed out, the American public "appears ready for a truce in the long-running war on drugs." There is even a bipartisan effort in Congress to reform mandatory minimum sentencing laws for federal drug offenses. After decades of trying - and failing - to stomp out illicit drug use, voters and policymakers are slowly moving toward the types of reforms that advocates and medical professionals have said for years would save lives and reduce the harm that drugs cause to individuals and society.

But we still have a long way to go. In the meantime, my friends and I will continue sharing skills that can help us keep each other alive, healthy and safe, and, if possible, keeping some naloxone around in case anyone feels the need to take it home and put it on their bathroom shelf.

Learn the steps to recognizing and responding to an overdose and administering naloxone from the detailed guides provided by the Harm Reduction Coalition:

"Recognizing an Overdose: Assessment and Stimulation"

"Overdose Response: Recovery Position and Calling 911"

"Performing Rescue Breathing"

"Administering Naloxone"

"Aftercare: Addressing Withdrawal and Re-overdose Risk

Correction: This article originally stated that laws passed in New Mexico and other states allow pharmacists to "give" naloxone to people in need of the drug. Naloxone is not given away for free; it is sold by pharamcies like any other drug. This article also stated that California is considering a bill that would provide legal cover for doctors who prescribe naloxone and laypeople who administer it to others. That bill, AB 635, was passed by the California legislature and signed into law on January 1 2014. 

Copyright, Truthout. May not be reprinted without permission.

Mike Ludwig

Mike Ludwig is an investigative reporter at Truthout and a contributor to the Truthout anthology, Who Do You Serve, Who Do You Protect? Follow him on Twitter: @ludwig_mike.


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