When Kevin Donovan first saw a woman waving down traffic on I-81 north, he thought she was crazy. There no sign of an accident, or even a flat tire. When Donovan pulled over, he saw the woman’s boyfriend lying on the side of the highway. He exhibited the typical symptoms of an opioid overdose: his skin was blue, his eyes rolled into the back of his skull, and his pulse was faint. Another good Samaritan attempted to perform CPR on the man, but struggled to revive him. As cars sped by, Donovan retrieved an overdose prevention kit from his vehicle. He opened the bag, pulling out two doses of naloxone nasal spray. Donovan peeled back the packaging, placing the plastic nozzle into one of the man’s nostrils. He pressed firmly on the plunger, administering the first dose. Donovan tilted the man’s head back, supporting the jaw and pinching the nose. For the next two minutes, he performed a series of rescue breaths. Donovan administered a second dose of naloxone, this into the man’s opposite nostril. Five more rescue breaths in, the man gave one breath back. Oxygen filled his body. The color returned to his skin. Then, he stood up.
As the Overdose Prevention Coordinator at ACR Health, Donovan is familiar with the Lazarus-like effects of naloxone. ACR Health is a non-profit health clinic in Syracuse, New York. ACR offers free, biweekly naloxone training to members of the public, as well as to staffs at treatment facilities and private businesses. Since 2014, 3,000 people have been trained as a result of the program, now a New York state registered Opioid Overdose Prevention Program. Donovan, a recovering injection drug user, teaches ACR’s training sessions in eleven counties across central New York.
Community-based organizations like ACR Health are one example of many groups increasing access to naloxone. “The way we feel is that if you saturate the market with naloxone, meaning schools, businesses and everyday citizens,” says Donovan, “[fewer] people are going to die.”
The World Health Organization speculates 20,000 opioid overdose deaths could be prevented in the US each year if naloxone continues to be made more available. As of this year, all 50 states allow the prescribing naloxone to individuals at risk of opioid overdose, while 46 states have legalized purchases of naloxone without a prescription. In April 2018, U.S. Surgeon General Jerome Adams issued a national advisory urging Americans to learn how to use naloxone. It was the first advisory by a surgeon general since 2005.
In 2017, more than 30,000 people died from opioid overdoses according to NIDA. Drug overdoses are now the leading cause of death for people under 50, and for the first time since 1963, life expectancy in the US declined two years in a row as a result of overdose deaths, as reported by The Centers for Disease Control and Prevention. “One of the greatest tools we have to reduce opioid overdose deaths is naloxone,” says Lindsey Vuolo, the associate director of health law and policy at the Center on Addiction.
Naloxone is a medication that rapidly reverses opioid overdoses. “It works by adhering to opioid receptors in the body, and essentially kicks the opiates off of the opioid receptors. So it’s temporarily clearing the substance from the body,” says Dr. Dessa Bergen-Cico, the coordinator of Falk College’s Addiction Studies program at Syracuse University. The medication immediately induces withdrawal, inducing symptoms such as body aches, nausea, increased heart rate and trembling. Naloxone is just one pillar of harm reduction strategy used to combat opioid addiction, others being syringe exchange programs and opioid replacement therapy.
Naloxone was first patented in the 1960s as a less harmful alternative to previous opioid antagonists. The medication can be injected intramuscularly, but it’s now more commonly found as a nasal spray. Narcan Nasal Spray is the most prescribed form of naloxone, averaging up to 12,000 prescriptions per week in the US. One package of Narcan contains two separate four milligram doses. Over one million units of Narcan were distributed in 2017, equating to over two million doses. Thomas Duddy, the vice president of corporate communications at Adapt Pharma, the company that produces Narcan, expects this number to increase in 2018. While Narcan didn’t become FDA approved until 2016, Adapt Pharma first started working with NIDA in 2013 to formulate an opioid reversal agent better suitable for community use. “You don’t have to assemble, there’s no needle, so it can be easily used by non-medically trained people like you and I,” says Duddy. The retail price of Narcan is $125 for a package of two doses, though 75% of all insured Narcan prescriptions only have a co-pay of ten dollars or less.
In New York state, for example, the Naloxone Co-payment Assistance Program covers up to $40 in co-payments for each prescription. The innovative program was first launched by the New York State Health Department in August 2017. N-CAP allows individuals who are at risk of overdosing or their family members to obtain naloxone with a prescription. Those without a prescription can get naloxone at over 2000 pharmacies statewide through New York’s standing order.
Co-prescribing legislation in several states is another method healthcare professionals are using to increase access to naloxone. In July, Rhode Island mandated the co-prescribing of naloxone to a variety of high risk patients. Patients with the most risk have been prescribed high doses of opioids, or who have a history of opioid use disorder or overdose. Additionally, the law requires healthcare professionals to co-prescribe naloxone to patients with benzodiazepine prescriptions. Benzodiazepines like Valium or Xanax are potentially fatal when taken with opioids.
Dr. Jeffery Bratberg, a professor at the University of Rhode Island’s College of Pharmacy, worked to help pass this legislation. Bratberg is also a contributor to prescribetoprevent.org, a website dedicated to providing healthcare professionals with opioid overdose education and naloxone training. For Bratberg, the website is an important tool for teaching healthcare professionals to counteract one of the greatest barriers to naloxone access: stigma. “Prescribetoprevent.org helps talk to pharmacists and role-play with them how they’d have a conversation about naloxone for people who are at risk of overdose,” says Bratberg. While one of Bratberg’s colleagues at URI, Dr. Anita Jacobson, says that stigma surrounds all aspects of addiction, naloxone stigma among pharmacists could inhibit dispensary. “If pharmacists hold beliefs that naloxone is enabling drug use, they may not be proactive in identifying people at risk for overdose, or making a strong recommendation for them to have it,” says Jacobson. Providing naloxone in pharmacies is a potential entryway for preventing overdose deaths, as pharmacies are a primary point for sale prescription opioids.
While the CDC reports that high dose prescription opioids have remained relatively stable since 2012, the overprescribing of such medications in the ’90s helped birth what we now refer to as the opioid epidemic. Under pressure from big pharma, doctors began to dole out explosive numbers of prescription opioids. The CDC estimates that between 1991 and 2011, the number of prescription opioids more than doubled from 76 million to 219 million. NIDA reports that 200,000 overdose deaths occurred as a result of prescription opioids from 1999 to 2016, mirroring the nationwide splurge in scripts. As of 2018, over 60 percent of opioid overdose deaths now involve fentanyl, a synthetic version of the painkiller. This up from 11 percent just five years ago, according to the National Center on Health Statistics. Fentanyl is commonly slipped into drugs sold on the street, things like heroin, cocaine and MDMA, though fentanyl itself is also sold under seemingly harmless pseudonyms like Dance Fever and Jackpot, according to NIDA. Fentanyl’s popularity is partially related to its price and potency. The drug is 50 times more powerful than heroin, yet it is cheaper to produce and obtain according to American Addiction Centers.
How to use an opioid overdose prevention kit
In June of 2018, Brandon Harrison was released from jail. Harrison was arrested for a slew of drug possession charges, but was released on his own recognizance granted that he complete outpatient treatment. Harrison, now a recovering injection drug user, had no intention of using again after his release, but after spending two days waiting to start treatment, he found himself restless. The things that used to bring him joy were no longer options. He couldn’t see his son because of a previous child endangerment charge, and he’d been fired from his job. To Harrison, jail seemed like a better vacation than binge-watching NCIS on his mother’s couch, something any citizen of suburbia, or Liverpool, N.Y., might spend their time doing. “My biggest fear used to be being a normal person,” says Harrison, “I didn’t want to be one of those normal ass white kids, I wanted to do dumb shit, like do drugs and get high.” On that humid June evening, Harrison texted one of his friends, a fellow injection drug user. Harrison wanted to do heroin for the last time before starting treatment. His friend and his friend’s girlfriend picked up Harrison in Liverpool, and drove down to the south side of Syracuse, where they usually get their dope. Two hours after Harrison shot up in his friend’s car, he overdosed on heroin laced with fentanyl. When Harrison’s friend realized he was overdosing, he sped back to his own home in Liverpool, where he knew he had Narcan. He gave Harrison a dose while he lay unconscious in his car. Harrison stirred to the pang of his body hitting gravel, and to the sound of his friend’s girlfriend wailing as she begged for Harrison to wake up. That was the last time Harrison ever got high.
Where Harrison resides in Onondaga County, the opioid overdose mortality rate is higher than the statewide and national average. Preliminary data suggests that opioid overdose deaths in the county have decreased as of March 2018. While Donovan would like to believe this is a positive sign, he realizes these numbers may be underreported. “For example, if somebody got an infection due to injecting opioids and they ended up passing away from cardiac arrest, it might not necessarily get reported as an opioid-related death,” says Donovan. Still, he has hope for the future of his community, as he continues to educate hundreds about the life-saving properties of naloxone. With the advent of increasingly potent substances like fentanyl, providing naloxone training workshops is more relevant than ever. It’s more pertinent still for high risk drug users who may not know what they’re really purchasing on the street. “Community access is the number one way to get naloxone in the hands of people at high risk of overdose,” says Bratberg. Groups like ACR Health continue to provide free opioid overdose kits, which include Narcan, to high risk drug users and their friends or loved ones.
The fight to end the opioid crisis is far from over. Naloxone is just one thread in the skein of comprehensive strategy needed to mitigate opioid use disorders. Breaking down addiction stigma through education and providing greater access to treatment are two other important factors. “Ultimately, what it’s going to be is targeting school-age children, and really helping to break down the stigma when they’re still young,” says Jacobson, “moving away from fear-based language towards teaching compassion and understanding of how the disease works in the brain.”
As of December 2018, Harrison is clean. If he continues his treatment, completes his community service and doesn’t piss dirty, his previous charges will be dropped. A few months ago, he got a face tattoo: three dots in triangular shape just below his right eye. A common prison tattoo, the dots signify the phrase “my crazy life.” Harrison aspires to become a drug and alcohol counselor, and even live the normal life he always feared. For Harrison, the tattoo is a symbol of his past. Now the ink, just like the memories of his worst days, will be part of his life forever.