Pubdate: Thu, 23 Jun 2016
Source: Reno News & Review (NV)
Copyright: 2016, Chico Community Publishing, Inc.
Author: Kris Vagner


There's An Antidote for Heroin Overdose, and a Former Addict Is Among 
Those Working to Spread It Far and Wide

Joshua Livernois woke up hazy, sick and splashed with Dr. Pepper in a 
hospital bed in Salinas, California. He couldn't piece together the 
events of the previous day or so, and he's still not even sure which 
year it was, probably 2005 or '06. He'd been using heroin off and on 
for about 10 years and almost daily for five.

"There was some crazy dope in town," he said. "I don't know what was 
up with it. It tasted different than normal, had kind of a vitamin-ey 
flavor." As a long-time user, he didn't often get what he craved, 
which was "the full effect of being fully loaded." This new heroin, 
he said, "got me really, really high."

This much he remembers: He'd been homeless for a while. His 
then-girlfriend had been in jail for a couple of weeks. They were in 
a motel room with a few other friends. They were on a four-day bender 
doing MDMA, crystal meth, alcohol and that potent heroin that had 
just hit town.

This part he pieced together later: After he shot up, he started 
babbling incoherently. His friends worried that he might be 
overdosing. Two women loaded him into a car and drove toward the 
emergency room. On the way there, he passed out, turned blue and 
started breathing shallow, infrequent breaths. The driver stopped at 
the home of an acquaintance because it was closer than the hospital. 
The acquaintance gave Livernois an injection of naloxone, which he 
said helped him recover from the overdose, and eventually the two 
women got him to the hospital.

About the antidote

Naloxone, also sold under brand names such as Narcan, reportedly 
reverses the overdose effects from opiates, including heroin and 
prescription painkillers, by taking over the opiates' place on the 
brain's receptors. Different formulations of it can be injected into 
a muscle or vein, or sprayed into a nasal cavity. It was approved by 
the Food and Drug Administration in 1971. It's been available by 
prescription in Nevada for a long time, but it was effectively 
illegal until 2013, when a statute was changed to decriminalize 
possession of syringes. (The nasal spray version wasn't an option 
then; that wasn't approved by the FDA until 2015.)

Naloxone can have side effects including nausea, sweating and fever, 
but, in the experience of Cindy Green-a 17-year veteran EMT, 
supervisor and educator for ambulance service REMSA-it very often 
doesn't. She and her colleagues administer the drug about 53 times a 
month. (Green stressed that "53" isn't necessarily the number of 
opiate overdoses that REMSA responders encounter monthly. If they 
find someone unconscious and they don't know why, they might 
administer Naloxone to rule out an overdose. She didn't have a number 
readily available, but she said that happens noticeably often.)

"The medicine itself will never hurt you. It will only benefit you," 
Green said. Livernois had been feeling pretty bad when he woke up 
that day in Salinas, though. In fact, he described it as a "fucking 
miserable, miserable experience," a type of situation that Green 
explained this way: "I guess there is a small caveat. If you have a 
major addiction, you could see some withdrawals. You do typically 
upset the person when you give it, because you take away the high."

Highs and lows

This is not a nice, neat, linear story of a guy hitting rock bottom 
and suddenly coming clean. It took Livernois six or seven more years 
to kick heroin. The last time he took it was in 2012.

During those six or seven years, he volunteered at the syringe 
exchange in Salinas, moved to Reno, and joined with a few other 
activists to start a grassroots group called the Public Health 
Alliance for Safety Access (PHASA). That group formed in large part 
to push for a law that would make naloxone more widely accessible.

Among the members of the fledgling group were Melanie Flores, an 
activist named Penny Jernberg from Truckee, and Livernois' now 
long-term partner, Leslie Castle.

"They were really stoked when I showed up on the scene," Livernois 
said. "They had everything they needed except an actual drug user. 
They didn't have anybody to bridge the gap between them and the 
community they want[ed] to serve. Sometimes it's hard to find people 
to self-identify."

He pointed out that identifying as an addict is hard to do in a lot 
of circumstances, and that often because of that people who need 
counseling or medical help don't get it.

"Stigma kills," he said. "It's the number-one killer. If you woke up 
tomorrow with a giant, festering wound on your arm, you'd go in. Many 
times, a heroin user with a similar problem would avoid a hospital 
visit. Many times a provider treats you like dog shit. The way that 
they look at you, you'll never go again. ... Stigma is a real bitch." 
In a position to help

Today, Livernois is a community outreach worker for Change Point, the 
syringe services program at Northern Nevada HOPES. The program 
provides clean needles, which helps slow transmission rates of HIV 
and Hepatitis C. It also offers counseling, access to rehabilitation 
programs and HIV and Hep-C testing.

Livernois said that HOPES makes a point of hiring staff members who 
represent the communities they work with. Sometimes, for example, the 
non-profit health organization seeks out transgender employees or 
Latino employees.

In his case, he said, "You can't really put out a Craigslist ad 
saying you're looking for somebody who used to shoot heroin, who's 
been to prison, who's been homeless, but that is what they were 
looking for." Livernois, now 38, has a slim build, a long 
salt-and-pepper beard, a piercing on each side of his lower lip, and 
intense brown eyes. Fashionwise, he might fit right in with his 
clients at the exchange, but he's alert, articulate and authoritative 
on the job. It's clear as he manages the flow of clients in Change 
Point's tiny, busy front office that his experience as a user helps 
him relate to his community. One moment he listens compassionately to 
a man who appears spaced out, scared and a little angry. The next 
moment he firmly reprimands a guy for verbally harassing the intern. 
The guy apologizes and promises it won't happen again.

Harm reduction

Heroin and prescription opiate overdoses have been on the rise 
nationally and locally. Here are a few figures to put that into perspective:

The Centers for Disease Control and Prevention this year reported a 
200-percent increase in the rate of overdose deaths involving 
opioids-opioid pain relievers and heroin-since 2000.

Nevada ranks in the top quartile of overdose deaths nationwide.

Between 2010 and 2014, about a billion prescription pills were 
prescribed in Nevada, and about a quarter of those were painkillers, 
the most likely to lead to overdose deaths.

A Washoe County Health Department report showed that in 2012, 50 
deaths in the county were associated with heroin overdose.

As usage rates and death rates have risen, the way medical 
professionals and law enforcement agencies handle drug cases has 
shifted in large part from a punitive "just say no" approach to a 
"harm reduction" model. The basic principle of harm reduction is that 
a 100-percent abstinence rate is unrealistic. Proponents say that 
clean needles are far safer than contaminated ones, access to medical 
care improves users' health, and rehab and counseling are more 
appropriate and effective than jail time.

Officer Tim Broadway of the Reno Police Department said, "The 
attitude has changed over the years in regards to illicit drug use. 
The first priority for us is for the victims. If someone is using 
they're still a victim." He added, "We've seen in today's society, 
you get more bees with honey, when you're an approachable agency. You 
want to get the victims the help that they need." He said that when 
RPD officers arrive in a situation where drugs are being used, 
they're likely to seize the drugs and paraphernalia but, unless 
another crime has been committed, they're more likely to refer 
someone to services than to make an arrest.

Broadway said, "due to the recent arrests with the Ford dealership we 
are working closely with Northern Nevada HOPES, and we do a lot of referrals."

He attributed the shifts in policing policy to the federal 
government's lead and to public perception.

Dr. Karla Wagner, professor in the School of Community Health 
Sciences at the University of Nevada, Reno, connected changes in 
public perception with the rising frequency of overdose deaths. She 
said, "What's changed in the conversation is: 'When everybody I know 
knows somebody [affected.]'"

Wagner added, "I think that one of the things that's important in 
this effort is to normalize conversations around opioid use. It's 
important that we get to a place that we can talk about these risks 
realistically. Where people don't judge."

Spreading effects

Melanie Flores, who works with the Nevada Division of Public and 
Behavioral Health and teaches public health courses at UNR, was one 
of the founding members of PHASA. Back in 2010, she was a grad 
student. Shortly before she started a career in public health, she 
experienced the type of shift in perception Wagner alluded to. Flores 
had been working in local radio. Even though she described the 
industry as having a "sex, drugs, rock 'n' roll culture," at the 
time, she was shocked when friends started using heroin and even more 
shocked when a close friend died of an overdose.

She was also pretty surprised when, after she graduated, a mentor 
suggested she work on harm-reduction legislation.

"I was new. I didn't totally understand it. At first, needle exchange 
sounded like an awful idea," Flores said. She wondered, "Doesn't this 
promote drug use?" She soon became a proponent and ended up writing 
the bill that became Senate Bill 459, the Good Samaritan Drug 
Overdose Act, as her thesis project.

Next for Flores and the rest of the PHASA group came a failed attempt 
at passing the bill, a two-year wait for the next legislative 
session, mountains of research, and testimony from many experts. One 
of them was Chief of Police Ken Ball from Holley, Georgia, where 
police carry Narcan, funded by traffic tickets, and the department 
educates law officers, first responders, high school students and 
prom chaperones in its use.

The second time around, in 2015, SB 459 passed, making it so that a 
drug user could call 911 in an emergency and avoid arrest. According 
to the PHASA members, it's a positive step in policy direction that 
allows more naloxone to get to more places where overdoses are likely 
to occur-and save more lives.

What's next for naloxone?

Currently, naloxone is legally available through Change Point and can 
be prescribed by doctors. A letter sent from state health officials 
to health-care providers in January to explain the new law reads, 
"One important component of the legislation allows first responders, 
family members, and friends the ability to obtain and administer naloxone .."

Proponents are pleased, but they say SB 459 is one of several steps. 
Now, they'd like to see the drug even easier to access. Livernois 
said he'd like to see a standing order from the state's Chief Medical 
Officer that could make naloxone as readily available from a pharmacy 
as a Plan B pill or a flu shot, both drugs that can be purchased 
without a prescription.

The Chief Medical Officer position is officially vacant for a few 
more days. Incoming Chief Medical Officer John DiMuro, who takes the 
post July 1, said, in an email message, "Naloxone is just one 
important piece to the puzzle regarding opiate drug overdose and its 
use should not be taken lightly." He added that he is "in the process 
of exploring standing orders" to ensure that they are safe and effective.

Wagner said, "Having naloxone in the hands of people who are at risk 
and their friends and their family members is the way we can drive 
down death rates." She added that she'd also like to see people 
offered naloxone when they're released from incarceration. During the 
weeks after a person leaves prison, the risk of relapse increases 
drastically. A National Institutes of Health report reads, "One man 
in his mid-forties struggling to stay abstinent from drugs after his 
release: 'You get asked 50 times if you want some coke before you get 
into the [shelter] door.'"

REMSA's Cindy Green said if the decision were in her hands she'd 
favor even wider distribution of naloxone than a standing order would allow.

"It could be available at 7-Eleven," she said. But would that 
arrangement present any drawbacks?

"Absolutely not," she said. "People who do drugs are going to do it. 
You can't stop them, but you can save a life."

Life after addiction

As for Livernois, he's happy to be alive and grateful to be in a 
position to help. He said it takes a lot of effort to stay clean. 
Working at a syringe services, he said, "Every day I'm reminded of 
what I don't want. Every day, past Josh comes in and talks with 
present Josh and reminds him what he doesn't want. And reminds him to 
stay grateful." He remembers often what the employees and volunteers 
at the syringe services facility in Salinas did for him.

"To walk into a place when I was used to basically being invisible to 
the population at large, and have people get to know your name, 
remember who you are, smile at you, welcome you, treat you with 
dignity, it made a huge difference," he said. He also does this job, 
he said, because he needs to. He's rejected a life of prison 
sentences, homelessness and waking up nauseous from withdrawal, but 
he hasn't rejected the people who still struggle with those problems. 
Being part of that community, he said, has been critical to his survival.

"I feel like that's the most important thing that can turn somebody's 
life around," he said. "I don't care if it's Alcoholics Anonymous or 
NA or Jesus Christ or fucking Tupperware or you know, kickball. It's 
finding your community of people that make you feel happy to be 
alive. That's where I found it, in the harm reduction community."
- ---
MAP posted-by: Jay Bergstrom