Pubdate: Sun, 31 Jul 2016
Source: New York Times (NY)
Copyright: 2016 The New York Times Company
Author: Katharine Q. Seelye


PORTLAND, Me. - A woman in her 30s was sitting in a car in a parking 
lot here last month, shooting up heroin, when she overdosed. Even 
after the men she was with injected her with naloxone, the drug that 
reverses opioid overdoses, she remained unconscious. They called 911.

Firefighters arrived and administered oxygen to improve her 
breathing, but her skin had grown gray and her lips had turned blue. 
As she lay on the asphalt, the paramedics slipped a needle into her 
arm and injected another dose of naloxone.

In a moment, her eyes popped open. Her pupils were pinpricks. She was 
woozy and disoriented, but eventually got her bearings as paramedics 
put her on a stretcher and whisked her to a hospital.

Every day across the country, hundreds, if not thousands, of people 
who overdose on opioids are being revived with naloxone. Hailed as a 
miracle drug by many, it carries no health risk; it cannot be abused 
and, if given mistakenly to someone who has not overdosed on opioids, 
does no harm. More likely, it saves a life.

As a virulent opioid epidemic continues to ravage the country, with 
78 people in the United States dying of overdoses every day, 
naloxone's use has increasingly moved out of medical settings, where 
it has been available since the 1970s, and into the homes and hands 
of the general public.

But naloxone, also known by the brand name Narcan, has also had 
unintended consequences. Critics say that it gives drug users a 
safety net, allowing them to take more risks as they seek higher 
highs. Indeed, many users overdose more than once, some multiple 
times, and each time, naloxone brings them back.

Advocates argue that the drug gives people a chance to get into 
treatment and turn their lives around and that there is no evidence 
naloxone increases the use of opiates. And, they say, few addicts 
knowingly risk needing to be revived, since naloxone ruins their high 
and can make them violently ill.

With drug overdoses now killing more people than car crashes in most 
states, lawmakers in all but three - Kansas, Montana and Wyoming - 
have passed laws making naloxone easier to obtain. Its near-universal 
availability reflects the relatively humane response to the opioid 
epidemic, which is based largely in the nation's white, middle-class 
suburbs and rural areas - a markedly different response from that of 
previous, urban-based drug epidemics, which prompted a "war on drugs" 
that led to mass incarceration, particularly of blacks and Hispanics.

This more compassionate response has been on display this week at the 
Democratic National Convention in Philadelphia. Speakers there have 
talked about addiction and the need for more accessible treatment, 
and a call by Senator Jeanne Shaheen of New Hampshire for all 
emergency responders to carry naloxone drew applause from the delegates.

Nonprofit organizations began distributing naloxone to drug users in 
the mid-1990s, but most of the state laws making it more accessible 
have been enacted only in the last few years. Between this and 
so-called good Samaritan laws that provide immunity to people who 
call 911 to report an overdose, the chances are much greater now that 
someone who overdoses will be saved and given medical attention 
instead of left for dead or sent to jail.

The federal government still requires a prescription for naloxone, 
but that is under review by the Food and Drug Administration, which 
has also approved a Narcan nasal spray that is easier to administer 
and is growing increasingly popular.

There is no question that the nation's death toll from heroin and 
prescription opioids would be significantly higher without naloxone. 
Prince, the pop superstar, is just one of those who were saved by it. 
After he overdosed on Percocet, an opiate painkiller, on his airplane 
in April, the plane made an emergency landing, and he was revived on 
the tarmac with naloxone - only to overdose on fentanyl six days 
later and die when no one was around to administer naloxone.

In 2014, in Maine alone, 208 people died from overdoses. That year, 
emergency responders saved 829 lives with naloxone. But that was just 
a fraction of those saved here, as most uses go unreported. In 83 
percent of cases, according to a national survey last year by the 
Centers for Disease Control and Prevention, naloxone is given by 
other drug users, the people most likely to be on the scene, not by 
emergency responders.

But in Maine this spring, Gov. Paul LePage, a Republican, questioned 
the effectiveness of naloxone and vetoed legislation that would have 
increased access to it.

"Naloxone does not truly save lives; it merely extends them until the 
next overdose," Mr. LePage wrote in his veto message in April. 
"Creating a situation where an addict has a heroin needle in one hand 
and a shot of naloxone in the other produces a sense of normalcy and 
security around heroin use that serves only to perpetuate the cycle 
of addiction."

Yet most users loathe naloxone's effects. By blocking opiate 
receptors, it plunges them into withdrawal and makes them "dope 
sick," craving more heroin or pills.

"I hate it," said Melissa Tucci, 44, a heroin user here who has been 
revived seven times. "When I start withdrawing, I vomit, you get 
diarrhea, you sweat profusely, your nose will run, you sneeze and 
have runny eyes, and you ache so bad you can't even walk."

She said she has overdosed so often not because she relied on 
naloxone to save her, but rather because she underestimated how 
potent the heroin was. And she said she keeps using heroin to avoid 
the agony of withdrawal.

The Maine Legislature easily overrode the governor's veto. According 
to the Network for Public Health Law, Maine is now one of 34 states 
with what is called a standing order, essentially a prescription that 
makes naloxone available to the general public.

Still, Mr. LePage gave voice to the troubling reality that some 
people repeatedly overdose, and can seem stubbornly resistant to help.

"They're usually very angry when we bring them around," said Deputy 
Chief John Everett of the Portland Fire Department. "One kid yelled 
at me, 'You think this will make me stop doing drugs?' I said, 'No, 
the only thing that will make you stop doing drugs is a body bag.'"

On the other hand, Sarah Connolly, 26, said she was alive because of 
naloxone. Seven years ago she was revived after overdosing in the 
bathroom of a Burger King in Michigan. "Most of my veins were so 
deteriorated from using that they had to give it to me in my hand," 
she said recently at a training session here on how to administer 
naloxone. She said that after overdosing, she left an emergency room 
against medical advice and went out to find more heroin.

She continued to use heroin, but stopped cold when she became 
pregnant. Now she is unrecognizable from her days of addiction. She 
moved to Maine, married her son's father, is pregnant with their 
second child, and is studying to be a high school English teacher.

"I have a real sense of purpose now," she said. "I believe I'm a 
miracle because I had a second chance."

Gov. Tom Wolf of Pennsylvania, a Democrat, said in a recent interview 
that the only responsible approach to the epidemic ravaging his state 
was to make naloxone widely available and provide more treatment. 
Pennsylvania is one of the states with a standing order for naloxone.

"This is a disease, not a moral failing," Mr. Wolf said.

Dr. Alexander Y. Walley, an addiction medicine specialist at Boston 
Medical Center, said arguing that naloxone encourages riskier drug 
use was like saying that seatbelts encourage riskier driving.

"A person with an opioid use disorder is by definition using despite 
harmful consequences," Dr. Walley said. That aside, he said, 
"receiving naloxone not only reverses the overdose, it also reverses 
the euphoria and withdrawal relief that the opioid user is seeking. 
Thus, it is only used as a last resort."

Dr. Mark Publicker, an addiction medicine specialist in Portland, 
said that repeated overdoses were often the result of increasingly 
potent heroin, especially when combined with drugs like fentanyl and 
sedatives, producing a lethal cocktail.

"While your psychological tolerance becomes greater, your 
cardiorespiratory tolerance doesn't," he said. "You keep pushing the 
limit because your reward threshold has become impossibly high."

Naloxone can start to wear off 20 to 30 minutes after it is 
administered and dissipate entirely after 90 minutes. The withdrawal 
from the opiate can be so brutal that it often drives people to use 
heroin again right away.

"I had a woman who overdosed three times in one day," said Zoe 
Odlin-Platz, a community health promotion specialist at the India 
Street needle exchange here. After the third overdose, she said, the 
woman broached the possibility of seeking treatment.

The bigger problem, advocates say, is the dearth of available 
treatment, particularly for people without insurance. Nevertheless, 
Portland paramedics make every effort to take revived drug users to a 
hospital, and hope that in those moments after being revived, they 
might decide to seek help.

"People are vulnerable at that point, and I ask them if they want to 
talk," said Oliver Bradeen, a substance use disorder liaison for the 
Portland Police Department, who responds to most emergency overdose 
calls. And, he said, "sometimes the universe comes together and it works out."

But sometimes it doesn't.

Bruce Carleton, a veteran paramedic with the Portland Fire 
Department, was among those who responded last month when the woman 
in the parking lot overdosed. He talked her into going to the 
hospital, but when he went by her room later on, her bed was empty.
- ---
MAP posted-by: Jay Bergstrom