View attachment 51340 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 brought back to life 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, 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 was 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 is 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.
By Katharine Q. Seelye - The NY Times/July 27, 2016
Photos: Tristan Spinski, nyt
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