Trying to Prevent Heroin Deaths One Shot at a Time

By Jean Marbella, The Baltimore Sun

Robert Taylor Jr., and Camille Haviland thought they were being safe—within the bounds of their dangerous heroin habit, that is.

Having bought from a new dealer, Taylor tried just one capsule instead of his usual three or four. Haviland left on an errand; when she returned 15 minutes later, she found him collapsed on the ground, bluish and not breathing.

She started CPR. When paramedics arrived, they injected Taylor with the overdose-reversing drug, naloxone.

"At the time, I would have liked to have had this," Haviland said recently after she and Taylor were trained and certified to administer the drug themselves. "I've had a lot of friends die because people just left them."

Maryland health officials, desperate to stem an 88 percent rise in heroin overdose deaths from 2011 to 2013, have launched an initiative to put naloxone into the hands of addicts, their families, police and other nonmedical personnel.

Heroin in particular is taking a toll: Of the 848 people in Maryland who died of drug or alcohol intoxication last year, 464 overdosed on heroin. The grim trend continues this year: In the first three months, the most recent for which statistics are available, 148 of the 252 who died had used heroin.

The city and region have struggled for decades with high rates of heroin addiction, but fatalities are on the rise here, as elsewhere in the country, as purer forms of the drug, or formulations that include another potent opioid, fentanyl, become more widely available, health officials say.

As a result, states increasingly are turning to naloxone, also known by its brand name, Narcan, which reverses overdoses of heroin and other opioids such as oxycodone, but not of cocaine and other drugs. In 2012, then-federal drug czar Gil Kerlikowske called for broadening naloxone's availability, saying that for some addicts it could be "the difference between life and death."

During the 2013 Maryland legislative session, families of addicts who had died of heroin overdoses pleaded their case to lawmakers and won unanimous approval for a measure allowing nonmedical personnel to be trained to administer the drug and receive a prescription for it.

Taylor and Haviland are two of the roughly 2,200 people who have been certified to use naloxone since health departments and other groups began offering classes in March.

Still, the measure remains controversial in some quarters.

Critics say the new program, like those that distribute clean needles, encourages heroin addicts to continue using by reducing the consequences.

"It exacerbates the problem because people think they can overdose [and] 'someone can bring me around,' " said Israel Cason, the former heroin addict who has run the treatment program I Can't We Can in Park Heights for 17 years. "They're only treating the symptoms. They're not dealing with the problem."

But Maryland Health Secretary Dr. Joshua M. Sharfstein said naloxone is an important component of a larger strategy to cope with the flood of more powerful heroin, often mixed with fentanyl, that has sent the rate of fatal overdoses skyrocketing.

There is no evidence in existing research, Sharfstein said, that making the antidote available increases drug use.

"People use for all sorts of reasons," he said. "The fact that they have naloxone available is not a contributing factor.

"Heroin just destroys people's lives completely. What keeps them in recovery is not just the fear of death, it's losing their family, their house, everything."

Taylor and Haviland, who attended a class at the Howard County Health Department in Columbia last month, started methadone programs during the winter and say they are committed to their recovery. They say having naloxone in their apartment in Laurel gives them a sense of security in case of an emergency.

"I hope I never have to use it," Haviland said. "We both have a lot of goals now. We're just tired of getting high. We want a life, we want something better."

Naloxone works by attaching itself to the same parts of the brain that receive heroin and other opioids, and reversing the effects of the drugs.

At the class, Bethany DiPaula, an associate professor at the University of Maryland School of Pharmacy, demonstrated how to use the device that vaporizes the naloxone into a nasal spray. Naloxone can also be injected into a muscle. DiPaula has also trained prison inmates near release so that they can take the antidote home with them. Having naloxone available, she believes, does not encourage drug use.

"Naloxone puts them in withdrawal. They're not going to want to do that," she said. "It saves people's lives. For people who have an overdose, it's so traumatic, it can lead them to treatment."

While some in the class work with addicts or were addicts themselves, others simply wanted to learn a new skill.

"It's a wonderful thing to know you're not helpless," said Dorothy Keener, the health assistant in the county's school system.

When the Anne Arundel Police Department decided its 400 officers would carry naloxone, some had "mixed emotions," said Cpl. Nicholas Tackett, a 12-year veteran.

"It's not normally something police handle," he said. "But our job is to help people."

It took only a couple of months this year before Tackett put his new skills to use. He was around the corner from a home in Brooklyn when the occupants called 911 about someone banging on the garage door. When they opened the door, they said, they found a man collapsed on the other side. They pulled him inside and onto a couch. Tackett, having seen more than 100 overdose victims over the course of his career, said he recognized the symptoms immediately.

"They get a bluish-gray tint to the skin, the fingers," he said. "The breathing is shallow, their pulse is almost nonexistent—you feel your own before you feel theirs. They're very clammy and sweaty."

He retrieved his naloxone kit and was able to squirt the drug into one nostril then the other before paramedics arrived. The man survived.

A month later, Tackett again arrived before the Fire Department to help an overdose victim. Tackett found the woman unconscious on a bed, a spoon and needle on a table nearby, and administered naloxone.

"This person woke up and started crying," Tackett said. She thanked him for saving her.

Tackett's two rescues are among nine his department has made since officers started carrying naloxone in March, said Lt. T.J. Smith, a department spokesman.

The Maryland State Police, Frederick County and Carroll County sheriffs and other law enforcement agencies have also started training and equipping officers. In Baltimore, where last year 150 people died of a heroin overdose, police do not carry naloxone; a spokeswoman said the department is reviewing how other agencies use it.

Smith said the Anne Arundel Police Department realized its officers often arrive at an overdose scene before paramedics, especially in rural areas. By last week, county officers had responded to 252 opioid overdoses this year, or about one a day on average, he said. Thirty-three were fatal.

He's heard the argument that people who use drugs knowingly risk their lives and should accept the consequences, even if that means death. He rejects it.

"Our job is not to do a background check on an individual who is a victim" of an overdose, Smith said. "These are human beings, they've made bad decisions—is that worthy of a death sentence?

"We don't just stand there and watch people die."

In 2001, New Mexico became the first state to expand access to naloxone. It was followed by 23 others, including Maryland, and the District of Columbia, according to the Network for Public Health Law.

The Baltimore Health Department, the first agency in the state to launch a naloxone program, has been training drug users, their families and friends, prisoners and others who might come into contact with overdose victims since 2004. The city's Staying Alive Program has trained more than 11,600 people and dispensed more than 5,100 units of naloxone. Program officials have documented about 220 overdose reversals but say they believe the actual number is higher because people don't always tell them when they have used naloxone.

The drug costs about $30 per dose, Sharfstein said, and the state has budgeted about $200,000 for the training program this year and $500,000 next year. The money comes from state and federal sources.

To date, those trained under the new program have successfully treated 12 overdose victims, according to the state. Sharfstein said it is too early to tell whether the training programs are reaching the right people or if the self-reporting of its use is accurate.

Twenty-nine health departments and other groups are authorized by the state to teach the class and certify graduates. Typically, graduates go home with two doses of naloxone and devices to administer them. They take the class and get the drug for free.

Earlier this summer, the woman who launched the effort to expand access to naloxone in Maryland helped train a group of people who, like her, had lost a loved one to heroin addiction.

Toni Torsch of Perry Hall found her son overdosing in his bedroom in 2010. By the time paramedics arrived, he was dead.

"I don't know if it would have saved Dan," she said. "That's hard to accept."

It was only after her son's death that she learned about naloxone. She started a local chapter of the national support network Grief Recovery After Substance Passing, or GRASP, and conducted a naloxone training program before the group's regular monthly meeting in July.

It was too late to help the sons and daughters they'd lost to heroin, but some had other children and relatives who still were using.

They arrived at a church hall on Joppa Road, across from a cornfield, a bucolic setting that seemed an unlikely front in the battle against heroin. But it has been a long time since heroin was solely an inner-city, and black, problem as was its reputation.

State statistics show that 69 percent of those who died of a heroin overdose last year in Maryland were white. And while Baltimore still had the most heroin fatalities—150 of the 464 victims last year—no part of the state has been untouched. Frederick County, for example, saw the number of heroin deaths double from 2012 to 2013.

Inside the church hall were a CPR dummy, syringes, tiny vials of a clear liquid and a basket of oranges. GRASP members learned how to uncap the vials, insert the needle, draw out the naloxone and inject it—into the oranges for practice that night, perhaps into an arm, thigh or buttocks of someone overdosing on heroin or other opioids someday in the future.

Some had never handled a syringe before and fumbled a bit.

"You can go right through a shirt," they were told by Dr. Christopher Welsh, a University of Maryland psychiatrist who specializes in substance abuse. "And don't worry about a bubble in the syringe," he said, because they weren't injecting into a vein.

"It's not like 'Pulp Fiction,'" Torsch said, referring to the scene in that movie when Uma Thurman's character is brought back to consciousness with a giant, stabbing injection of adrenaline to her heart. "It's not that dramatic."

The group of about 14 people listened mostly silently as Torsch and Welsh led the class. There were nods and sighs of recognition as they took in the all-too-familiar information about the symptoms of an overdose.

One woman, who asked that her name not be used, said she had lost one daughter to heroin and another was in rehab. She said the training gave her a sense of a little bit of power over a situation she largely feels powerless to fix.

"It's peace of mind," agreed Torsch, speaking to the support group members. "And, hopefully, you won't have to use this."

http://www.baltimoresun.com/news/maryland/sun-investigates/bs-md-heroin-narcan-naloxone

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