DistrictLine One-Hit Wonder
This affordable opioid antidote prevents overdose deaths. Why doesn’t D.C. have enough of it? By Andrew Giambrone RighT befoRe The world went dark, David thought it was all going to end. The native Washingtonian had gotten high at a friend’s house with prescription painkillers and a street drug containing opioids. It wasn’t his first time: Now in his 50s, David started using narcotics recreationally when he was a senior at Dunbar High School. But the blend of substances he took a couple months ago produced a stronger effect than any marijuana, heroin, or methamphetamine he’d ever used. “It was one of the scariest moments in my life because I never overdosed before,” says the Northwest resident, who asked to be identified only by his first name. “I never went out like that, and I’ve been using for a long time— over 25 years. I was unaware of my surroundings, I was incoherent, I didn’t know my head from my tail.” “But,” he adds, “when they shot me with that Narcan, it brought me back to reality.” David is referring to the brand name of a wonder drug whose chemical name is naloxone. An antidote or “antagonist,” it binds to opioid receptors in the brain, effectively blocking the effects of drugs like morphine and Oxycodone, which can depress respiration or shut down a person’s central nervous system. While naloxone may lead to withdrawals in users who are physically dependent on opioids, it has no risk of abuse itself. Since his scare, David has participated in a pilot program the D.C. Department of Health quietly launched in April. Through it, he’s been given two naloxone doses that he stores in a “safe place” at home and occasionally keeps in his shoulderbag. “It’s quite handy: easy to carry, and to use,” he explains of the device used to administer the drug, both manufactured by Adapt Pharma. Were he to use opioids and feel a loss of consciousness coming, David could shoot the spray into one of his nostrils, and it would work within a minute, if properly done. He could also administer it to someone else at risk of an overdose.
“I haven’t had to, thank goodness, but I know the fentanyl is on the streets,” David says, alluding to a synthetic drug that resembles heroin but can be up to 50 times more potent. Suppliers have increasingly adulterated dope with fentanyl in the past few years, unbeknownst to buyers down the distribution chain. That’s resulted in more opioid overdoses, even among experienced users. Already, though, DOH’s potentially lifesaving pilot program appears to be a victim of its own success. On June 21 (after just two months), HIPS—a community-health nonprofit based on H Street NE—ran out of their supply of the antidote, which DOH had provided for free. This year, as fatal opioid overdoses are on course to exceed numbers from previous years, clients asking for intranasal naloxone are being told to wait. Despite the nonprofit requesting more during the third week of May and the first half of June, DOH didn’t confirm that it had initiated a resupply until June 13. Even then, HIPS staffers note, the details regarding when it would arrive were hazy. “We were very frustrated by the holdup of getting naloxone into the hands of people where it can save their lives,” says Cyndee Clay, HIPS’ executive director. “We’re grateful for what [the government] has done, but we’re frustrated by the inability to make [the drug] easier to access.” NaloxoNe has beeN around for almost as long as David has. Pharmacologists developed it in the 1960s, when a heroin epidemic hit U.S. cities hard, and users frequently ended up in emergency rooms. The antidote can enter the body in three main ways: intravenously, intramuscularly (with a needle or an autoinjector), or intranasally (with a spray). Its price has jumped amid a rash of opioid deaths. Nationally, more than 28,000 people died from opioid abuse in 2014—a record, according to the Centers for Disease Control and
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Prevention, and an increase of 14 percent from the year before. Deaths from opioid overdoses have quadrupled since 2000, and those stemming from heroin (in excess of 10,500) have tripled since 2010. In some places like Austin, Ind., which saw a rash of HIV infections last year, the abuse of prescription drugs has precipitated more prevalent syringe use. In the District, new data from the Office of the Chief Medical Examiner shows that there were 83 opioid-related overdoses in 2014, 114 in 2015 (an increase of roughly 40 percent), and 47 in the first four months of 2016 alone. March was especially pernicious: With 18 fatal overdoses, it was the deadliest month in five years. David, who worked from age 16 until last year, is one face of D.C.’s opioid problem. Based on a 65-day surveillance period conducted in 2015, the majority of the city’s heroin users are older than 50, with men outnumbering women four to one. Eighty percent of those studied were black, 15 percent white, and two percent Hispanic. One in five were recorded as having no fixed address, suggesting they were experiencing homelessness or unstable housing situations. OCME’s stats, which cover Jan. 1, 2014 to April 30, 2016, indicate that Wards 7 and 8 have been disproportionately affected by overdoses, followed by Wards 5, 6, and 4. Ward 8 residents saw at least 50 drug deaths during that period. “That paints a bit of a picture for you of who we’re talking about,” says Kaitlyn Boecker, an analyst at the Drug Policy Alliance, which has a D.C. office. “Frankly, it also paints a picture about why there haven’t been larger cries [for reform]. We need to take this problem seriously no matter who’s affected.” Like many others who have overdosed, David believes his life was saved “in the nick of time.” The friend he’d taken drugs with immediately called for an ambulance when David passed out, allowing him to get treatment
at Prince George’s Hospital Center. D.C.’s “good samaritan” laws protect overdose witnesses with limited legal liability so they will be more likely to report emergencies. Others haven’t been as fortunate. David says he knows at least 15 people who died this year from opioid overdoses, some involving fentanyl. He’s attended about 10 funerals so far in 2016. “I was very close with several of them,” he says. “The last funeral I went to was one of my best friends, Mark, who was 56. It was so sad because they left him to die in an apartment building... It really hurt me so bad.” ThaT was a little over a month ago. In April, DOH trained employees from HIPS and Family and Medical Counseling Services, which is based in Anacostia, to administer intranasal Narcan to their clients as part of the pilot program. Last year, a coalition of advocacy groups had pressed the department to develop what’s known as a “standing order.” This legal mechanism permits physicians to prescribe naloxone to third parties who are in a position to aid at-risk opioid users. The rationale behind standing orders is that social service agencies and loved ones often know best when users need immediate medical attention. Emergency responders can be slow to arrive on the scene of an overdose, and the vicissitudes of addiction are such that users don’t reliably seek direct prescriptions from doctors. In 2015, D.C. Fire and Emergency Medical Services treated patients with naloxone 1,737 times, up from 1,523 in 2014. In the first half of 2016, FEMS used it 224 times a month on average, compared to 133 times a month on average in 2015. Through the pilot, David got his Narcan from HIPS, where he volunteers weekly. Adapt Pharma sells the boxes for $75 per pack to government agencies, school districts, and health nonprofits, based on “public-interest pricing.” DOH procured 250 boxes (or 500 doses) and