Building a Ground Army to Fight Heroin Deaths

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A sign for a Baltimore overdose reversal program. To stem the death toll in the opioid epidemic, cities and states, as well as the federal government, are promoting greater use of the overdose rescue drug naloxone. (The Pew Charitable Trusts)

This story has been updated to reflect North Dakota’s good Samaritan law.

BALTIMORE — A crowd quickly gathers here on one of West Baltimore’s many drug-infested street corners. But it isn’t heroin they’re seeking. It’s a heroin antidote known as naloxone, or Narcan.

Two city health department workers are holding up slim salmon-colored boxes and explaining that the medication inside can be used to stop someone from dying of a heroin overdose. Most onlookers nod solemnly in recognition. They’ve heard about the drug. They want to know more.

Nationwide, more than 150,000 people received naloxone kits from community outreach programs like Baltimore’s between 1996 and 2014, and more than 26,000 overdoses were reversed using those kits, according to a recent survey funded by the U.S. Centers for Disease Control and Prevention.

In addition, police, emergency medical technicians and emergency room physicians have used the drug to save tens of thousands of lives. Baltimore police officers started carrying the kits last year.

But as the opioid epidemic seeps into nearly every small town and suburb across the country, state, local and federal officials are trying to make the life-saving prescription drug available everywhere, particularly at local pharmacies.

To accomplish that, New Mexico last week became the 29th state to adopt a law that allows doctors and other prescribers to write a naloxone prescription known as a standing order, enabling local pharmacists to distribute the overdose rescue drug to anyone who asks for it.

Maryland adopted a similar measure in October. The day after it took effect, Baltimore’s health commissioner, Dr. Leana Wen, wrote a standing order for the entire city, allowing anyone who completed a simple naloxone training — like the demonstration offered on the West Baltimore corner last week — to walk into a pharmacy, show a certificate of completion, and walk out with a kit.

“I like to say I became the prescriber-in-chief,” Wen said.

New Mexico’s new law updates a 15-year-old law that allowed lay people to administer naloxone. In addition to allowing standing orders, the new measure allows people without a medical license to distribute naloxone kits in their communities, a legal provision found only in Maryland and 12 other states. This exception allows jails, treatment centers, homeless shelters and others to hand out the drug. Even the local PTA could offer it.

“It needs to be in everyone’s first-aid kit and medicine cabinet,” Wen said.

Kits Stats

A Nationwide Movement

Forty-two states have enacted laws to make naloxone available beyond hospitals. New Mexico, which has had one of the highest drug overdose rates in the country for more than two decades, was the first to act with its 2001 law.

After more than a decade, Massachusetts in 2012 became the second state to enact a law. Most other states adopted so-called rescue drug measures in 2014 and 2015 after the opioid epidemic began making headlines.

This year, “States are going back and expanding or tweaking their laws,” said Amber Widgery, who tracks these and other drug related laws at the National Conference of State Legislatures.

Thirty-one states also have adopted so-called good Samaritan measures, which give limited legal immunity to a bystander or friend who calls 911 to report an overdose. Those laws also need to be expanded, said Corey Davis, an attorney who tracks the laws for the Network for Public Health Law.

In Maryland, for example, the law only protects overdose bystanders from being arrested, charged or prosecuted for possession of a controlled substance or use of drug paraphernalia. It does not protect them against arrests for open warrants or probation and parole violations, which are common among heroin and opioid addicts. As a result, residents of West Baltimore or other communities where drug use is prevalent may be unwilling to call 911.

In addition to state and local actions, initiatives at the federal level are picking up. Last week, the U.S. Senate passed a comprehensive opioid addiction and overdose prevention bill that would expand the use of naloxone, and the U.S. Department of Health and Human Services announced additional funding for naloxone and other drug treatment services.

Reversal Map

A 'Miracle' Drug

The majority of opioid overdose victims die from lack of oxygen one to three hours after they have taken a drug, leaving a substantial amount of time for someone to intervene and administer naloxone or call for help.

Naloxone, approved by the U.S. Food and Drug Administration in 1971 in injectable form and widely used as a nasal spray, is a relatively cheap generic drug that has been proven safe and effective at reversing the deadly lung suppression that can cause a fatal overdose. Once the drug is administered, most victims instantly begin breathing again; they also experience nausea and other withdrawal symptoms.

But until the late 1990s, naloxone was only used, intravenously, in hospital emergency departments and operating rooms. Even emergency medical personnel and other first responders did not use it initially.

In 1996, a community group in Chicago that provided clean needles and other assistance to drug addicts began handing out naloxone as a nasal spray as well. Later, similar pilot programs began cropping up in places like San Francisco and New York.

When people began coming back and reporting that they had saved a life with naloxone and wanted another kit, researchers took notice. Eventually, these and other programs handing out naloxone caught the attention of federal and state officials, said Daniel Raymond, policy director for the Harm Reduction Coalition, which advocates for the greater availability of naloxone and other health care services for drug addicts.

In 2006, Massachusetts began using naloxone in public health and social service centers. Along with New Mexico, it funded statewide distribution of the life-saving medication in communities with large numbers of known drug addicts.

But in other parts of the country, naloxone initiatives were limited and mainly local. Then in 2012, the FDA, along with the National Institutes of Health and the CDC, convened a meeting with state and local officials to discuss ways to expand availability of the drug nationwide. Initially, some objected to making naloxone widely available, arguing that it would simply enable more drug addicts to continue shooting up.

Now that more Americans are dying of heroin and prescription painkiller overdoses than from homicides — roughly 28,000 people in 2014 — that argument rarely comes up. Politicians from both parties vigorously support the use of naloxone. Along with increased access to treatment and safer opioid prescribing, expanding the use of naloxone is among the Obama administration’s top three weapons against the epidemic.

Baltimore’s commitment to naloxone began when the health commissioner, Wen, took office, in January 2015. Since then, the department has distributed nearly 6,000 kits to city residents. In addition, the department launched an online training site, dontdie.org, last month. Wen said she plans to work with local pharmacy chains to make it easier for people to walk in, get trained, and leave with naloxone.

Reversal Line Graph

More Work Needed

In February, the pharmacy chain Walgreens announced it had used state standing order authority to make naloxone available without a prescription across New York and would do the same in Indiana and Ohio. Pharmacy chain CVS made a similar commitment in Ohio.

But advocates for greater use of the overdose reversal drug worry that most local drugstores won’t stock the drug or supply it on demand. They also fear that pharmacists won’t allow people to use their insurance plans to pay for it.

According to Davis, the public health law researcher, insurance companies are on board with covering the drug. But, because people with naloxone prescriptions won’t be using the drug on themselves, many pharmacists appear to be worried they won’t get reimbursed for, essentially, a third-party prescription, the claims for which are traditionally rejected by insurance companies.

Baltimore has negotiated a $1 copay with the state Medicaid agency and private insurance companies have generally agreed to cover it, Wen said.

Even in Massachusetts, where standing orders have been allowed for years, not all pharmacies stock the medication and not all pharmacists know about it, according to Dr. Alexander Walley, medical director for the state health department.

“We have the legal pathways but not the implementation experience, yet, to make it as successful as policymakers had hoped,” he said. “We’re in the steep part of the learning curve right now.”

From their folding card table in West Baltimore last week, Daryl Mack and Darryl Burrell handed out 15 naloxone kits in less than a half-hour.

After witnessing friends, family members and strangers die on these streets from overdoses, most onlookers seemed eager to try to prevent at least one fatality.

Speaking one-by-one to each person who wanted a kit, Mack emptied the contents of a box onto the table and quickly demonstrated how to assemble and activate the tiny nasal atomizer used to squirt naloxone into an overdose victim’s nostrils.

You’re not going to harm someone who’s unconscious by giving them naloxone, he told them. And you can’t give them too much. But first, try to make sure they’re not just sleeping or passed out from alcohol, Mack said. Rub your knuckles up and down their chest bone to try to wake them up. If that doesn’t work, they need help, he said.

Maryland is the only state that requires anyone using naloxone to complete a brief training, Davis said. Several people who approached the table already knew the drill and were there to get refills. They also got a copy of Wen’s standing order so they could pick up additional kits at their local drugstore if needed.

One passerby heard the word “heroin” and waved the health workers away, saying, “I don’t have nothing to do with that stuff.” But when Mack explained that he could save someone’s life, the elderly man stopped and signed up.

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