City Paper is not for tourists
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 life-saving 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 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 distributed 125 boxes each—at no cost—to HIPS and FMCS in the spring, explains Travis Gayles, a chief medical officer at DOH. Gayles authorized the necessary standing order for the program, which applies exclusively to these two organizations and only offers intranasal naloxone.
“It’s another frustration that they’re not looking at a standing order that encompasses all types of naloxone,” Clay says. “Injection works for our population, and it’s less expensive [than intranasal].”
According to Andrew Bell, a HIPS manager, the nonprofit’s outreach workers learned in June, by word of mouth, of 33 overdose deaths. But in the period that the group dispensed naloxone via the pilot, they reported more than a dozen successful opioid reversals. “To say [it] would cause an incentive [for opioid abuse] is a really difficult conversation to have with a mother who just lost her child in an preventable death because [naloxone] wasn’t available,” Bell says.
Drug-related fatalities are often avoidable. Adam Visconti, a family medicine resident enrolled in a joint Georgetown University-Providence Hospital program, says working with opioid patients convinced him that naloxone was “safe and effective.” Visconti has been dispensing the drug for more than five years—first from his home city of San Francisco and now at a clinic in Maryland. There, a statewide standing order lets physicians prescribe naloxone to third parties, provided that they are certified under an “overdose response program” introduced in 2014. Because the clinic is right across the border, Visconti encounters many Washingtonians.
“After Prince overdosed, I had a lot of people who were like, ‘What’s this naloxone thing?’” he recalls. But he can’t provide it to non-Maryland residents. “It’s unfortunate when I have to tell someone, ‘You live in D.C. as opposed to Maryland.’”
Some doctors are concerned about prescribing medication to people who are not their patients and whom they’ve never seen, Visconti says. But most of the drug’s doses aren’t self-administered by overdose victims. That’s why Visconti testified in support of a bill proposed in February by Ward 7 Councilmember Yvette Alexander that would carve out liability protections for pharmacists and physicians who prescribe naloxone. Alexander’s Committee on Health and Human Services held a public hearing about the legislation in March but took no action before the Council’s summer recess. Attorney General Karl Racine also testified in favor of the bill.
“I haven’t seen people become more risky from prescribing naloxone,” Visconti says. “From a humanistic perspective, you can’t help people—and get them better—if they’re dead. You could make the same argument that wearing bike helmets encourages people to ride more recklessly.”
With six councilmembers provisionally signed on to the proposal, proponents are optimistic it will eventually pass. But a few expressed consternation that DOH seemed unwilling at the time to go all-in on expanding access to naloxone beyond the most at-risk users. “There is no clear evidence that broad availability to untrained individuals is the next necessary step in the District of Columbia,” Michael Kharfen, a senior deputy director at DOH, told lawmakers at the hearing.
Boecker, of the Drug Policy Alliance, characterizes DOH’s apparent timidity toward broadening Narcan availability as “mind-boggling.” She cites a 50-percent jump in naloxone use by D.C. EMTs between 2013 and 2014 as well as the presence of standing orders in most U.S. states as reasons to permit third-party prescriptions. More than 130 organizations at 644 sites across the country distributed naloxone kits to 150,000-plus laypeople between 1996 and 2014, according to a 2015 study, leading to at least 26,000 reversals of opioid overdoses.
“DOH could be more innovative and progressive with their adoption of reduction measures,” Boecker says. “And they could treat this as more of an emergency. I have had a feeling the ongoing death of drug users isn’t rising to the point of an emergency, as it absolutely should.”
In a June report on 2020 health goals, the District ranked “substance use” seventh on a list of 13 priority areas. (It placed “mental health and mental disorders” first, above “injury and violence prevention,” and “access to health services.”) Under this category, it identified drug deaths and hospitalizations as troubling developments. But nowhere in the report is naloxone mentioned.
Gayles says the agency’s pilot is patterned after Massachusetts’ rescue-kit program, noting that each jurisdiction “does it differently,” and D.C.’s epidemic “looks a little different than elsewhere.” He says DOH is restocking naloxone based on the first supply, but this time the agency will “order more kits to keep in-house as backup,” so there isn’t another lapse for its community-based partners. New provisions procured for HIPS should arrive by the end of July, DOH told the nonprofit last week.
Diane Jones, director of special programs at FMCS, says her group hasn’t run out of intranasal Narcan (a few boxes were left on Monday), though it could soon. “We’re not at panic point yet,” she says, adding that the group is “on target” to meet client needs. FMCS received its training and kits roughly one month after HIPS did, she says. It’s now tracking successful reversals.
Both groups were pleased when DOH informed them earlier this month that it was extending the pilot program for another three years, until 2019. Gayles says the decision was driven by the unexpectedly “high demand” for naloxone at its partner sites. “And that’s a good thing,” he notes. “If the word is out in the community, people are getting education on it.”
As the program progresses, Gayles says DOH will analyze best practices, and that the agency remains open to ideas about the best way to dispense naloxone. It’s also considering town-hall-style meetings on opioids and the signs of overdose. The agency is part of a multijurisdictional opioid task force along with OCME, the Metropolitan Police Department, the FBI, and other partners.
But activists worry that the extension of the pilot could stall more robust action, such as bringing other nonprofit and private partners into the fold, or backing needle- and injector-administered doses. Some are concerned that gaps in supply will persist, despite assurances.
“When we couldn’t receive anymore, it was terrible,” recalls Maurice Abbey-Bey, a D.C. native who supervises the mobile syringe exchange at HIPS. “Deaths. ‘Such-and-such sister died. You know Mike, that got the three children? He sit on the step and died. Man, if I woulda had the Narcan, I could’ve saved him. I called the ambulance… but I could’ve saved him.’”
If the trend in overdoses seen through April endures until the end of the year, 2016 would surpass 2015 in fatal opioid overdoses. “A lot of mothers wearing black because of this, a lot of funerals,” Abbey-Bey says. “I’ve seen a lot of mothers crying, and it’s not just one group.”
“You can tell there’s a need for them to do more,” his colleague Alvin Wynn explains of the government’s obligation to mitigate the crisis. “[The deaths] are still occurring.”
Gayles acknowledges that overdoses have worsened year-over-year, in part because fentanyl and synthetic cannabinoids have penetrated supply chains. As for the prolonged pilot program’s budget, he says “there’s no monetary value per se,” although DOH has pledged to match needs.
“We have to reconfigure [our initial strategy of targeting those at the highest risk] to reach the most people and make it the most cost-effective,” Gayles says. “What [that] scale-up looks like—we don’t know quite yet, because this is a starting point.”
Asked whether the roll-out of the pilot so far has persuaded officials to issue a statewide standing order, Gayles responds, “I would say there’s no change in the current [DOH] position.”
In the meantime, many relatives and friends of opioid users in D.C. will have to wait. Some are grateful they have access to a drug that can mean the difference between life and death.
David, for one, says he’s “safe” with his supply of naloxone.
“Life is more important than getting high for the moment,” he reflects. “Life is much more important.”