City Paper is not for tourists
Every three or four days, John Matthews travels from his neighborhood in Southeast D.C. to the clinic at Bread for the City on 7th Street NW, in Shaw. There, he must wait in line, see a doctor, and get a prescription for the same drug he picks up on each visit. It’s an inconvenient errand, he says, but Bread for the City is effectively the only place in the metro area where he can easily acquire naloxone, an overdose-reversing drug that, he says, he’s seen used to save at least 50 lives in the past four years.
Matthews, a heroin user in his 40s who agreed to speak on the condition that we use a pseudonym, lives in an area where drug overdoses are common. For the past four years, he’s taken it upon himself to keep naloxone on hand when he visits the streets, parks, and hubs of drug use where overdoses are likely to occur. Matthews teaches others how to administer it, he says, and takes people with him on his frequent trips to pick up more naloxone.
“It’s common to have somebody there monitoring who can give [naloxone],” Matthews says. Federal and local laws restricting the distribution of the drug, however, make it difficult to keep supplies of naloxone in places where it’s needed most.
“There’s too many stipulations,” Matthews says. “We have people dying.”
Naloxone is an opioid antagonist that was developed in the 1960s. It bonds to the opioid receptors in the brain without activating them, cutting off the effects of opiate drugs. Commonly known by the trade name Narcan, naloxone is carried by first responders, EMTs, and paramedics. It can be administered, in different formulations, intramuscularly, intravenously, or subcutaneously with a syringe or via an intranasal atomizer.
When given to someone who is overdosing, naloxone sends the body into instant withdrawal, triggering vomiting, physical pain, and other unpleasant symptoms. Matthews, who was once administered naloxone during an overdose, describes coming back from unconsciousness as a burst of new life but feeling miserable and no longer high.
“They’ll be mad as hell, but they’ll be alive,” Matthews says.
In places such as Massachusetts and New York state, naloxone has been made available without a prescription through what is called a “standing order.” Friends and family of opioid addicts, as well as other people likely to be around when an overdose occurs, are now able to buy or acquire naloxone kits with comparatively less hassle.
In D.C., creating a standing order for naloxone could allow more people like Matthews to acquire the life-saving drug and keep more on hand.
Following an April 2014 meeting with community health advocates, officials with the D.C. Department of Health expressed an intention to create a standing order modelled on the Massachusetts program. More than a year later, those advocates, as well as some of D.C.’s drug users, say they are still waiting for the city to follow through.
Nationwide, overprescription and abuse of painkillers is leading to rising numbers of drug overdoses. Forty-four people in the United States die every day from opioid overdoses; the drugs include heroin and prescription painkillers such as oxycodone and morphine, according to the Centers for Disease Control and Prevention. In 2013, more than 16,000 people died from overdosing on prescription painkillers, and around 8,000 people died from heroin overdoses.
At least sixty people died in D.C. of heroin, morphine, or methadone overdoses in 2013. The city doesn’t include data on deaths caused by prescription opioids, such as oxycodone, in the Chief Medical Examiner’s annual report.
Naloxone can be obtained in D.C. like any other prescription drug. Each time a user needs a new supply, he or she must go to the doctor and then to the pharmacy, where he or she is required to receive training in recognizing the signs of an overdose and administering the drug.
“Nobody’s getting it that way,” says Matthews. “Doctors will ask questions, want to know why you need naloxone. Users are afraid of being reported.”
Gerald Sabb, a community health nurse at Bread for the City, agrees that the stigma can keep people from seeking naloxone. Working with the nonprofit’s needle exchange, Sabb trains clients to use naloxone and, with the approval of their staff medical doctor, gives out rescue kits, which include two doses, from a private examining room in the clinic. He says he can’t imagine people wanting to stand in line and be trained to use naloxone in front of strangers at a regular pharmacy.
Bread for the City runs one of the District’s needle exchange programs and has the only clinic in the city where naloxone is prescribed and dispensed on site. They are still required to train clients to properly administer the drug, but compared to a normal pharmacy, the clinic offers a degree of privacy and anonymity. Bread for the City tracks the numbers of syringes and naloxone kits distributed through the needle exchange and requires clients to fill out paperwork. But clients’ names—which Bread for the City admits could be false—are never associated to the numbers.
In 2014, Bread for the City gave out just 95 naloxone kits. In the same year, the city’s three needle exchange programs supplied intravenous drug users with more than 700,000 sterile syringes.
Paramedics and EMTs in D.C. carry naloxone kits, and DOH reported a 50 percent increase in Narcan use by first responders between 2013 and 2014. The District’s “good samaritan laws” are intended to protect drug users present at an overdose from prosecution and encourage them to report overdoses. But Matthews says that even when drug users call 911, response times are often too long.
Ward 7 Councilmember Yvette Alexander, who chairs the D.C. Council’s Committee on Health and Human Services, says she knows the city has an issue with opioid drug abuse but does not believe the problem is as bad as in other jurisdictions. Still, she would be supportive of a standing order for naloxone if research shows it’s been successful in other cities, she says.
“We wouldn’t want to encourage risky behavior, but we want people to get all the help they can get,” Alexander says.
Sabb and Matthews agree with the latter point: The more people with regular access to supplies of naloxone, the more lives can be saved.
“There’s very little risk, it can’t do any harm,” Sabb says. “It can only help.”
In March of this year, U.S. Health and Human Services Secretary Sylvia M. Burwell issued a statement encouraging expanded use of naloxone as a strategy to combat rising numbers of opioid overdose deaths. The number of organizations in the U.S. that reported to the CDC providing naloxone kits to “laypersons” expanded from 48 in 2010 to 136 in 2014, according to a June report.
The Food and Drug Administration has been considering making naloxone available over-the-counter since at least 2012, but some states and cities have taken steps to expand access to the drug on their own.
In March 2014, then-Massachusetts Gov. Deval Patrick declared a state of emergency and led public health officials in the state to create a standing order for naloxone rescue kits. Under this policy, pharmacists in Massachusetts are able to sell kits without a prescription.
(Although nonprofits like Bread for the City provide the drug at no cost, over-the-counter costs can vary widely—and the price of the drug is rising. In D.C., where naloxone is covered by Medicaid as a physician-administered drug, the 80-percent rate of reimbursement for the injectable form of the drug will increase from $2.44 to $34.20 this August.)
A month after Patrick declared the state of emergency, Michael Kharfen of D.C.’s Department of Health met with Cyndee Clay, executive director of health- and social-services nonprofit HIPS, and Grant Smith of the Drug Policy Alliance about creating a standing order for naloxone modeled on Massachusetts’ program. Also in at the meeting was Dr. Walley Alexander, the medical director of the Boston Public Health Commission’s Opioid Treatment Program, who helped develop Massachusetts’ naloxone standing order.
Smith says DOH seemed interested in creating the standing order at the time of the meeting, but he never heard anything more about it.
“It is perplexing that in a jurisdiction of this size with such a problem with heroin and other drugs that we have that we don’t have more overdose resources in place,” he says.
Clay says she expected a standing order to be included in DOH’s request for applications for its 2015 needle exchange program. “Be we’ve been waiting forever and haven’t heard anything,” she says.
She hopes that a standing order would allow HIPS to begin distributing naloxone in their facility as well as through their mobile service vehicles, which take their needle exchange and other services directly to people who can’t travel to their location in Brentwood.
Meadhbha Monaghan, a former Global Health Corps fellow working with HIPS, says a standing order would also allow HIPS’ “secondary exchangers” to distribute naloxone with relative ease. Secondary exchangers are well-connected, trusted individuals who distribute clean syringes in their communities.
Creating peer-based models of distribution for naloxone like this would “empower addicts to take their health into their own hands, rather than infantilizing or punishing them,” Monaghan says.
Kharfen, who is senior deputy director of DOH’s HIV/AIDS, Hepatitis, STD, and Tuberculosis Administration, says the department is still intent on creating the standing order based on the Massachusetts program. (DOH determined that expanding naloxone access could be done administratively through the standing order model, rather than legislatively through the Council.)
The delay stems from a staffing issue, Kharfen says, as DOH has been struggling to hire a new medical director for his administration, a role that Kharfen says is needed to oversee the implementation of a naloxone standing order.
“The commitment is still there to move forward,” Kharfen says. “We just need this critical component, the medical director.”
But in the streets and parks, the need for more naloxone seems urgent to Matthews. Heroin mixed with fentanyl, an anesthetic upwards of 15 times more potent than heroin, is becoming more common in the District, he says. Fentanyl looks just like a dose of heroin, but carries an increased risk of overdose and requires higher doses of naloxone to rescue a user from an overdose.
“It’s turning dealers into serial killers,” says Matthews. “We’ve got a lot of people dying who could have been saved if we had more Narcan.”