- The Washington Times - Tuesday, May 1, 2018

Mark Curtis says the first time he nearly died from an opioid overdose, the room service guy found him in his Florida hotel.

Luckily, the paramedics who arrived that day in 2010 carried naloxone, an overdose-reversing drug that few Americans had heard about at the time.

“Had they not had it, I’d probably be dead,” he said.

The second time was in 2014, when a security officer called for help after he found Mr. Curtis overdosing on a bad batch of heroin in a parking garage. The third was in 2016, when a hospital suddenly had to give it to him as he sought treatment for a blood infection from intravenous drug use.

When he came to, a doctor leveled with him, saying he would likely die soon if he didn’t get clean.

So Mr. Curtis got help, beating back an addiction that began accidentally — a hefty supply of prescription opioids for high school surgeries made him feel pretty good, and it was easy to get more pills after he injured himself doing mixed martial arts in college.

Now he volunteers at a Monday night group for people in recovery and, chuckling at the irony, said he recruits health care professionals for a living in Sarasota, Florida.

“I didn’t choose to become a drug addict. Because of those three times I got hit with Narcan, I didn’t die. I have the opportunity to do what I do today,” he said, referring to a nasal spray version of the drug.

Naloxone has taken on almost mythic proportions in the effort to combat opioids. While it can’t address the heart of an epidemic with roots in modern medical practice and rural poverty, it gives people with an addiction the chance to survive an overdose.

Trained professionals use an injectable form of naloxone. Two products are available for general use: Narcan nasal spray and an auto-injector known by the name Evzio, which talks to users and explains how to press it against the thigh of someone who has overdosed.

U.S. Surgeon General Jerome Adams recently advised family members and friends of people at risk of overdosing, or those who are abusing opioids themselves, to carry one of the devices and understand how to use it. Three-quarters of overdoses occur outside of a medical setting, and more than half occur at home.

It was the first national public health advisory issued by the surgeon general’s office in 13 years.

“The surgeon general is spot on. This is exactly the thing to do,” said Dr. Dan Ciccarone, a professor at the University of California, San Francisco, who studies the opioids issue. “The biggest issue is not whether naloxone works. It’s access — timely access to treat an overdose victim. What’s the best access? Household access.”

The Health and Human Services Department said the advisory is paying off. The number of prescription-based retail sales jumped from 9,150 in the week before the announcement to about 9,600 in the week of and to 11,650 in the first full week after the advisory, the department said.

‘Dummy key’ for the brain

Opioids work by attaching to receptors in the nervous system and open them like a key in a lock, releasing a flood of chemicals and activity in the body, said Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse.

Some of those receptors control pain, and they are dulled by opioids. Other receptors control respiration, and opioids slow the breathing process. Too much opioid intake — an overdose — stops or slows breathing to the point that it’s fatal.

Naloxone is an opioid “antagonist” that clears opioids from receptors to restore breathing. Dr. Compton called them “dummy keys.”

“They are keys that fit in the receptors but don’t turn,” he said, effectively jamming the lock and kicking the opioid drugs off the receptors.

It can take multiple hits of naloxone to revive someone who has overdosed. The police chief in Mansfield, Ohio, said one person required 20.

Fentanyl, a synthetic opioid that is flooding the illegal opioid market, can affect the body far longer than heroin and can outlast a naloxone hit.

Naloxone can still be effective, but health officials say a better formulation would help them keep pace with potency.

“We do think we may need a high-potency antagonist, a little different from naloxone,” Dr. Compton said.

The National Institutes of Health last month awarded Opiant Pharmaceuticals a three-year, $7.4 million grant to develop a product known as OPNT003, which tests show may have potency for hours longer than naloxone.

Surging demand

Every Wednesday, residents stream into the Cabell-Huntington Health Department in West Virginia and ask the receptionist where to find “C.K.”

They are looking for Charles Babcock, a clinical assistant professor at Marshall University who runs a short training course in naloxone for the general public. He hands out the overdose-reversing drug at the end of the session.

The program has handed out roughy 5,000 doses of Evzio and Narcan, which were donated by their manufacturers, since it started in February 2016.

“We have people from the community who just want to save people,” Dr. Babcock said.

State and local officials across the country are eager to get naloxone into more hands. West Virginia, which leads the nation in overdose death rates, is hoping to lead the way.

Starting in 2015, it enacted a law that lets people purchase naloxone without seeing a doctor first, and a Good Samaritan law that provides legal immunity to those who administer naloxone to themselves or others after illegal drug use, and then seek help.

In Baltimore, Health Commissioner Leana Wen issued a standing order for naloxone — a blanket prescription for 620,000 city residents — in 2015.

Since then, people administering the drug have saved about 1,800 opioid users, she said.

Baltimore’s health department also distributes naloxone through churches and nonprofit groups, but limited government funding hasn’t caught up with the cost of the drug, Dr. Wen said, even at a discounted rate of $75 for a two-dose kit of Narcan for government purchasers.

“We cleared the path when it comes to policy. The problem that remains is the price,” she said. “We are being priced out of the ability to save people’s lives because we can’t afford it.”

If this were Zika …

The Trump administration said it is doing what it can to get naloxone into more hands with millions of dollars in state grants and donations of 30,000 units of products from manufacturers after the surgeon general’s advisory.

“Fortunately, the majority of Americans see substance use disorder as a public health problem and are supportive of equipping first responders and community members with an emergency treatment for opioid overdose,” said Health and Human Services Department spokeswoman Kate Migliaccio.

Some Democrats say the federal government can do more, either by using its negotiating power to bring down the price of naloxone or posting more taxpayer funding.

A bill pushed by Sen. Elizabeth Warren, Massachusetts Democrat, and Rep. Elijah E. Cummings, Maryland Democrat, would devote $100 billion to the opioid scourge over a decade. That would include $500 million per year for naloxone.

Gary Mendell, founder and CEO of Shatterproof, a nonprofit that seeks to destigmatize opioid addiction and recovery, said the trends are heading in the right direction but addiction still isn’t treated with same type of urgency as other health scares.

“If Zika were spreading around this country, and we had a vaccine that we knew if someone exhibits certain symptoms, they would take that vaccine they would live, and where alternatively, if they didn’t, they would die, the federal government would ship it to every household in the United States,” Mr. Mendell said. “Here, that’s not happening.”

Vermont is trying to set a national example by saturating the public sphere with naloxone. Anyone can walk into a city pharmacy and pay for it, and people who overdose leave the hospital with Narcan in hand in case it happens again.

The state also has 36 sites where people can walk in and get naloxone. The program, funded by a tax on drug manufacturers’ sales through state Medicaid, has expanded from roughly 1,440 kits in 2014 to 6,680 in 2017.

Dispensed doses have been used to revive people at least 1,300 times since the program launched in 2013, based on data collected from people who come back for more doses.

“We’re viewing this epidemic as a community response,” said Jackie Corbally, the opiate policy manager for the city of Burlington who has had her own experience with the lifesaving drug.

A little more than a year ago, Ms. Corbally spotted a 27-year-old woman slump to the ground in a city park.

She delivered two hits of Narcan, which revived the woman.

“Without the Narcan, she would be dead,” Ms. Corbally said.

She used her position to get the woman into treatment.

Like flu and a sledgehammer

Though naloxone is easy for laymen to administer, it’s important to know the signs of an opioid overdose so naloxone isn’t used on people who are passed out from alcohol or are suffering from non-opioid conditions, health officials say.

Also, the revived user will be cranky — they wanted to get high, and now they are in withdrawal — so gratitude is a long shot.

“The response is typically a variety of cuss words in your face, and ‘How dare you touch me,’” Ms. Corbally said.

Dr. Babcock said he tells people to think about how annoying it is to be roused from a deep sleep. Yet people who overdose are experiencing withdrawal, too, feeling like they have the flu and “everyone’s hitting you like a sledgehammer.”

“They won’t know what’s going on,” he said. “Their brain does a reset. Just like a computer.”

West Virginians are required to call 911 after administering naloxone so the revived person can get advanced care.

Huntington will deploy quick response teams within 72 hours after an overdose to try to get people into treatment. The city said 19 of 35 people it reached in January opted to go into treatment.

Permission to use?

Dr. Ciccarone, the professor in San Francisco, said the surgeon general’s advisory shows how far the country has come in its views of drug addiction, since programs like needle exchanges to prevent the spread of HIV/AIDS were controversial.

“Fifteen years ago, when we were distributing to users, it was very questionable to do that,” he said. “Now, everyone can talk about it.”

Critics feared it would lend an imprimatur to drug use, perhaps encouraging more.

For naloxone, questions of whether it poses a moral hazard are persistent.

A study released in March by economists at the University of Virginia and the University of Wisconsin looked at states that increased access to naloxone versus those that did not. It found that broadening access “led to more opioid-related ER visits and more opioid-related theft, with no reduction in opioid-related mortality.”

The study ignited a firestorm online. Defenders of the research said critics didn’t like the findings. Naloxone advocates countered that the study confused causation with correlation during a worsening crisis.

A landmark Massachusetts study from 2012 found that giving naloxone to bystanders decreased overdose deaths. A study published last year by the National Bureau of Economic Research said states that adopted naloxone access laws showed a 9 percent to 11 percent drop in opioid-related deaths.

Officials in Vermont said their overdose death numbers appear to be flatlining. They credited increased treatment services and more naloxone.

Kenneth Coontz, chief of police in Mansfield, said a 44 percent drop in overdose deaths from 2016 to 2017 is likely attributable to that same combination of naloxone and early intervention, though numbers are creeping up this year as powerful fentanyl enters the market.

Many people on the front lines of the epidemic flatly reject the idea that naloxone invites people to use.

“Without being politically correct, that’s bulls—t. Never once did I use because, well, there’s Narcan out there,” Mr. Curtis said. “The addiction is so strong, I’m using whether there’s Narcan or not.”

Ms. Corbally said it’s difficult to draw broad conclusions about behaviors because addiction is “so individualized. “

For some people, one overdose will scare people into taking steps for treatment, but Ms. Corbally said she knows of a man who overdosed seven times in 14 days and had no interest in getting help.

“With any social crisis, you’re always going to get people who have that thought: ‘This is now a safety mechanism. I have a buddy who has Narcan,’” she said. “I do think, though, it’s not as simple as that, and that’s a very small group, frankly. I don’t think this is giving people permission [to use].”

Coordinators in the Huntington area say fewer people in their communities question the value of naloxone today than they did several years ago, in part because of the sheer number of users who are dying. Everyone knows someone who has been affected by the crisis, so they are more likely to see the drug as a way to help folks who aren’t bad people, even if they have bad problems.

“You get more bees with honey than you do with vinegar. Treating people like a human being shouldn’t be a forgotten thing in our society,” Dr. Babcock said. “As we reduce the stigma, more and more people want to help.”

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