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ALTIMORE — After two decades of sending a needle exchange van around this city, officials here last year started doing something new. They wouldn’t just hand out clean syringes; they would distribute the antidote to the opioid overdoses ravaging local communities.

When the van rolls through Baltimore these days, a member of the city’s health department teaches newcomers how to deliver naloxone, the life-saving medication that can reverse the effects of an opioid overdose, and gives them a free kit containing two doses.

Similar scenes are playing out at recovery centers, school orientations, and town meetings around the country as communities try to prevent fatal opioid overdoses, which quadrupled in the past decade and a half. Once a tool found mainly in ambulance and emergency departments, naloxone is increasingly being offered to the masses without prescriptions. Some advocates liken knowing how to use naloxone to knowing how to perform CPR, granting someone the opportunity to save another’s life.

“It’s been this gradual process to expand the presence of this drug in the community so it can be available when needed,” said Scott Burris, the director of the Center for Health Law, Policy, and Practice at Temple Law School.

Naloxone outtreach
A naloxone spray, provided by the needle exchange van, is assembled.
Naloxone outtreach
Harris, left, trains others how to use naloxone in the van.

In May, the Ohio Department of Health launched an advertising campaign complete with billboards encouraging people to carry naloxone. Fort Lauderdale, Fla., recently changed its health plan so that insurance policies covered naloxone for city employees and their family members. Inmates in states from North Carolina to New Mexico are being given naloxone kits when released from prison.

And in the past year, North Carolina and Pennsylvania joined the growing list of states with standing orders for naloxone — blanket prescriptions that allow residents to pick it up at a pharmacy without a prescription of their own.

For at least two decades, advocates have pushed to get naloxone to people with drug addictions and their families, and in recent years, campaigns have focused on equipping police forces with the antidote. Those groups remain the main audiences for the efforts.

But some initiatives are also trying to reach people regardless of whether they use opioids or know someone who does, just in case they find an overdose victim passed out in a car, unconscious in a restaurant bathroom, or dying on their own front lawn. Training sessions now include security guards, parking enforcement, and ordinary community members.

Naloxone outtreach
A Baltimore City Health Department needle exchange van in West Baltimore.

Here in Maryland, a change in state law allowed municipalities to issue their own standing orders, and Dr. Leana Wen, Baltimore’s health commissioner, signed one last year. Since the order took effect last October, the city has conducted about 15,000 training sessions for lay people, Wen said. The city also has an online training program.

“I have Narcan in my bag right now, because you never know,” Wen said in an interview, using one of the drug’s brand names.

In 2001, New Mexico changed its laws to make naloxone easier to get, and since then, every state except for Kansas, Montana, and Wyoming has altered policies to improve access to naloxone, according to the Network for Public Health Law. Many states allow people to get prescriptions if they are not the intended user and provide some legal immunity to people who call 911 and administer naloxone even if they have illegal drugs on them. Now advocates are pushing health officials in more states to sign standing orders.

“It might not be a friend or family member, but it might just be a person passed out at the bus stop,” said Evan Hoessel of Albuquerque Health Care for the Homeless, who has done trainings for church groups.

Overall, the policies helped increase the amount of naloxone distributed by retail pharmacies by more than 1,100 percent from the end of 2013 to the middle of 2015, according to a 2015 study from US health officials. The Centers for Disease Control and Prevention recommended this year that doctors consider offering naloxone when they prescribe opioids for pain if certain risk factors exist, such as prior substance abuse or if the dose is particularly high.

Shirley Buntain, a mother of four in Louisville, Ky., got trained to use naloxone last summer because she has a son who uses illegal substances. But she said she may have to save others as well and carries naloxone in a backpack wherever she goes.

“I trained for him, but I also trained for the people who didn’t want to admit that their child had a problem,” said Buntain, 54, an office manager at a machine shop. “I went from being a mom who carried an EpiPen for a bee allergy to being a mom who carries an antidote. It’s not a place I ever imagined being in.”

Naloxone outtreach
Training sessions in the delivery of naloxone nasal spray last just a few minutes.

Naloxone, which was first approved by the Food and Drug Administration in 1971, works by blocking opioids from acting on receptors in the brain and reverses the depressed breathing caused by overdoses. It is either sprayed up the nose or injected into a muscle, and rescuers sometimes have to use several doses to revive someone.

Even if it were used on someone who had not overdosed on opioids, naloxone has few side effects and is itself not addictive. It does, however, produce acute withdrawal symptoms, and many people who are revived wake up agitated and “dope sick.”

“That shit works wonders,” 30-year-old Andrew Chamberlain said one day last month as he left the needle exchange van here with clean syringes. “By the time you put in the second [dose], they’re jumping up.”

Chamberlain said he had used naloxone several times in the past year on fellow drug users and got refills of the drug at methadone clinics, among other places.

“I’ve used it three times in the past week,” chimed in a woman standing on the sidewalk, which was littered with needle caps. “Once in that alley, once in that alley over there,” she said, pointing to alleys into which some people vanished after they stepped off the van.

The woman, combing her soaking wet hair, added: “I’ve had it used on me.”

The FDA says it is working with naloxone manufacturers to take the steps to make the antidote available over the counter, so even a standing order wouldn’t be needed. The agency also launched a contest last month for people to develop an app that could connect people who overdose with people nearby who are carrying naloxone.

(Whether naloxone manufacturers want to apply to make naloxone available over the counter is a different story. One of them, Kaleo Pharma, told STAT it has no plans to get its naloxone auto-injector approved for over-the-counter use.)

Critics of wider access to naloxone argue that it encourages people to keep using drugs. They also note that it doesn’t get at the root of drug addiction: It saves people from overdoses, but it doesn’t prevent them.

“Naloxone does not truly save lives; it merely extends them until the next overdose,” Maine Governor Paul LePage wrote in April when he vetoed a bill that would have made it easier to get naloxone (the legislature overrode the veto).

Naloxone outtreach
People who are trained to use naloxone receive a card so they can get refills at local pharmacies.
Naloxone outtreach
A man leaves the needle exchange van after getting clean syringes and learning how to use naloxone.

Public health advocates say such views reflect the stigma against people struggling with addiction; they also note that overdoes are often caused when users inadvertently take heroin laced with more potent opioids like fentanyl or carfentanil.

But even if naloxone did encourage riskier behavior, experts say that it saves far more people than it could ever endanger. Cities and states report hundreds of lives saved each year. A recent survey of 140 organizations found that lay people had reversed more than 26,000 overdoses from 1996 to 2014; more than 80 percent of the people who saved someone with naloxone were fellow drug users.

Karen Johnson of Louisville, Ky., learned how to use naloxone one night last year at a drug information seminar. Her son was in rehab at the time, but until then, she had never heard of Narcan.

Just two weeks later, her son was back home and overdosed. She injected him with the naloxone in the leg as he was turning blue — “I stabbed him hard,” she said — and saved his life. She now keeps the nasal spray at home.

“It’s just a hell world, being thrown into the world of addiction,” she said. “I’m sure there’s all sort of mixed reviews about naloxone, but it is definitely something I will always have.”

Naloxone manufacturers have donated thousands of doses to communities and offer discounts to first responders, but the rising cost of the drug — combined with the rising need — has forced some programs to cut back on what they can buy.

Emily Metz, who coordinates a naloxone training program in the Cleveland area, said the price of the nasal spray the program purchased has gone from $12 to $30 per dose in recent years. The program is switching to an injectable version it can buy for about $12.

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In Baltimore, the health department is now paying $37.50 per dose compared with $25 last summer. Every kit given out at the needle exchange costs the city $75.

For the people picking up the kits from the city’s van, the drug can prove invaluable.

On a recent afternoon, those who came through for their one-on-one trainings all paid close attention, nodding along and saying a comprehending “OK” as the instructor demonstrated each step on a manikin.

As one man prepared to leave the training, clean needles and a naloxone kit in hand, he said: “Hopefully I don’t have to use this stuff.”

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  • What’s next? Handing out free heroin?

    Seriously, this is not the way to solve the problem. You have to cut the source of the drugs off. That means preventing them from entering the country in the first place. Second, remove incentives for living this way and increase opportunities to straighten out their lives. There will always been some people who will turn to drugs no matter what, but most people end up there to escape the reality of their lives of hopelessness.

    Passing out a “get out of death free” card in the form of a drug isn’t saving anyone’s lives. It is only prolonging their inevitable death and giving people the idea that heroin is no longer dangerous because some miracle drug can always bring you back. Which of course will increase usage.

    This is completely irresponsible, I don’t care how “well intentioned” it may be.

    • Some thoughts:

      “Remove incentives for living this way”: I’m a researcher on opiate addiction, and spend lots of time interviewing people who have had their lives ruined by drug use. I challenge you to find a single person who enjoys “living this way” or who uses drugs for “incentives” that we offer. No one chooses to become addicted.

      “Increase opportunities”: I could not agree more. As you note, drug use so often stems from a desire to escape the realities of life in poverty. Programs focused on increasing education and offering alternatives to people who are at risk for drug use are what will help.

      “A ‘get out of death free’ card in the form of a drug isn’t saving anyone’s lives”: Tell that to the man I talked to last week who was revived by naloxone 15 times during the course of his addiction. He has currently been sober for 3 years, has a full-time job, and volunteers helping parents deal with their child’s opiate addiction. You wouldn’t deny a diabetic insulin, despite the fact that many diabetics will eventually die of complications of the disease.

      You and I agree that no one should use drugs. But to say that we shouldn’t be protecting those who use drugs, often the most vulnerable members of society, is to undermine their humanity. That’s the first step down a very dangerous road.

    • When it’s your daughter or son that you go to the morgue to identify in a body bag, I am willing to bet that your sentiments will be slightly shifted. That one extra chance or that one last overdose may be might have been the one that ultimately saved her life and opened up the opportunity to get clean. If your child is dead however, you will simply never know but instead would be constantly reminded by the emptiness that you felt drugs shouldn’t exists (though they do and will, regardless of our efforts), and that a second or 10th chance is unwarranted, making an overdose response drug unavailable to your dead child simply because you personally have had no serious drug addiction of your own and don’t understand those that do.

  • The heroin epidemic is indicative of health care crisis: Too many people who make irresponsible choices are getting too much of our health care resources.

    Free Narcan for drug addicts, purchased by cities and municipalities for first responders like police and EMS, has driven up demand, 1100% since 2007. And with increased demand comes increased price.

    Many addicts have been resuscitated multiple times in pursuit of their illegal behaviors. Yet they are rewarded by taxpayer funded services to resuscitate them.

    What other crime is the perpetrator rewarded?

    This is not a sustainable business model.

  • The comparison of Naloxone to CPR is ridiculous. Every person who receives resuscitation with Naloxone has broken the law against possession and/or selling a controlled substance. Yet we provide first responders with a medication, at public expense, to resuscitate them. Some heroin users have been revived multiple times because they purchased impure heroin or heroin laced with fentanyl.

    What other crime do we reward criminals? What’s next compensating criminals for stealing cars or breaking into homes?

    • The public has long been rewarding the criminals by re-electing them to violate the highest law of the land, the U.S. Constitution 8th and 9th amendments, with their junk statutes prohibiting heroin and other drugs (thus denying a relatively safe source by creating the contraband market with its adulterated powders).

      Remember that an amendment was required to prohibit the manufacture, sale and transportation of alcoholic beverages.

      The drug “laws” are junk statutes. Those voting for them are the criminals.

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