BALTIMORE — Deep into a three-day heroin binge at a local hotel, Samantha told the newbie he was shooting too much. He wasn’t accustomed to heroin, she said, and hadn’t waited long enough since his last injection.
“But he didn’t listen,” she said. Sure enough, he emerged from a visit to the bathroom, eyes glazed, and collapsed from an overdose.
Samantha, who declined to give her last name to avoid trouble with her bosses at a nearby strip club, said she grabbed her naloxone, the fast-acting antidote to opioid overdoses. She was too panicked to place the atomizer on the end of the syringe, but her boyfriend wasn’t. He sprayed the mist into the nose of the unconscious drug user, who awoke minutes later.
“I always have it because I’m scared to death,” said Samantha, who said she has been shooting heroin for 22 years. “I don’t want to be helpless.”
As the opioid epidemic has exploded in small towns and suburbs in recent years, officials have scrambled to put naloxone in the hands of drug users’ families and friends, and to make it more widely available by equipping police officers with the drug.
At the same time, thousands of lives are being saved by giving the antidote to drug users. More than 80 percent of overdose victims revived by “laypeople” were rescued by other users, most of them in the past few years, according to one national survey published in June.
Baltimore has trained 12,000 people on the streets to use naloxone in the past 11 years, 2,150 of them this year alone. “If someone is using a drug that could kill them, they should also have the antidote available,” said Leana Wen, the city’s health commissioner. Chicago, New York and San Francisco also hand out thousands of doses to drug users at little or no cost.
But the rising number of rescues also highlights the shortcomings of what is, at best, a stopgap effort. With treatment for addiction available to a small portion of the people who need it, many people who survive overdoses return to drug use. Some first responders express frustration at reviving the same people again and again without hope of permanent change.
In Charleston, W.Va., where President Obama spoke about the opioid crisis last month and rescue personnel have carried naloxone for decades, Fire Capt. Mark Strickland said he has revived one 34-year-old man six times and other drug users three and four times each.
“I can’t just take everybody to the hospital,” Strickland said. “ . . . There has to be a ‘What next?’ ”
The drug’s cost also is beginning to influence anti-heroin strategy. The price of a nasally administered dose of naloxone — often known by its brand name, Narcan — has quadrupled in two years or less in many places, to nearly $50. Federal, state and local officials are pressing for discounts from Amphastar Pharmaceuticals, the only supplier of that form of the drug.
New York and Ohio have succeeded. In San Francisco, the major nonprofit distribution program for drug users has begun using cheaper injectable naloxone instead.
“No company should jeopardize the progress being made in tackling this emergency by overcharging for a critically important drug like naloxone,” Rep. Elijah E. Cummings (D-Md.) and Sen. Bernie Sanders (Vt.) said in a July letter to groups that represent U.S. mayors and counties.
Amphastar officials did not return e-mails and telephone calls seeking comment on the price increases.
Deaths from heroin overdoses quadrupled to 8,260 between 2000 and 2013, according to the federal government, as did deaths from prescription opioids, which reached 16,235.
The number of people revived by naloxone is difficult to determine, but the Harm Reduction Coalition, a training and advocacy group, published a survey in June showing that 26,463 people had been revived by “laypersons” between 1996 and the first half of 2014. Nearly 83 percent of those rescues were made by other drug users.
More than 8,000 people were revived in 2013 alone, according to the coalition’s data, which covers only half of the organizations that distribute naloxone. Almost 38,000 kits were handed out to laypeople that year. These rescue efforts overwhelmingly involve people who have taken heroin, not prescription drugs.
“Drug users are the primary witnesses to drug overdoses,” said Eliza Wheeler, program manager for the coalition’s drug overdose prevention and education effort in San Francisco, who compiled the report. “This was about putting the effective tool into people’s hands.”
Baltimore started handing out naloxone in 2004, mostly through its needle-exchange program, eight years after the approach was pioneered in Chicago. Baltimore now makes it available to all residents via a prescription signed by Wen, the health commissioner, who is a former emergency room doctor. Drugstores sell it for a dollar to anyone on Medicaid. The city also trains soon-to-be-released jail inmates and others on the use of naloxone.
The only requirement for carrying it is a five-minute training course, like the one Samantha took recently in the back of the city’s needle-exchange van, parked by a seedy row of strip clubs, porn shops and food outlets known as “The Block.” A steady stream of drug users stepped into the small recreational vehicle to trade used needles for new ones, pick up condoms and register for a card that prevents police from arresting them for carrying drug paraphernalia.
Samantha was there for more naloxone. On this night, the city was handing out kits donated by the company Kaleo that sell for $575 apiece. About the size of a pack of cigarettes, the recently approved device contains two doses administered through an auto-injector, with audio instructions on how to use it.
Health educator Nathan Fields ran through the signs of an opioid overdose: slowed or nonexistent breathing; blue lips, skin and nails for whites or a grayish pallor for African Americans.
Anthony Williams was first in line that night, although he said he doesn’t use heroin. “I’m an alcoholic. I drink,” he said. But he lives in an abandoned building with several heroin users, he explained, including one who is going through a rough time.
“When you’re in a space, living with people [who] any moment they can go overdose and die, this is a very life-sustaining issue,” Williams said.
People revived by naloxone can flail or vomit when they awake, Fields warned Williams, and they will plunge immediately into the painful symptoms of withdrawal.
“That person will usually jump up, and the first thing he’ll say is what?” Fields asked.
“You f---ed up my high!” Williams responded, and they both smiled.
Naloxone hydrochloride, approved by the Food and Drug Administration in 1971, has long been carried by rescue personnel and used in emergency rooms. It works only on opioid overdoses, reversing them by blocking the receptors in the brain where opiates attach. Overdose victims usually resume breathing and awaken within minutes.
Baltimore officials long ago rejected the notion that widespread distribution of naloxone encourages drug use by prompting recklessness among drug abusers. And they are not troubled about helping “frequent fliers,” because research and experience show that relapses are common, even with treatment.
“You want to keep the person alive,” said Derrick Hunt, director of the city’s Community Risk Reduction program, “until they make better choices.”