Why are modern cars equipped with airbags? Because, unfortunately, accidents happen — not to all drivers, but certainly to many.
The vehicles owned by perfect drivers have airbags. The vehicles owned by careless drivers have airbags. Airbags are not just an accessory of the irresponsible. They are widely accepted security measures for all.
Many public-health advocates dream of a day when the powerful overdose-reversal drug naloxone will be perceived the same way.
“It’s not you,” says Traci Green, the deputy director of the Injury Prevention Center at Boston Medical Center. “The airbags in your car are not [there] because you’re a crappy driver.”
Green and other medical professionals want to shift public perception away from demonizing intravenous drug users and toward keeping them safe.
In one 24-hour period this past April, Pittsburgh police responded to 10 heroin overdoses. And last year, more than 250 people died from heroin overdoses in Allegheny County.
The accessibility of naloxone could reduce that number. When administered to an individual suffering from an overdose of heroin or other opioids, naloxone reverses the overdose.
The drug, commercially known as Narcan, is available as a nasal spray, an intramuscular injectable or an intravenous injectable.
“It blocks the receptors in your brain that opiates attach to,” says Alice Bell, the overdose-prevention program coordinator at Prevention Point Pittsburgh. “If your body is dependent [on opioids], you’re going to feel [like you’re] in withdrawal.”
A state law, known as Act 139, that allows first responders and families and friends of intravenous drug users to carry naloxone, went into effect in November 2014. And in April, Gov. Tom Wolf’s administration announced that funds had been raised to ensure that Pennsylvania State Police troopers are equipped with the drug.
While the act was a breakthrough, there are still barriers preventing naloxone from getting into the hands of those who need it most. The cost can be prohibitive; pharmacies and pharmacists are still adapting to administering the antidote; and more training is necessary to ensure that opiate users are aware of the benefits of the medication and how to use it. These factors stand in the way of making naloxone the widely accepted airbag of intravenous drug users.
Few legal barriers exist between naloxone and those who could benefit from its use and availability. With a prescription, an at-risk individual can acquire it. And Act 139’s “Good Samaritan” provision provides immunity from prosecution for individuals reporting overdoses.
Moreover, on May 20, Karen Hacker, director of the Allegheny County Department of Health, issued a standing order for naloxone in Allegheny County. Under this provision, individuals can acquire naloxone in the form of nasal spray at participating pharmacies without a prescription.
But so far, only 14 pharmacies in Allegheny County have opted to participate. While advocates say it’s not complicated for pharmacies to distribute naloxone, they are required to take a number of steps.
“They need to have [naloxone] on site at the pharmacy,” Hacker says. “We ask them to provide a pamphlet, and we recommend that they have the training that the state offers.”
And those aren’t the only requirements. The nasal spray covered by the county’s standing order requires assembly, which creates extra steps for naloxone providers and users.
“That requires the pharmacy to stock naloxone, stock the syringes that naloxone goes in and stock the atomizer,” says Corey Davis, a lawyer with the National Health Law Program, a group that advocates for the health rights of low-income and underserved individuals and families.
Advocates say the exclusion of injectable naloxone from the standing order also fails to cushion buyers and users from the drug’s variable prices.
“For a long, long time, intranasal was more expensive than intramuscular,” says Green, who has helped develop first-responder naloxone toolkits and training. “Then it switched, because there were shortages of the injectable and the actual cost of naloxone itself went up substantially.”
Recently, “the price of these devices, of the intranasal for example, has skyrocketed,” says Janie Simmons, the creator of GetNaloxoneNow.org.
For those with health-care coverage, the fluctuating price is not a problem.
“Many of the states have it covered,” Green says. “Medicaid is really encouraging naloxone to be covered on every state formulary. A lot of the private insurers tend to follow suit.”
However, says Bell from Prevention Point, “For people with no insurance or a high co-pay on their insurance, the intramuscular is going to be a lot more affordable for them.”
Additionally, the unstable price of naloxone creates a considerable obstacle for organizations like Prevention Point, which has been providing free naloxone to intravenous drug users for more than 10 years. Prevention Point Pittsburgh is the only community organization in Pennsylvania, outside of Philadelphia, that engages in syringe exchange and naloxone distribution.
“We’ve given naloxone to over 1,600 people and have had over 1,300 documented [overdose reversals],” says Bell.
Funding such an operation is no easy feat. Two-thirds of the program’s funding comes from private donations and grant money. And currently, federal and state governments are not providing funding for naloxone.
“Because [the prices have] not been consistent, it’s been one of the single most difficult things for community organizations to handle,” says Green. “We’ve had shortages in the past — it will probably happen in the future.”
In addition to working to put naloxone in the hands of intravenous drug users and their families and friends, public-health advocates are seeking to increase access to naloxone training.
Simmons, a researcher with the nonprofit National Development and Research Institutes, in New York, responded to many states’ calls to require naloxone training by creating a short instructional course that both EMTs and laypeople can complete online. She intends to collect data from users of GetNaloxoneNow.org to evaluate its helpfulness, and says that since November the website has reached 8,000 individuals nationally.
“There’s a lot of people dying from prescription overdoses, people who are using alone, who are isolated from other people who are using, and we need to reach those people. And the way to reach those people is not through the traditional channels,” Simmons says. “They’re not going to syringe exchanges. They’re not going to harm-reduction sites. They might not even be going to community agencies.”
Getting opiate users trained on how naloxone can prevent overdose death is also key to making sure more people are taking advantage of the drug. And it’s important for users and their families to have the antidote before an overdose occurs, because if you have to go get it at the time of an incident, it’s too late.
This information is also important for pharmacists, who have one of the best chances of engaging with drug users visiting the pharmacy to purchase syringes. Green says pharmacists should be trained to offer naloxone on a more regular basis.
“Store by store, we visited pharmacies in a community to ask them to offer it to literally everyone coming in purchasing syringes, to offer them naloxone directly,” says Green.
Pharmacists are particularly suited for increasing access to naloxone for several reasons. “They understand the pharmacology of what is happening in addiction,” Green says. And of the nearly 3,000 pharmacists she has trained in naloxone distribution, Green says, many “understand that this is no different from other chronic diseases in many respects.”
And public-health advocates say an understanding of the effects opiods have on users is important for pharmacists and others who may be helping users transition out of rehabilitation or incarceration.
“There is a lot of potential for death reduction by focusing on incarcerated populations, people leaving detox, and people who are transitioning from the emergency departments after having been medically treated for an overdose,” says Green. “Those instances and those transition points we know are very high-risk.”
For example, periods without opioid use lower an individual’s tolerance. Thus, a typical amount used before a period of detox could be a fatal amount after.
This kind of knowledge can be life-saving for an opiod user coping with addiction. But it’s difficult for public-health advocates to stay on top of the epidemic when the opiod drugs on the street are in constant flux.
“The challenges that we have now are not the challenges that we had yesterday,” says Green. “Five years ago, we were dealing with prescription opioids and a little bit of heroin, and now we are dealing with a lot of heroin and a little bit of prescription opioids.”
For instance, batches of fentanyl-laced heroin have entered the supply in Allegheny County, causing almost two dozen deaths in 2014. New developments like these leave the public-health community struggling to get ahead of this deadly issue.
But part of that effort also involves changing perceptions about users. Advocates say this includes a commitment to recognizing the humanity in intravenous drug users, and treating them like any other patients with a disease.
“You can live with addiction — in your past, your present and potentially, you never know, in your future,” says Green. “You can succeed, and you’re human.”