Out of harm’s way

Joshua Livernois woke up hazy, sick and splashed with Dr. Pepper in a hospital bed in Salinas, California. He couldn’t piece together the events of the previous day or so, and he’s still not even sure which year it was, probably 2005 or ’06. He’d been using heroin off and on for about 10 years and almost daily for five.

“There was some crazy dope in town,” he said. “I don’t know what was up with it. It tasted different than normal, had kind of a vitamin-ey flavor.” As a long-time user, he didn’t often get what he craved, which was “the full effect of being fully loaded.” This new heroin, he said, “got me really, really high.”

This much he remembers: He’d been homeless for a while. His then-girlfriend had been in jail for a couple of weeks. They were in a motel room with a few other friends. They were on a four-day bender doing MDMA, crystal meth, alcohol and that potent heroin that had just hit town.

This part he pieced together later: After he shot up, he started babbling incoherently. His friends worried that he might be overdosing. Two women loaded him into a car and drove toward the emergency room. On the way there, he passed out, turned blue and started breathing shallow, infrequent breaths. The driver stopped at the home of an acquaintance because it was closer than the hospital. The acquaintance gave Livernois an injection of naloxone, which he said helped him recover from the overdose, and eventually the two women got him to the hospital.

Naloxone, also sold under brand names such as Narcan, reportedly reverses the overdose effects from opiates, including heroin and prescription painkillers, by taking over the opiates’ place on the brain's receptors. Different formulations of it can be injected into a muscle or vein, or sprayed into a nasal cavity. It was approved by the Food and Drug Administration in 1971. It’s been available by prescription in Nevada for a long time, but it was effectively illegal until 2013, when a statute was changed to decriminalize possession of syringes. (The nasal spray version wasn’t an option then; that wasn’t approved by the FDA until 2015.)

Naloxone can have side effects including nausea, sweating and fever, but, in the experience of Cindy Green—a 17-year veteran EMT, supervisor and educator for ambulance service REMSA—it very often doesn’t. She and her colleagues administer the drug about 53 times a month. (Green stressed that “53” isn’t necessarily the number of opiate overdoses that REMSA responders encounter monthly. If they find someone unconscious and they don’t know why, they might administer Naloxone to rule out an overdose. She didn’t have a number readily available, but she said that happens noticeably often.)

“The medicine itself will never hurt you. It will only benefit you,” Green said. Livernois had been feeling pretty bad when he woke up that day in Salinas, though. In fact, he described it as a “fucking miserable, miserable experience,” a type of situation that Green explained this way: “I guess there is a small caveat. If you have a major addiction, you could see some withdrawals. You do typically upset the person when you give it, because you take away the high.”

This is not a nice, neat, linear story of a guy hitting rock bottom and suddenly coming clean. It took Livernois six or seven more years to kick heroin. The last time he took it was in 2012.

During those six or seven years, he volunteered at the syringe exchange in Salinas, moved to Reno, and joined with a few other activists to start a grassroots group called the Public Health Alliance for Safety Access (PHASA). That group formed in large part to push for a law that would make naloxone more widely accessible.

Among the members of the fledgling group were Melanie Flores, an activist named Penny Jernberg from Truckee, and Livernois’ now long-term partner, Leslie Castle.

“They were really stoked when I showed up on the scene,” Livernois said. “They had everything they needed except an actual drug user. They didn’t have anybody to bridge the gap between them and the community they want[ed] to serve. Sometimes it’s hard to find people to self-identify.”

He pointed out that identifying as an addict is hard to do in a lot of circumstances, and that often because of that people who need counseling or medical help don’t get it.

“Stigma kills,” he said. “It’s the number-one killer. If you woke up tomorrow with a giant, festering wound on your arm, you’d go in. Many times, a heroin user with a similar problem would avoid a hospital visit. Many times a provider treats you like dog shit. The way that they look at you, you’ll never go again. … Stigma is a real bitch.”

Today, Livernois is a community outreach worker for Change Point, the syringe services program at Northern Nevada HOPES. The program provides clean needles, which helps slow transmission rates of HIV and Hepatitis C. It also offers counseling, access to rehabilitation programs and HIV and Hep-C testing.

Livernois said that HOPES makes a point of hiring staff members who represent the communities they work with. Sometimes, for example, the non-profit health organization seeks out transgender employees or Latino employees.

In his case, he said, “You can’t really put out a Craigslist ad saying you’re looking for somebody who used to shoot heroin, who’s been to prison, who’s been homeless, but that is what they were looking for.” Livernois, now 38, has a slim build, a long salt-and-pepper beard, a piercing on each side of his lower lip, and intense brown eyes. Fashionwise, he might fit right in with his clients at the exchange, but he’s alert, articulate and authoritative on the job. It’s clear as he manages the flow of clients in Change Point’s tiny, busy front office that his experience as a user helps him relate to his community. One moment he listens compassionately to a man who appears spaced out, scared and a little angry. The next moment he firmly reprimands a guy for verbally harassing the intern. The guy apologizes and promises it won’t happen again.

Heroin and prescription opiate overdoses have been on the rise nationally and locally. Here are a few figures to put that into perspective:

The Centers for Disease Control and Prevention this year reported a 200-percent increase in the rate of overdose deaths involving opioids—opioid pain relievers and heroin—since 2000.

Nevada ranks in the top quartile of overdose deaths nationwide.

Between 2010 and 2014, about a billion prescription pills were prescribed in Nevada, and about a quarter of those were painkillers, the most likely to lead to overdose deaths.

A Washoe County Health Department report showed that in 2012, 50 deaths in the county were associated with heroin overdose.

As usage rates and death rates have risen, the way medical professionals and law enforcement agencies handle drug cases has shifted in large part from a punitive “just say no” approach to a “harm reduction” model. The basic principle of harm reduction is that a 100-percent abstinence rate is unrealistic. Proponents say that clean needles are far safer than contaminated ones, access to medical care improves users’ health, and rehab and counseling are more appropriate and effective than jail time.

Officer Tim Broadway of the Reno Police Department said, “The attitude has changed over the years in regards to illicit drug use. The first priority for us is for the victims. If someone is using they’re still a victim.” He added, “We’ve seen in today’s society, you get more bees with honey, when you’re an approachable agency. You want to get the victims the help that they need.” He said that when RPD officers arrive in a situation where drugs are being used, they’re likely to seize the drugs and paraphernalia but, unless another crime has been committed, they’re more likely to refer someone to services than to make an arrest.

Broadway said, “due to the recent arrests with the Ford dealership we are working closely with Northern Nevada HOPES, and we do a lot of referrals.”

He attributed the shifts in policing policy to the federal government’s lead and to public perception.

Dr. Karla Wagner, professor in the School of Community Health Sciences at the University of Nevada, Reno, connected changes in public perception with the rising frequency of overdose deaths. She said, “What’s changed in the conversation is: ’When everybody I know knows somebody [affected.]’”

Wagner added, “I think that one of the things that’s important in this effort is to normalize conversations around opioid use. It’s important that we get to a place that we can talk about these risks realistically. Where people don’t judge.”

Melanie Flores, who works with the Nevada Division of Public and Behavioral Health and teaches public health courses at UNR, was one of the founding members of PHASA. Back in 2010, she was a grad student. Shortly before she started a career in public health, she experienced the type of shift in perception Wagner alluded to. Flores had been working in local radio. Even though she described the industry as having a “sex, drugs, rock ‘n’ roll culture,” at the time, she was shocked when friends started using heroin and even more shocked when a close friend died of an overdose.

She was also pretty surprised when, after she graduated, a mentor suggested she work on harm-reduction legislation.

“I was new. I didn’t totally understand it. At first, needle exchange sounded like an awful idea,” Flores said. She wondered, “Doesn’t this promote drug use?” She soon became a proponent and ended up writing the bill that became Senate Bill 459, the Good Samaritan Drug Overdose Act, as her thesis project.

Next for Flores and the rest of the PHASA group came a failed attempt at passing the bill, a two-year wait for the next legislative session, mountains of research, and testimony from many experts. One of them was Chief of Police Ken Ball from Holley, Georgia, where police carry Narcan, funded by traffic tickets, and the department educates law officers, first responders, high school students and prom chaperones in its use.

The second time around, in 2015, SB 459 passed, making it so that a drug user could call 911 in an emergency and avoid arrest. According to the PHASA members, it’s a positive step in policy direction that allows more naloxone to get to more places where overdoses are likely to occur—and save more lives.

Currently, naloxone is legally available through Northern Nevada HOPES and can be prescribed by doctors. A letter sent from state health officials to health-care providers in January to explain the new law reads, “One important component of the legislation allows first responders, family members, and friends the ability to obtain and administer naloxone …”

Proponents are pleased, but they say SB 459 is one of several steps. Now, they’d like to see the drug even easier to access. Livernois said he’d like to see a standing order from the state’s Chief Medical Officer that could make naloxone as readily available from a pharmacy as a Plan B pill or a flu shot, both drugs that can be purchased without a prescription.

The Chief Medical Officer position is officially vacant for a few more days. Incoming Chief Medical Officer John DiMuro, who takes the post July 1, said, in an email message, "Naloxone is just one important piece to the puzzle regarding opiate drug overdose and its use should not be taken lightly." He added that he is "in the process of exploring standing orders" to ensure that they are safe and effective.

Wagner said, “Having naloxone in the hands of people who are at risk and their friends and their family members is the way we can drive down death rates.” She added that she’d also like to see people offered naloxone when they’re released from incarceration. During the weeks after a person leaves prison, the risk of relapse increases drastically. A National Institutes of Health report reads, “One man in his mid-forties struggling to stay abstinent from drugs after his release: ’You get asked 50 times if you want some coke before you get into the [shelter] door.’”

REMSA’s Cindy Green said if the decision were in her hands she’d favor even wider distribution of naloxone than a standing order would allow.

“It could be available at 7-Eleven,” she said. But would that arrangement present any drawbacks?

“Absolutely not,” she said. “People who do drugs are going to do it. You can’t stop them, but you can save a life.”

As for Livernois, he’s happy to be alive and grateful to be in a position to help. He said it takes a lot of effort to stay clean. Working at a syringe services, he said, “Every day I’m reminded of what I don’t want. Every day, past Josh comes in and talks with present Josh and reminds him what he doesn’t want. And reminds him to stay grateful.” He remembers often what the employees and volunteers at the syringe services facility in Salinas did for him.

“To walk into a place when I was used to basically being invisible to the population at large, and have people get to know your name, remember who you are, smile at you, welcome you, treat you with dignity, it made a huge difference,” he said. He also does this job, he said, because he needs to. He’s rejected a life of prison sentences, homelessness and waking up nauseous from withdrawal, but he hasn’t rejected the people who still struggle with those problems. Being part of that community, he said, has been critical to his survival.

“I feel like that’s the most important thing that can turn somebody’s life around,” he said. “I don’t care if it’s Alcoholics Anonymous or NA or Jesus Christ or fucking Tupperware or you know, kickball. It’s finding your community of people that make you feel happy to be alive. That’s where I found it, in the harm reduction community.”