Narcan can bring overdose victims back from the dead, so why is it so hard to get in California?
Sacramento’s deadly fentanyl outbreak underscores antidote’s access barriers
Presh doesn’t remember what it’s like to come back from the dead.
But her mom sure does.
It was about three or four years ago. Jolene (not her real name) got a call from a local emergency room informing her that her daughter was being treated for a near-fatal heroin overdose after paramedics found her unresponsive in the back seat of a parked car.
“I didn’t even know she was using heroin,” said Jolene. “When they found her, she was blue and barely breathing.”
On the way to the ER, Presh, now 35, who agreed to use her real first name but asked to withhold her last name, received a muscle injection of naloxone hydrochloride, a fast-acting medication that can revive overdose victims within seconds.
It works by blocking the opioid receptors in a person’s brain. Except for sending regular drug-users into immediate withdrawal, it has few side effects. And naloxone can even reverse the effects of fentanyl, which has recently scourged the Sacramento area with 52 suspected overdoses—12 of them fatal—since March 23.
“Its only purpose is to save a life,” said Presh, who has been in recovery for more than three years now.
So why isn’t this wonder drug widely available?
Better known by the brand name Narcan, naloxone was patented in 1961 and approved to treat opioid overdoses a decade later by the Federal Drug Administration. Yet 55 years later, with the nation gripped by an expanding opioid epidemic that knows no demographic or geographical boundaries, government regulators have been slow to release their grip on it.
In most places, hospitals and medical first-responders carry Narcan, but most cops and school nurses do not. Meanwhile, the reluctance of users to call 911 can mean the difference between an overdose that gets reversed and one that proves fatal.
For instance, regarding the deadly fentanyl outbreak concentrated in Sacramento County, public health officials say first responders administered Narcan to every victim who still had a chance at survival. Not everyone did.
“Some were found at home and it was already too late,” said Dr. Olivia Kasirye, the county’s public health officer.
So far, 12 people have died following the outbreak of counterfeit street pills. Some of the surviving victims have said they believed they were taking the painkiller Norco, but instead ingested powerful doses of the much stronger synthetic opioid, fentanyl, which is 50 times more potent than heroin.
Toxicology tests have officially linked the deaths to fentanyl.
The age of the overdose victims ranges between 16 and 67 years old, with less than 10 percent being minors, according to Dr. Melody Law, the county’s assistant health officer.
Kasirye and Law spoke to SN&R on April 12, when it appeared the crisis had ended. A week later, three more overdoses were announced—two of them fatal—bringing the figures to their current total.
Outside of this fentanyl outbreak, rising opioid abuse has been an emerging public health crisis for more than a decade. Between 2000 and 2014, fatal opioid overdoses rose 200 percent, according to the Centers for Disease Control and Prevention. Heroin use has also skyrocketed, cutting across most demographics but with its users sharing one thing in common: Most first got hooked on prescription painkillers.
Ironically, some of the companies that profited from aggressive opioid marketing and overprescribing are now the ones selling the antidote. Hospira, which is owned by Pfizer and once had the monopoly on the Narcan autoinjector, and Amphastar Pharmaceuticals Inc., which is based in Rancho Cucamonga, have both been accused of marking up prices to the point that community-based addiction programs can’t get off the ground.
Both Ohio and New York have asked Amphastar for Narcan price rebates. According to the American Society of Health-System Pharmacists, Narcan access is slowly increasing—but so is the price.
Harm Reduction Services and Sacramento Area Needle Exchange, both in Oak Park, are the only places in the entire region where users and their loved ones can pick up free doses of Narcan and be trained to use it.
It’s a simple procedure, says HRS Executive Director Melinda Ruger. At the HRS office on Stockton Boulevard, staff and volunteers show trainees how to conduct chest compressions and clear the airway of an overdose victim before injecting Narcan into one of the victim’s muscles. If the victim remains unresponsive after a few moments, trainees are told to administer another dose. (They are each given two.)
HRS has been collecting survey data since beginning its Opiate Overdose Prevention Program in February 2014. As of April 15, HRS has trained 626 people to administer Narcan and distributed 1,164 individual doses. Thus far, 185 lives have been saved.
Most overdose reversals have taken place in Sacramento County, where HRS is located, but have been reported as far as Nevada and Contra Costa counties.
Eighty-two percent of the people who administered the Narcan were friends or acquaintances of the victims.
“Junkies are saving other junkies,” said Presh, who received Narcan injections four times—and only once from a medical practitioner.
More than three years after that near-fatal episode, Presh is teaching others to administer Narcan at HRS. She’s even trained her mother.
“If Narcan had not been present during my overdoses, I wouldn’t have had the opportunity to make different decisions,” she said. “It’s that old phrase: A junkie can’t get clean if they’re dead.”
“Given the opportunity to make a difference, these people are,” Ruger said. “This is the pragmatic and honest approach to addressing opiate use amongst these populations.”
California is slowly catching on.
In October 2013, Gov. Jerry Brown signed legislation intended to increase Narcan’s availability by allowing pharmacists to provide it over the counter to the public, without prescription. It then took more than two years to develop the protocols to make that happen.
As of today, only two CVS locations in the entire region actually sell Narcan, according to the Drug Policy Institute.
State lawmakers are also in the very early stages of considering a bill that would authorize school nurses and trained personnel to administer emergency Narcan in the case of an opioid overdose.
Assembly Bill 1748, from Assembly Republican Leader Chad Mayes, R-Yucca Valley, follows FDA approval last year of Narcan Nasal Spray, from a start-up called Adapt Pharma. According to a release from Hayes’ office, the Clinton Health Matters Initiative partnered with the product’s manufacturer to offer two free doses to every high school in the United States.
Sacramento schools have yet to accept the offer.
Representatives from the Sacramento City, Twin Rivers and Elk Grove unified school districts all said their schools don’t stock the medication and couldn’t say whether that would change.
Most cops don’t carry Narcan, either, unless it’s for their own protection.
According to William Ruzzamenti, director of the Central Valley High-Intensity Drug Trafficking Area task force, agencies are giving Narcan to officers who raid clandestine fentanyl labs. “Just the fumes can cause an overdose death,” he noted.
Carrying Narcan to save overdose victims is more common for cops on the Eastern Seaboard, Ruzzamenti says, where fentanyl has struck communities harder. “They’ve actually saved a bunch of lives,” he said.
Spokespeople for the Sacramento County and Placer County sheriff’s departments, and the Sacramento and Roseville police departments, say they have no plans to start carrying Narcan.
Strangely, the only downside to using Narcan might be how well it can work.
Sacramento Fire Department spokesman Chris Harvey and firefighter Dan Underhill say it sends patients into such immediate withdrawals that they can come to shivering, nauseous and irritable, and sometimes prone to hallucinations and vomiting. Harvey says he once approached an overdose victim, splayed out on a lawn and unable to move, who tearfully begged him not to administer Narcan. There have also been cases where people on gurneys have regained consciousness and tried to extract their own tracheal intubation tubes, Underhill says.
“We train extensively on administering it slowly,” he said.
Narcan’s immediate effects can also give its recipients a false sense of security.
Both Kasirye and Ruger noted that strong opioids can have a longer life than naloxone, meaning that a person can fall back into an overdose once the Narcan wears off. That’s why Kasirye urges people to call 911 no matter what.
Of the people who participated in HRS’ Overdose Prevention Program, most were white, living indoors and at a high risk of overdose, either because they had used alone in the past year (78 percent) or had taken time off in the past year (63 percent).
HRS conducted more trainings and reported more overdose reversals during the second year of the program than its first, largely due to word of mouth. Fifty-five percent of participants said they heard of the program from their friends, partners or families.
Presh is one of HRS’ success stories. But the truth is she got extremely lucky.
She was six months clean at the time, which is a vulnerable place to be in for longtime substance-users. “That’s the perfect opportunity to overdose, because I had a low tolerance for it,” she explained.
Upset with her boyfriend, Presh says she knew exactly what she was doing when she met up with an old friend to get high. Instead, she almost died. And the people she was with left her in the car.
“That was the last time I used heroin,” she said. “Being part of this family just redirected my life into a much more positive direction.”
Outside Ruger’s office hangs a framed mural commemorating dozens of people who weren’t so lucky.