E. Tammy Kim / Al Jazeera America

A Lazarus drug goes mainstream in the heroin war

In Georgia, race of overdose victims may be a factor in new legislation expanding access to naloxone

Editor's note: This is the first in a two-part series on naloxone, an anti-overdose serum, and how the difference in access from state to state has affected users. The second installment can be found here.

ATLANTA — Kareem’s most recent Lazarus moment came in March, while getting high at home with a friend before his graveyard shift at the meat cutting plant. A tall, bony African-American man, he has used heroin four or five times a day for most of his 58 years. It usually puts him in just the right mood to play chess or shoot pool, but this time, he said, “I noticed the drug had overpowered me.” When he awoke to his friend’s terrified face, he knew he had overdosed.

Twice before in his long affair with heroin, Kareem, who did not provide his last name for legal reasons, had OD’d and been saved by paramedics using naloxone (brand name: Narcan), which immediately induces withdrawal from opiates. In March, though, it was his friend getting high alongside him who acted as a first responder. “He noticed I became non-responsive; I stopped breathing. He got the Narcan and the syringe and put in the prescribed dose. It didn’t work, so after five minutes, he put it in again.”

Kareem would have died without naloxone, but his supply, like the heroin, was contraband. Last year, health workers slipped him a zip-up kit containing a vial of the serum, a syringe, a nasal adapter and instructions, and he told his family and friends where to find it, just in case. 

Emergency rooms and paramedics have stocked naloxone for years, but until recently, state pharmaceutical regulations kept it otherwise out of reach. On April 24, however, Georgia Governor Nathan Deal signed the 9-1-1 Medical Amnesty bill, relaxing restrictions on the drug and granting immunity to users who call for emergency medical help. Within a year, the bill went from draft to statute in this conservative, Republican-led state, and similar bills have moved just as quickly in North Carolina, Kentucky, Ohio, Vermont, Virginia and New York. 

There’s a perception that the younger, whiter, suburban face has been part of the changing landscape and has brought more people to pay attention to this issue.

Dan Bigg

Chicago Recovery Alliance

Since the mid-1990s, when San Francisco, Chicago and Massachusetts began to pass local and statewide legislation expanding access to naloxone, an estimated 10,000 people have been revived — most by fellow drug users. Nearly 20 states now permit lay people and first responders to carry naloxone, either by individual prescription or through a “standing order” deputizing syringe-exchange clinics and other health organizations to hand out easy-to-use kits. Many states have also passed companion “medical-amnesty” bills that assure drug users who call for help that they will not be charged with possessing drugs or drug paraphernalia.

Unintentional drug overdose is now the leading cause of accidental death in the country, far outpacing motor-vehicle fatalities. Between 2000 and 2010, the number of people who died from overdoses doubled, to more than 38,000 per year, causing public health experts to declare an “opiate epidemic.” But some believe that in addition to spiraling rates of addiction, the race and class of overdose victims have hastened the enactment of these life-saving policies. According to Dan Bigg of the Chicago Recovery Alliance, a pioneering harm-reduction group, “There’s a perception that the younger, whiter, suburban face has been part of the changing landscape and has brought more people to pay attention to this issue.”

History of an epidemic

A naloxone kit distributed by the Harm Reduction Coalition in San Francisco, a leader in overdose prevention.
E. Tammy Kim / Al Jazeera America

Until the 1980s, the U.S. medical establishment reserved powerful opioid-based medicines — derived from the poppy plant and used since ancient times to treat pain — for grave, often terminal illnesses. But when drug trials in the 1990s showed no significant problems, physicians also began prescribing OxyContin and Vicodin to patients afflicted with lumbar trauma, arthritis and sports injuries. “Opioids had been used since the ’50s or ’60s for cancer pain. … [If opioids helped cancer patients,] why wouldn’t it be true that people who were suffering from chronic, non cancer pain could benefit?” said Dr. Lynn Webster, former president of the American Academy of Pain Medicine.

By the early 2000s, easy access to these pills bred widespread addiction and a profitable, legal trade in painkillers. In 2012, some 2 million people tried prescription-strength opiates recreationally for the first time. “They would take [OxyContin] and crush it or take the whole amount at once,” Webster said. Patients replenished their supplies through “doctor shopping,” and opportunistic physicians went through stacks of prescriptions at fraudulent pain clinics. Most of the consumers were Caucasian. Opiates are “a white drug,” according to Sandra L. Kuehn, president of the Center for Chemical Addictions Treatment in Cincinnati. One explanation, she said, is “the proliferation of narcotics with sports injuries, which traces back to pills.” Whites may also benefit from higher rates of health insurance, but Medicare and Medicaid patients have also seen high rates of addiction. 

As overdose deaths skyrocketed across the country, law enforcement cracked down on predatory pain clinics, or “pill mills,” squeezing one end of the opiate supply. The void was filled by a chemically identical drug, available for a fraction of the price: heroin. By making home deliveries and selling it for $10 or $20 per bag, compared with $40 for one prescription tablet, depending on the variety, dealers enticed suburban and rural users to go from swallowing and snorting pills to shooting heroin directly into their veins.

When someone black [in the Bluff] overdoses, you never hear about it and see it on the news, but someone white, they deserve to be recognized.

Marshall Rancifer

Harm-reduction activist in Atlanta

Overdose prevention has become a major health concern. Naloxone is all over the national news and endorsed by such high-profile officials as Attorney General Eric Holder. Prior to 2012, however, only a handful of cities and states had passed laws broadening access to naloxone or granting medical amnesty to 911 callers, and strategies outside the drug-treatment paradigm were harshly stigmatized, too fringe and controversial to inform public policy.

“It was thought that this harm-reduction thing is radical,” said Eliza Wheeler, of the San Francisco-based Harm Reduction Coalition. “The real shift in the mainstreaming of this has happened since prescription-drug use has fueled a rise in heroin use throughout the country, in communities that maybe weren’t as affected in the past.”

“Before, you had to go to a dark, scary place to get these drugs. Now you just go to your school bathroom,” said Robin Elliott, a real-estate agent in suburban Atlanta whose son Zack, a promising student-athlete, died of a heroin overdose in 2011. “You used to think of [heroin users] as being outsiders, not in the mainstream group. Not the beautiful, blonde, high-achieving daughter that goes to the University of Georgia.”

As the epidemic spread, young people like Zack were OD'ing and succumbing to respiratory failure, collapsing and turning blue. Co-users and other witnesses were failing to call for help, fearing arrest and imprisonment. In Georgia, Elliott and a band of grieving mothers and fathers lobbied for the naloxone bill like it was their second job. Justin Leef, Zack’s best friend, was instrumental in drafting it.

Outreach worker Verna C. Gaines of the Atlanta Harm Reduction Coalition reviews a list of drug users exchanging needles in April.
E. Tammy Kim / Al Jazeera America

The first advocates for naloxone distribution were health workers and grassroots activists who ran syringe-exchange programs and worked closely with active drug users. Long before there was a medical-amnesty bill, organizations such as the Atlanta Harm Reduction Coalition (AHRC) were preventing overdose deaths and needle-borne illnesses as best they could. For nearly two decades, AHRC has given away clean needles, condoms, food and clothing and offered free HIV tests, showers and Internet access to local residents in the notorious, low-income neighborhood known as the "Bluff," home to seasoned users and the center of Atlanta’s opium trade. Kareem’s naloxone kit came from AHRC whose efforts, even now, remain exceptional: It operates the only syringe exchange in the entire state.

“The only economic development happening in this neighborhood in the last 30 years is the heroin trade,” said Marshall Rancifer, a former AHRC staff member. “This community has had no infrastructure upgrades or economic development. When someone black over here overdoses, you never hear about it and see it on the news, but someone white, they deserve to be recognized.”

AHRC Director Mona Bennett, who has long advocated for the widespread distribution of naloxone, agreed. Although opiate abuse seems to have re-emerged in just the past few years, “heroin never really went away.” Bennett, whose gray Afro poofs out from beneath a Braves baseball cap adorned with social-justice buttons and condom wrappers, explained that, in the inner city, “the face of heroin is my face.”

Looking ahead

Nat Nwizu runs GPA Treatment Inc., a methadone clinic in Doraville, Georgia.
E. Tammy Kim / Al Jazeera America

Hope P., a blonde mother of five, recovering heroin user and methadone patient at GPA Treatment Inc., outside Atlanta (she declined to give her last name), sees the naloxone kits and medical amnesty as life-saving reforms. “I’ve had people overdose in front of me that I’d have to keep alive until the paramedics came, maybe 10, maybe 15 times. The fear of getting arrested makes people leave them,” she said. “Some [drug users] aren’t gonna trust that they won’t get in trouble — they’re not gonna be trusting of cops. But I know they would carry around those kits.”

Her instinct has proved true in California, which has a longer history with naloxone. In early April, the Harm Reduction Coalition staffed a women’s-outreach night on Capp Street, in San Francisco’s Mission neighborhood. About 50 women — young adults and pensioners, white, black, Asian and Latino — came through the storefront for a hot meal, free clothing and tampons, meetings with a case manager, needle exchange and naloxone kits. As “Love Potion No. 9” played over a set of speakers, Wheeler, who oversees the naloxone program, trained a young woman named Princess wearing black anarcho-punk garb on how to identify and help friends OD’ing on heroin. “You start with a sternum rub, then call for help and give them the Narcan,” Wheeler said, demonstrating how to prepare the syringe and place a nasal sprayer over the needle. In less than 10 minutes, Princess left with the take-home kit.

No one quite knows how the rollout and distribution of naloxone will unfold in Georgia. In theory, police officers, firemen and pharmacies will now carry this Lazarus drug — an intervention that has already saved lives in Massachusetts and New York — and advocates hope to reach active and recovering users, family members and friends. “I wouldn’t count on the state to fund education or infrastructure,” Jeremy Galloway, an activist, graphic designer and former addict, said as he stood in Atlanta’s Grant Park neighborhood. “It’s gonna have to be a grassroots thing. The first step would be educating people in the Bluff.”

“Our next steps are to tell people about the 9-1-1 Amnesty bill and start training people about how to respond to opioid overdoses,” AHRC’s Bennett said. Until the law passed, she and her staff had made do with “the little naloxone that the naloxone fairy brought us” — illicit kits imported from Chicago that saved 15 lives in the Bluff. “Now that we can do this work legally,” she said, “I hope we will bid farewell to the naloxone fairy very soon.”

Correction: This story was updated to reflect that the program run by the Harm Reduction Coalition is not a one-for-one needle exchange.

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