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Every week, Beth Herman gives about 75 drug users a medication designed to rapidly reverse opioid overdoses.
The drug is called naloxone, or Narcan, and the retired nurse hands out the version that can be injected into the thigh or arm of someone suffering from an accidental overdose. It takes just seconds to revive people who aren’t already too far gone.
Herman runs a small nonprofit called All Peoples’ Encinitas Inc. She has a deal with a naloxone supplier, and since last summer she’s been buying the drug herself and setting up next to the region’s only clean syringe exchange program, which three days a week dispenses clean syringes to anyone who wants them via an RV parked at various locations in San Diego. Needle exchanges allow drug users to get free, clean syringes in order to prevent the spread of blood-borne diseases such as HIV/AIDS and hepatitis.
“Some of my clients do call me the Narcan Lady,” Herman said. “Naloxone should be in the hands of every drug user. I give them instructions on how to use it when they get the vials, and they can train their friends. It saves lives.”
That doesn’t mean the drug, or needle exchanges, are without controversy. Critics say the programs only encourage and perpetuate drug use. They also claim some drug users are pushing the limits with opioids, taking even more than they would otherwise because they know they have naloxone nearby to help revive them.
“Narcan can be used in a very positive way,” said Bryan Sharp, vice president of admissions at Pacific Bay Recovery, a substance abuse treatment center downtown. “But we’re also noticing a lot of the younger people that are dealing with heroin addiction are utilizing that because they want to get all the way to that point of almost overdosing.”
State bills that would facilitate more safe injection sites where drug users could obtain clean needles have failed in the California Legislature over the past several years. Though Republicans tend to be the loudest critics of such efforts, Democrats have also helped kill those bills.
The needle exchange where Herman sets up is run by Family Health Centers of San Diego, with a small portion of funding coming from the city’s Community Development Block Grant program. Dozens of other needle exchange programs across the country also hand out naloxone. It can be hard to reach drug users, and needle exchanges are often the best way, the reasoning goes. So far, though, Family Health Centers has yet to add naloxone to its offerings.
That’s why Herman decided to do it herself.
“Family Health Centers set up a table for me, and they’re aware that I’m there at the needle exchange,” she said. “But they always give me a long, convoluted reason for why they’re not doing it themselves.”
Family Health Centers of San Diego cited its substance abuse treatment program and other efforts to help people addicted to drugs. A spokesman said in a written statement that the center is “currently working to develop a Naloxone program at our clean syringe exchange sites, but first must ensure it meets all state requirements and liability concerns.”
On a recent Thursday evening, Herman stood outside the RV that serves as the hub for the pop-up needle exchange. About a dozen people stood in line to get their free needles. A few trickled by Herman’s table to pick up doses of naloxone.
Amber Willoughby stopped by to talk to Herman and stock up on naloxone. Willoughby said she’s been coming across more people nodding out after they use. She wants to carry naloxone in her purse just in case.
“I don’t want to see anybody die,” she said. “If I can help someone and keep someone else safe, especially in this realm, it helps.”
Herman said anyone making an argument that naloxone should not be freely and widely distributed to drug users is misinformed.
“It’s bullshit,” she said. “There’s no good reason not to do it.”
She’s a nurse who worked in the field of psychiatry and addiction for 20 years. She said while naloxone is not a long-term solution to the opioid problem, it is an important stopgap measure that keeps people alive until they can get into treatment. The overdose antidote is part of a harm-reduction approach to opioid abuse. When she retired, Herman said she didn’t see enough people or organizations working to keep drug users alive in the region, so she stepped up to do it herself.
Harm reduction is the idea that service providers should reduce negative consequences associated with drug use while they work toward more permanent, long-term solutions and treatment. It’s an idea that’s gaining steam. Lots of people now think naloxone should be in everyone’s medicine cabinet.
Herman is working to obtain the state approval and permits she needs to start her own clean syringe exchange program in North County. She wants to open sites in Oceanside and Vista.
“This is just what I think needs to be done,” she said.
California hasn’t been hit as hard as states like West Virginia and Ohio. But opioid overdoses are killing over 200 people a year across the San Diego region. To put things in perspective, 20 people died during the San Diego Hepatitis A outbreak that made its way into the center of local public health policy debates.
In San Diego last year, the first opioid-related death happened on Jan. 1. While the final analyses of the opioid-related deaths for 2017 is still being completed by the county medical examiner’s office, a preliminary data search found 258 overdose deaths by the end of the year, both from prescription and illicit opioids. That number is down slightly from 2016, when 268 people in the county died from opioid-related overdoses.
One disturbing trend the numbers show: 90 people died in part because fentanyl, an especially powerful and dangerous opioid, was mixed in with their drugs, according to preliminary data from the medical examiner’s office. That’s a sharp rise from 2016, when 33 died with fentanyl in their systems. Fentanyl is frequently laced into or taken alongside popular illicit drugs. In San Diego, it’s started appearing more often in cocaine and meth.
Naloxone used to require a prescription, but in recent years, every state has broadened naloxone access laws. In most places, you can now get it over the counter. On April 10, the U.S. surgeon general issued an advisory recommending that more Americans carry the overdose-reversing drug.
‘Naloxone’s a Double-Edged Sword’
Not everyone thinks drug addicts should be given naloxone.
A recent study found that broadening naloxone access can increase opioid-related crime and emergency room visits, reduce interest in drug treatment and have no net effect on drug overdose deaths.
“Naloxone’s a double-edged sword,” said Corey Scott, a clinical pharmacist at Pacific Bay Recovery. “It can save lots of lives, but it is also pushing a lot of these individuals to not be scared of overdose because they have that available.”
Scott said in the last few months, two patients have tried to smuggle in both naloxone and opioids when they were admitted to rehab. The patients told Scott they got prescriptions for both opioid pain relievers and naloxone at the same time during visits to local emergency rooms.
Doctors are more regularly recommending naloxone alongside prescriptions for strong opiate pain relievers. That’s one way the drug is getting distributed in the region. Emergency responders, San Diego County Sheriff’s deputies and some San Diego Police officers also carry the drug in case of emergencies.
There are also volunteer groups and nonprofits like Herman’s working to distribute naloxone more widely. A New PATH is a nonprofit made up of parents who’ve lost children to drug overdoses and other volunteers. The group hands out naloxone and trains people how to use it.
But Herman said she thinks the people who need access to naloxone most are drug users themselves. She said cities and the county should be doing more to expand access to naloxone.
“I don’t know of any comprehensive, regional plan to get naloxone to more people,” she said.
At the needle exchange, Herman is also giving out fentanyl test strips, kits that can detect the presence of fentanyl and many of its known analogs in a drug sample. Family Health Centers provides the strips, and she said people have told her they’ve been using them and avoiding the more dangerous drugs with fentanyl.
Gretchen Burns Bergman, the cofounder and executive director of A New Path advocacy group, said naloxone is one of the keys to fighting the opioid epidemic. She has two sons who struggled with addiction, and she knows how hard it is to find treatment programs. The free or more affordable ones have long waitlists.
“And in the meantime, parents are worried their kids will die,” Bergman said. “Naloxone is a very safe drug that can very quickly reverse overdose death. It’s a tool that should be in every toolkit.”
Like Herman, Bergman is critical of Family Health Centers’ reticence when it comes to handing out naloxone. Bergman and Herman also think sober living homes and treatment centers should be handing out naloxone, but most aren’t.
“It should be given out everywhere,” Herman said. “Anyone can learn how to do this. This isn’t rocket science. That’s why the clients are teaching each other. They’ve given Narcan to other people to save their lives, trained those people, and then those people have gone on to save lives.”