Pubdate:  05 - 11 Jan 2000
Source: Village Voice (NY)
Copyright: 2000 VV Publishing Corporation
Contact:  36 Cooper Square, New York, NY 10003
Feedback: http://www.villagevoice.com/aboutus/contact.shtml
Website: http://www.villagevoice.com/
Author: Maia Szalavitz
Cited: Lindesmith Center: http://www.lindesmith.org/
Chicago Recovery Alliance: http://www.anypositivechange.org/

HEROIN HASSLES

MEDICAL AND LEGAL ISSUES KEEP OVERDOSE ANTIDOTE OUT OF USERS' HANDS

Valerie S. was getting high in her Brooklyn apartment when a friend "went 
out." She says, "I wasn't really close to the guy. He was a neophyte, a 
married, college-educated professional, about 30. I made connections for 
him and he sampled the product at my house. "It happened in stages. I was 
nodding also, but I looked back and I saw that his legs were in a weird 
position, spread on the floor. Something got my attention, maybe the 
syringe falling. The first thing I saw when I looked closely was that he 
was on the floor and blue.

"There wasn't time to think," she says."I tried mouth-to-mouth, I tried 
CPR, but I realized, 'Wow, he's going.' By the time I realized I should 
have called [an ambulance], it was too late. I had the naloxone in the 
house, so I found a vein and injected him. He took a sharp inhalation of 
breath and sat up."

Valerie's experience using naloxone, a prescription drug, to save a fellow 
user from opiate poisoning makes a strong case for training others to do 
the same and making the antidote more widely available.

Raising awareness is just what the Lindesmith Center, a drug policy think 
tank in New York City, and 19 other agencies and organizations intend to 
do. Later this month, they are sponsoring an international conference in 
Seattle, "Preventing Heroin Overdose: Pragmatic Approaches." Attendees will 
include scholars, service providers, outreach workers, and others who deal 
with or are affected by heroin overdose.

Unfortunately, the need for naloxone is growing. Nationwide, according to 
statistics from the U.S. government's Substance Abuse and Mental Health 
Services Administration, there were 217,868 admissions to treatment 
facilities for heroin addiction in 1997, up 24 percent from 1992. Between 
1988 and 1997, heroin-related emergency room visits nearly doubled, from 
18,100 to 36,000, according to the government-funded surveillance study 
Drug Abuse Warning Network (DAWN). In New York, DAWN trends are confounded 
by the HIV epidemic, but approximately 700 people die from opiate overdose 
annually, according to the study's figures, which are compiled by local 
medical examiners.

With heroin use up, inevitably, the incidence of overdosing rises. Among 
those who take heroin, an overdose experience is the rule, not the 
exception. Valerie has overdosed at least three times over the last several 
years. Research studies from several countries consistently show that about 
two-thirds of long-term heroin addicts report that they've overdosed at 
least once. Nearly 80 percent have seen someone else do it. At least one 
overdose a week is reported to New York's Positive Health Project needle 
exchange. Though most overdose episodes aren't deadly, they can be.

It is impossible to overdose on naloxone, and there is no potential for 
abuse. The drug can, however, produce unpleasant withdrawal symptoms if 
given to an opiate addict in high doses. These symptoms are not 
life-threatening. The medication is far more likely to cause dysphoria than 
euphoria.

While conceivably adrenaline, cocaine, or speed could be used to treat 
overdoses, each of these drugs has a significant chance of doing more harm 
than good. About two-thirds of opiate overdoses involve a mixture of drugs, 
according to DAWN, so adding a stimulant is risky because an "up" drug like 
cocaine might be the real cause of the overdose. Unlike stimulants, 
however, naloxone isn't likely to do harm. And if heroin is one of a 
cocktail of "downs," removing the opiate effect alone is usually enough to 
save the person's life.

So why aren't service providers handing out naloxone at needle exchanges 
and training addicts in CPR and other aspects of overdose treatment? One 
obstacle, according to naloxone advocates, is that the medical profession 
is wary of allowing those with no medical training to treat overdoses. 
Although naloxone generally is not dangerous, it's certainly medically more 
prudent to take anyone who is unconscious and not breathing to a hospital 
where doctors can deal with any complications.

In ordinary circumstances, if the poison weren't an illegal drug, almost no 
one would disagree with such a recommendation. But expecting addicts to 
risk arrest and the contempt often meted out to them by medical 
professionals is naive, according to Dr. Karl Sporer, an emergency room 
physician at San Francisco General Hospital.

Sporer says that even in Australia, which has a much more humane attitude 
toward addicts, only 14 percent of users call an ambulance first. "We can't 
get the police to promise not to arrest them, and the police often need to 
be there," he says. A recent article in the Santa Cruz County Sentinel 
cites needle exchange officials who report that 65 percent of participants 
in the Santa Cruz Needle Exchange Program who have overdosed or witnessed 
an overdose "did not call 911 because they feared criminal charges."

"[Naloxone will] work," says Dr. Clifford Gevirtz, chief of anesthesiology 
at New York's Metropolitan Hospital and a leading addiction specialist. 
"But our society is a little too litigious." Family members of addicts who 
died despite naloxone might sue prescribers, claiming that the addict would 
have gone to the hospital and had a greater chance of survival if the 
naloxone hadn't been available.

A related concern is that making naloxone more accessible could encourage 
users to take more drugs. Dan Bigg, of the Chicago Recovery Alliance, which 
has trained several dozen users in administering naloxone, says this is 
unlikely. "Using naloxone is always unpleasant even for those without 
opiate tolerances," he says. "I have never seen nor heard of such increased 
reckless reactions to its availability. This is similar to the myth that 
sterile syringes incite more use."

Around the world and in small underground programs in San Francisco and 
Chicago, people have begun to research (albeit, somewhat informally, 
sources say) whether naloxone can actually reduce deaths. Italy has the 
most experience. In 1987, the Italian health ministry decided that naloxone 
could be sold without a prescription. In 1995, researchers in Torino began 
distributing the drug with instructions on its use at needle exchange 
programs. Susanna Ronconi, coordinator of the Torino Outreach Project, says 
that there is no data yet showing a decrease in the number of deaths, but 
naloxone is widely accepted and no problems have been reported.

ER physician Sporer believes the advantages of providing naloxone far 
outweigh the disadvantages. When naloxone works, an addict's return to 
consciousness is dramatic and almost instantaneous. However, he mentions a 
final potential complication. "Narcan [the brand name for naloxone] is not 
totally benign," he says. "There are a small number of people, about 1 
percent, who have seizures. They are short-lived and not fatal. Compared to 
near-certain death, it's an easy choice."

The mother of one 16-year-old girl, who found her daughter dead of a heroin 
overdose this summer, says it best, her voice shaking: "Never give up on 
your child. Never." She insists, "I don't think [providing naloxone] would 
encourage people to use drugs, but it would help families to save the lives 
of drug users. I think it's a great idea.'

Valerie has decided to give up heroin. As of late December, she had gone 48 
days drug free.
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