One moment, I was dabbing off a smudge of eyeliner in front of the bathroom mirror, just a commonplace, mundane thing I’d done a thousand times without a second thought.
The next, my friend was falling into the bathroom behind me, his words slurring into mumbled gibberish. At first, it was almost comical, the way his legs jerked and his body lurched, his mouth distended, like a grotesque, over-the-top dance. But when his knee banged the counter and his torso slumped over the sink, I realized this wasn’t one of his characteristic off-color jokes.
I managed to lead my friend out of my small bathroom while he was still upright, but it was clear he needed more help. He was nodding hard, frozen in a pose that looked like a fall suspended mid-way. I tried to guide him to a sitting position on the bed, but his legs began to jerk again. I wasn’t sure if he was seizing, but then he slipped from my grip and fell to the ground.
I began carrying naloxone everywhere with me a few years ago, after having several of my own overdoses reversed by people with the drug. But I had not been called upon to use it on someone else.
The day my friend overdosed in October this year, I knew what to do from training, from reading about it, and from hazy memories pulled from the less severe of those overdoses. Narcan, the brand name for intranasal naloxone, is fairly easy to administer. Pop it out of the container, place it into one nostril while holding the other closed, and squeeze down. You can hear it release—a soft spraying sound—so you know it’s deployed. Of course, administering it during a true emergency is quite different from practicing on empty air with a dummy vial.
The instructions tell you to wait two-to-three minutes before administering a second dose. Those few minutes are agonizing.
I ran for the naloxone and cradled my friend’s limp head in my arms while administering the dose. His face was a dingy purple-grey, and his lips were violet. He had urinated on himself. He wasn’t making any noise, and he wasn’t breathing.
I tried to open his mouth to administer rescue breathing, but his jaw was clenched shut. I pushed my fingers in between his teeth, and managed to pry his jaw open enough to push in a breath before it locked shut again.
The Narcan instructions tell you to wait two-to-three minutes before administering a second dose. That’s because the drug takes that long to start working. Those few minutes are agonizing.
“That’s a long time. It’s not comfortable seeing someone who’s blue. If you’re trying to help them breathe, that feels like forever, but it still takes three minutes to work,” commented Taliesin Magboo Cahill, nursing team lead of the safe consumption site at Sandy Hill Community Health Centre in Toronto, Canada.
I didn’t have a phone, and I didn’t know where my friend had put his. Even if I had known, I didn’t have his passcode and he didn’t use biometric locking. So I had to guess how much time had passed—not an easy task under dire pressure. Every breathless second felt like a minute. Knowing I had only one more dose and no way to call emergency services made it that much worse. This had to work.
After what I estimated was three minutes, I administered a second dose. I’d been afraid before then, but having used my last dose of naloxone, I began to truly panic. I had a choice to make: stay with him and try to get his mouth open to do rescue breathing, or run outside and bang frantically on neighbors’ doors until someone opened and agreed to dial 911.
Although I didn’t supply the drugs, this had happened in my home. And this was in Florida, which has drug-induced homicide laws that can carry the death penalty.
Besides the danger of leaving my friend alone, there were other potential consequences to going out and trying to alert the authorities. There was the social stigma of drug use; the fear and disgust the neighbors might have felt toward me, particularly during the pandemic, and the threat of eviction from my month-to-month lease. There was also the fear of police action.
Although I didn’t supply the drugs or really have any part in his using them, this had happened in my home. And this was in Florida, which has drug-induced homicide laws that can carry the death penalty for certain opioids—including fentanyl, which my friend had used. The state does have Good Samaritan laws, which are supposed protect people from prosecution if they dial 911 during an overdose—but they don’t supersede drug-induced homicide laws.
Such justified fears are part of the reason why Sarah Wakeman, an addiction medicine physician at Massachusetts General Hospital, says it’s so important that people who use drugs have liberal access to naloxone.
“People who use drugs are the frontline responders when it comes to overdose. Unfortunately because of our racist and punitive drug policies, even despite Good Samaritan laws, some people who use drugs may be hesitant to call 911 for fear of criminal legal sanctions or simply being treated poorly,” Dr. Wakeman told Filter. “Even if they do, it will take time for an ambulance to arrive and every second counts when it comes to an overdose, particularly in the current era of fentanyl adulteration of the drug supply.”
I chose to stay with my friend. I struggled to get his head tilted back and his mouth opened so I could breathe for him. His jaw was less rigid this time, and I managed to get in a few puffs.
I don’t know if that air was the kick-start he needed, or if the naloxone took effect at just that moment, or both—but it was then that, like a miracle, his face flushed, his eyes rolled open, his chest began to rise, and he began to stand. I’ve never felt more relieved in my life.
Laws and Law Enforcement Restrict Access
“It’s kind of amazing how well it works,” said Cahill of naloxone. “If you’ve seen someone use you can be almost 100 percent, if not 100 percent, effective at keeping people alive.”
She also noted that because her site is equipped with other resuscitation tools like oxygen and experienced staff, they are sometimes able to reverse less severe overdoses without using naloxone. But sites like the one Cahill runs in Canada, where people can inject drugs under medical supervision, have struggled to open legally in the United States.
Even the simple distribution of naloxone is tangled in red tape, the extent of which varies from state to state and sometimes even between counties. Even in states that allow for prescription-free naloxone distribution, many people who use drugs don’t have the extra cash to buy an antidote that can cost upwards of $100.
The US has been inching its way toward a harm reduction approach. Legal syringe distribution programs—which often also give out free naloxone—have been implemented in most states, though not widely enough. Semi-legal or technically illegal operations—like the Church of Safe Injection in Maine, founded by Jesse Harvey, who passed away this year, reportedly from an overdose—try to fill the gaps.
“Technically it is illegal [in Iowa] to dispense naloxone to laypersons without a pharmacist.”
“Naloxone distribution is so important to target directly to people who use drugs and I think that has been really successful in some states and some communities,” said Sarah Ziegenhorn, the founder and former executive director of Iowa Harm Reduction Coalition, which also runs a naloxone distribution program that sometimes operates outside of Iowa’s strict dispensing laws. “But for most of the US it’s still not really a reality, and people are still really struggling to get naloxone in rural communities I think in particular, and in the plains and prairies states like Iowa.”
“Technically it is illegal [in Iowa] to dispense naloxone to laypersons without a pharmacist,” Ziegenhorn told Filter—adding that local medical and pharmaceutical communities have helped by essentially “looking the other way.”
Anti-syringe laws are another unexpected barrier to naloxone distribution in some areas. Although Narcan is applied intranasally and therefore doesn’t require a syringe and needle, naloxone can also be injected. More expensive formulations come in preloaded shooters (some of which talk you through the process!), but the less expensive varieties better suited to meet heavy demand on a slim budget come in liquid vials that require the use of an intramuscular syringe and needle.
“Here in Myrtle Beach, we don’t have any kind of [harm reduction] services … Because of our syringe laws, you can’t go to the pharmacy and buy syringes; if they think you’re a drug user you will not get syringes,” explained KC Nicole, a harm reductionist in opioid addiction recovery who does freelance syringe and naloxone distribution in South Carolina on a shoestring personal budget.
“Our syringe laws are so bad [that] I’ve had problems with law enforcement with giving out [intramuscular] naloxone,” Nicole told Filter. “I gave some IM naloxone to a friend of mine—who is not a drug user, who had no criminal record or anything like that—and they got pulled over.” When the friend admitted to having naloxone in his glove box, the police “used the syringes as probable cause to search his vehicle.”
In at least one county in Indiana, as Filter reported, naloxone administration itself can be used as probable cause to support drug prosecutions.
The Pandemic Makes Things Worse
And of course, any overdose prevention difficulties that existed prior to 2020 have been worsened by the pandemic. Isolation is one important factor: Naloxone will not help if you are using alone. Fear of viral contamination is another; it’s impossible to stay six feet apart while engaged in the very intimate task of saving someone’s life, with mouth-to-mouth rescue breathing sometimes necessary.
But as Brooke Feldman, who manages CleanSlate Centers in Philadelphia, told the Kensington Voice, “This is a public health concern, and the chance of someone dying, if you see them experiencing an overdose, is much higher than the chances of most of us dying from contracting COVID-19.”
“I definitely hear that access to harm reduction services, including naloxone, is down.”
“There is concerning data that both fatal and non-fatal overdoses are increasing in the context of COVID,” said Wakeman. “In my work with patients, I definitely hear that access to harm reduction services, including naloxone, is down. And of course the social isolation, stress, despair, and lack of economic opportunity that we are seeing during the pandemic can be deadly for someone who uses drugs.”
And at her safe consumption site, Cahill reported “a huge increase in overdoses”—all of them reversed—despite COVID-related staff shortages forcing the site to close earlier, resulting in fewer overall visits.
“COVID has complicated Narcan distribution so much,” said Zeigenhorn. “People really had to get outside of the office, moving around the community. But without funding for staff to do that, they couldn’t necessarily make that happen. I think that the biggest challenge of naloxone access and distribution right now is figuring out how the heck to get to it to people at all.”
Mail-order services already existed before the pandemic to help fill in some of the access gaps. And Wakeman argued that COVID has presented “a real opportunity to learn from innovations … to deliver services in even more flexible ways.”
“For example,” she said, “some service industries have pivoted in the face of COVID to offer more delivery, takeout or virtual services. We could learn from those examples to offer delivery services for naloxone, utilize the US postal service, have self-serve takeout venues where people could access naloxone, and have naloxone readily available in every healthcare touchpoint.”
“The priority should be getting naloxone to people who use drugs and it should be hiring people who use drugs to distribute the naloxone.”
“We are in the middle of a pandemic and a lot of the services, especially county services, have shut down, and people are being encouraged to shelter in place, and the places where you used to go to get naloxone are closed,” said Tracey Helton, who is on the board of directors for Next Distro, an organized mail-order naloxone distribution service.
Helton has also offered independent mail-order services for several years out of her home base in California. She advocated for the use of mail services for naloxone, and also espoused a new bicycle delivery operation in the Bay Area that began in response to pandemic-related service closures. Yet she’s quick to point out that most grant or government funding doesn’t go toward these vital services, but instead to treatment agencies and other facilities that require people to engage in lengthy training seminars, show up at difficult-to-access or stigmatizing locations, or present other barriers to people who use drugs.
“The priority should be getting naloxone to people who use drugs, and it should be hiring people who use drugs to distribute the naloxone,” Helton told Filter. “I’ve sent people large quantities of naloxone and they’re in the trap house giving it out; I’ve had drug dealers who I sent naloxone to giving it to customers; shooting galleries where you give people a bunch of naloxone to set up there, and everybody is saving each other’s lives.”
I am all the more conscious of the callous, stigma-fueled cruelty of laws that continue to make it inaccessible.
I carried naloxone, even when I had no expectations of using it, because if someone else hadn’t done the same, I wouldn’t be alive today. Because I did that, my friend (who gave me permission to share his story anonymously) is also now alive and well.
As an overdose survivor, I’ve known the importance of naloxone for a while. But now that I’ve also had the experience of cradling another person’s prone body in my arms and actually seeing naloxone take effect—in the form of the color returning to his face, malleability returning to his limbs, his eyes re-opening, and his chest resuming its rise and fall—I am even more aware of the miraculous utility of this drug.
And I am all the more conscious of the callous, stigma-fueled cruelty of laws that, in too many parts of the country, continue to make it inaccessible while people are dying for want of it.
Photograph by Elizabeth Brico of her naloxone refill, provided by Keri Ballweber, director of peer advocacy at Point to Point Kane County.