Every day in the United States, 120 people die as a result of drug overdose.
Deaths from drug overdose have been rising steadily over the last two decades and are now the leading cause of injury death in the United States [1]. In particular, deaths from overdose involving heroin have almost quadrupled from 2000 to 2013, with the majority of the increase occurring after 2010. A recent study using data from 28 states reported that the death rate for heroin overdose doubled from 2010 through 2013, whilst deaths from prescription painkiller overdose in the US was recently described as an epidemic by the CDC.
But there is a drug that can help stem this tide.
Naloxone is a non-addictive opioid antagonist and is the only proven method that works to reverse the effects of an opioid overdose. In the United States, naloxone is classified as a prescription drug. Whilst it is legal to prescribe naloxone in every state, dispensing the drug by licensed prescribers at point of service is governed by rules that vary by jurisdiction, and is heavily influenced by stigma, prejudice, ignorance and a general lack of understanding and education around substance use and the behaviors associated with it. This is often the same stigma, prejudice and ignorance which bolster a lack of support for syringe exchange programmes, despite their proven record of reducing rates of HIV and Hep C amongst injection drug using populations.
HIPS provides low barrier harm reduction focused health resources and wraparound case management services to sex workers, injection drug users and their communities in Washington, D.C. The Mobile Services Department at HIPS runs one of only three syringe exchange (DC NEX) programmes in the District of Columbia – an area with one of the highest HIV rates in the US, with an estimated 3.2% of the population living with HIV. The prevalence of injection drug use in the District and in the neighboring states of Maryland and Virginia is also high, whilst viral hepatitis C is considered ‘a major public health problem’ in the District. In the last eight months at HIPS, we have distributed over 700,000 condoms, handed out approximately 165,000 new syringes, and registered over 580 new people for the Washington D.C. syringe exchange programme.
In addition to our four-person Mobile Services team, we are supported in this work by a base of 80+ volunteers and four ‘secondary exchangers’. Secondary Exchangers are members of the local DC community who receive a small stipend in return for exchanging large quantities of used syringes and registering new participants for DC NEX on a monthly basis. Secondary Exchangers are often well-connected to the communities in which we work and are viewed as peers by many of those they serve. As such, they have a unique relationship with the individuals we work with. By removing the service provider/client barrier, they are invaluable in reaching individuals who either cannot access HIPS services, or who we cannot reach due to issues of trust, accessibility, fear of discrimination, or simply a scarcity of resources. Through their work we are able to expand our reach to those who frequent neighborhood shooting galleries in private houses, underground clubs and local parks with high-density injection drug use where professional ‘hitters’ inject others for money.
During my GHC fellowship year at HIPS, I developed and delivered a programme to increase awareness of, and education around, opioid overdose and prevention and to increase access to naloxone, in conjunction with other Mobile Services staff and Robin Pollini, an epidemiologist whose research focuses on reducing the adverse health effects of injection drug use. The purpose of this project initially was to train staff and secondary exchangers to recognize the signs of opioid overdose, to equip them to better engage the community in harm reduction focused conversations around opioid use and overdose, and to encourage access to Naloxone.
Following a training on opioid overdose and prevention, each member of the Mobile Services Team and our four secondary exchangers traveled to Bread for the City’s Northwest DC center – which is the only place in DC where Naloxone is readily available – to collect their individual supply of Naloxone. Over the next month, our secondary exchangers replicated this training with members of their communities across DC. Through funding from HIPS secondary exchange programme, they were provided with a small cash incentive and transportation vouchers for each member of the community that they trained and accompanied to Bread for the City to collect a supply of Naloxone. By the end of the programme, 24 members of the community in total had visited Bread for the City, received training on opioid overdose and prevention and had been supplied with Naloxone.
In January 2015 we replicated this training for the team leaders on HIPS’ Night Outreach service and again in March for 20 members of HIPS’s 80+ volunteer corps. The hope is that in the future, HIPS will be able to distribute Naloxone to those who participate in our syringe exchange programme, adding another tool to our harm reduction toolbox and enabling participants to reduce the risk of the ultimate harm: death through overdose.
Naloxone saves lives. The reality behind the stigma is that those who die from opioid overdose do not fit a simple, clearly defined profile – according to a 2014 CDC report 46 people die every day in the US from an overdose of prescription painkillers including opioid or narcotic pain relievers such as Vicodin (hydrocodone+acetaminophen), OxyContin (oxycodone), Opana (oxymorphone), and methadone. Naloxone could be instrumental in preventing these deaths if it were included as standard in every first aid kit, just as it could prevent the death of a child who accidentally ingests their parent’s supply of codeine, or the death of an injection drug user who overdoses on heroin. Regardless of the face, the cause or the circumstance of an opioid overdose, no individual should have to die when that death might have been preventable.
Naloxone is another tool by which we empower the individual, regardless of their behaviors, choices or circumstance and another tool in our toolbox in the fight to promote and safeguard public health and the well-being of our communities.
[1] Drug-poisoning Deaths Involving Opioid Analgesics: United States, 1999–2011