The heroin crisis in Alabama has drawn responses in the form of conferences, stepped-up attention from law enforcement, and the passage of legislation designed to save lives of those are overdosing.
The legislation, passed earlier this year in the regular session of the Alabama Legislature, would enable more people to administer naloxone hydrochloride, a synthetic drug also known as Narcan, to temporarily reverse the effects of an overdose from heroin or a prescription opioid painkiller such as hydrocodone or fentanyl. Among those targeted in the new law are law enforcement officers, who often are the first to arrive when an overdose is reported.
The new state law is not yet operational, but another naloxone initiative is – through the Birmingham VA Medical Center – and it already has kept one overdosing veteran from dying. Part of the U.S. Department of Veterans Affairs’ Overdose Education and Naloxone Distribution (OEND) Program, the local effort began about five months ago. By early October, the medical center had distributed prescribed naloxone kits to 71 veterans. The kits distributed so far contain two naloxone doses, each contained in an autoinjector device that administers the drug through the outer thigh. The medical center also has a kit containing naloxone doses to spray in each nostril.
According to the VA, veterans most likely to need a kit are using heroin or an opioid painkiller. These vets are considered to be “at increased risk for opioid overdose or whose provider deems, based on their clinical judgment, that the veteran has [a need] for a naloxone kit.”
Erica Cleckler, a pharmacist in the medical center’s mental health department, said the hospital initiated its naloxone distribution effort in its outpatient substance abuse clinic, where staffers sought to identify patients with opioid abuse disorders, particularly any who may have not have had an opioid for a period of time, possibly because they had been in jail or hospitalized.
Should those patients take an opioid in the same amount that they were using before they stopped, they run a greater risk of having an overdose because their system has less tolerance for the drug, Cleckler said.
The OEND program has now expanded from mental health to the medical center’s physical medicine and rehabilitation department, commonly called the pain clinic, because a lot of its patients have opioid prescriptions and are at “a higher risk of an overdose,” said Lizmarie Aviles-Gonzalez, a clinical pharmacist in the department.
“It doesn’t have to be intentional,” Aviles-Gonzalez said. “It could be accidental.”
Those who get the kits receive training in how to use them and how to detect an overdose. They are told to call 911 and also encouraged to tell relatives and their caregivers that they have the kit. If a veteran agrees, those family members and caregivers can attend the training sessions.
Nationally, the OEND program, which started in 2013, has seen more than 100 of what the VA refers to as “reversal events” – instances in which naxolone administered from its kits has kept someone overdosing on heroin or an opioid painkiller from dying.
On Oct. 2, the Birmingham VA Medical Center saw the first such “reversal event” from its fledgling program, according to this edited account from Katherine Guillen, a medical center mental health specialist:
“He was in his room when he injected the heroin, and that is also where he was found down by someone else living there just across the hall. Patient’s naloxone kit was sitting out on his dresser in his room. Both of the doses in the kit were given to him and the paramedics were called. Another dose of naloxone was administered by the paramedic on the way to the ER.
“He ended up at the [VA Medical Center emergency room] late Friday night, Oct. 2, where he was admitted to ICU for two nights then transferred to the drug rehabilitation program at the Tuscaloosa VA that he had already been approved for prior to this incident.
“The patient said that this overdose was ‘not intentional… no way.’ He said that everything was going good and in a matter of minutes everything changed. He said ‘I was only given a small amount of heroin, but with me being clean for as long as I was, it was way too much.’ He stated with certainty that his life was saved because of the naloxone kit that he was given by the VA, and he feels extremely grateful to be alive.”
This year, through the end of July, Jefferson County has seen 151 deaths from “prescription and/or illicit drugs,” according to figures from Chief Deputy Coroner Bill Yates. That seven-month total is running narrowly ahead of the total for the same period in 2014. Of this year’s 151 drug deaths, 59 involved heroin, or heroin and one or more additional drugs. Fentanyl figured in 41 other overdose deaths. Methadone figured in 17.
In November, the Jefferson County Health Department will unveil its own program to get naloxone to the county’s at-risk population. According to an email from county Health Officer Dr. Mark Wilson, the county will offer prescriptions for naloxone to “an individual at risk of experiencing an … overdose, or … a family member, friend, or other individual in a position to assist” the at-risk person.
“Along with the prescriptions, the health department will provide basic information and instructions on how to administer naloxone,” the email states. “There will be no charge for the health department visit, but people will still need to pay to fill the prescription at a local pharmacy.” The program will operate on Mondays from 1 p.m. to 4 p.m. at the Central Health Center, 1400 Sixth Ave. South in Birmingham.
Meanwhile, under the new state naloxone law, the state Department of Public Health is required to approve a program that shows law enforcement officers how to properly administer naloxone to an overdose victim no later than Jan. 1, 2016.
Mark Jackson, interim director of the department’s Office of Emergency
Medical Services, said in an email that the state health department “will implement training guidelines by Dec. 31 … for first responders including law enforcement to administer (naloxone).
“The training guidelines will be available after completion on the Office of Emergency Medical Services (OEMS) website,” Jackson wrote.
State Rep. Allen Treadaway, R-Warrior, the chief sponsor of the naloxone law, said many law enforcement officers are eager to be able to administer naloxone, “especially those who have witnessed (an overdose) and have been on the scene when it could have been helpful.”
At UAB, clinical psychologist and associate professor Karen Cropsey is heading a study in which researchers will distribute 200 naloxone needle injection kits to heroin or opioid users and keep track of them to see if they use the kits and ultimately seek treatment for their addictions.
The study, publicized by flyers and other means, began about six weeks ago. By early October, no one had yet signed up to participate, Cropsey said. Researchers are planning to change their approach by going directly to treatment centers in hopes of meeting potential study participants there, giving them the naloxone kits and training them in their use. They already have permission to do that at UAB’s Beacon Addiction Treatment Center. Cropsey said she also hopes the study will get some participants through UAB Hospital’s Emergency Department.
“Some of these processes are just kind of getting up and going,” Cropsey said.
Dr. Wilson, the county health officer, acknowledged that when someone’s life is saved by naloxone, it does not necessarily mean they will end their addiction, but there are those who go on to live drug-free lives, with treatment.
“It comes as no surprise that many addicts go back to using heroin or other opioids after being revived from an overdose,” Wilson said. “This is the nature of addiction – continued use of the addictive substance despite harm – and it is not unique to heroin. (How many cigarette smokers, after a hospital intensive care unit stay for respiratory failure or a heart attack, return to smoking and are readmitted again and again? Similar analogies could be drawn for alcoholism.)
“Heroin/opioid addiction is a very difficult addiction to overcome, and even with treatment, the relapse rate is high,” Wilson added. “And many people do not have access to the treatment they need. This is why naloxone access is only one part of what must be a multi-strategy approach to this difficult problem. The good news is that some people who are brought back from an overdose will go on to long-term recovery from addiction. Obviously, if naloxone is not available to revive them, they will never have that chance.”
For an appointment to access the Jefferson County Health Department’s naloxone program, call (205) 930-1135.