An RV, needles, Narcan: Street-level services in an opioid epidemic

A robotic female voice speaks from a white plastic container smaller than a deck of playing cards.

“If you are ready to use, pull off red safety to inject. Press black end to outer thigh and hold in place for five seconds,” the voice says.

Savannah O’Neil obliges and the device clicks before starting the process.

“Five, four, three, two, one,” it says before making three rapid beeps. “Injection complete.”

There is no actual injection this time. O’Neil is using the training device that comes with each set of Evizo auto-injectors, which deliver a potentially life-saving dose of naloxone, a drug that counteracts the effects of opioid drugs. This includes both prescription drugs like hydromorphone, hydrocodone, and oxycodone, and street drugs like heroin and fentanyl.

Naloxone—also known as Narcan—blocks opioid receptors in the brain, immediately reversing an otherwise fatal overdose.

“That’s the entirety to using this device,” O’Neil says, reaffixing its safety guard and sliding it back into its container. “Some people might like that one because it’s pretty easy to use, but they’re incredibly expensive, so we only have these when we get a donation from the pharmaceutical company.”

In the very back of the HIV Education and Prevention Project of Alameda County (HEPPAC), tables and shelves in O’Neil’s office are stacked with various forms of naloxone, including the auto-injectors, nasal sprays and vials of the injectable drug. O’Neil is the coordinator and sole employee of Overdose Prevention Education and Naloxone Distribution (OPEND), a program dedicated to delivering these overdose-reversing medications to those who may need them across the county.

HEPPAC cannot offer to exchange hypodermic needles at their location on Foothill Boulevard in East Oakland because of community concerns it would bring drug users into the neighborhood, so they meet people who need their services where they are. These tend to be in homeless encampments and certain neighborhoods known areas for drug use and sex work, both of which carry increased risks of HIV transmission.

They commonly do so in a white 26-foot RV built on a Ford 450 chassis. Several times a week, the team drives one of their two RVs to locations across the county, where they offer needle exchanges and hepatitis C and HIV screenings. In addition to naloxone, they provide harm reduction services including distributing clean needles, condoms, hygiene products, snacks, and plastic sharps containers to safely dispose of used needles.

“Really it’s about approaching people with compassion and humanity regardless of the choices they make about their own lives,” O’Neil says. “And we all know what we do every day carries risk, so it’s about reducing the risk associated with those choices.”

***

Drug overdoses due to heroin or prescription opioids claimed roughly 30,000 lives in 2014, the latest year for which statistics are available, according to the National Institute on Drug Abuse. In Alameda County, fatal drug overdoses involving opioids tripled since 2005 and heroin-involved emergency room visits have dramatically increased since 2010, according to county public health department records. In 2013, the latest year for which data is available, 174 people in Alameda County died from drug overdoses, 31 of which involved prescription opioids, according to the Opioids Safety Coalition Network, the opioid-focused branch of the California Health Care Foundation.

It’s a warm Wednesday in November, and the six-person HEPPAC team—including two high school senior interns—is giving aid to residents of a homeless encampment under Interstate 580 at 35^th Street and Peralta in West Oakland. Unlike other tent cities in the Bay Area, this one is sanctioned by the city, complete with portable toilets and garbage services.

On the plastic garbage cans, O’Neil stacks several rectangular red pouches with black zippers on top. Inside each kit are varying forms of naloxone, a pamphlet that re-hashes training in case a person forgets a step, a prescription card that allows someone to legally carry it, and information on the Good Samaritan law in California, which allows drug users to contact emergency services without the reprisal of arrest.

Of the hundreds of opioid overdose kits OPEND has given out in Alameda County, by that November evening the team knew of 54 confirmed reversals that could have otherwise been fatal. A June, 2015, report by the Harm Reduction Coalition (HRC), a nationwide group with an office in Oakland that advocates for reducing negative consequences associated with drug use, found that the 152,283 naloxone kits distributed to laypersons from 1996—when the first community organization began distributing the kits—through the first half of 2014 resulted in 26,463 overdose reversals across the United States.

“Do both of you know what Narcan is?” O’Neil asks an elderly couple at the homeless camp.

“It’s the kind that helps bring people back,” the man says.

“Right, so it brings people out of an overdose. Just for opioids, just for heroin, prescription drugs, things like that,” O’Neil says.

“What is it? Liquid? Pills?” the woman asks.

“So, I’ll show you,” O’Neil says, unzipping a kit. “There’s a liquid you can inject. There’s also an auto-injector, so you can choose which one you want. Do you have a preference?”

These interactions are brief, informative and supportive. The OPEND team doesn’t preach an anti-drug message because their experience and research from agencies like the Substance Abuse and Mental Health Services Administration (SAMSHA) shows that doesn’t work. The team believes it’s the little things—even two one-milliliter vials of a clear drug—that can help prevent people from dying prematurely from their addiction.

Opioid addiction crosses racial, socioeconomic and geographical barriers, and many users start with prescription pills like OxyContin and hydrocodone before they try harder street drugs. With increased access to prescription pills—whether sanctioned by a doctor or obtained from friends for recreational use—many who use pills later turn to heroin because it’s cheaper and more effective at achieving the same high. Up to 80 percent of heroin users report using prescription opioids before beginning to use heroin, according to a 2013 study by the U.S. Centers for Disease Control and Prevention.

Before long, these habits aren’t about getting high, but rather taking enough drugs to achieve, what’s called in addiction treatment circles, a person’s “new normal.” It’s a problem people like O’Neil has been seeing for decades, but only in the past few years has the problem been acknowledged by the media and high-ranking officials due, in part, because more white and affluent people have died as a result.

“It’s been a problem in Oakland for a long time, and it still is. It’s still an increasing problem in rural communities,” she said. “This is the first election cycle where most candidates mentioned it, mentioned overdose, mentioned losing family to drug overdoses, and that is huge.”

The elderly couple O’Neil spoke to opted to take an auto-injector: the easiest to use, the most expensive, and hardest for groups like OPEND to obtain. While pricing varies—some kinds of auto-injectors cost up to $2,000—prices for some versions of the drug have increased 17-fold over the last two years. The ones donated by pharmaceutical company Kaleo are set to expire before the first of the new year, but they still could be used to reverse an overdose for months after.

The oldest and most prevalent treatment is for opioid addiction is methadone, a synthetic opioid taken in increasingly lower doses to wean a person off of opioids. It is, however, addictive as well, and can increase a person’s likelihood of overdose, which is why it is only delivered at highly-regulated clinics.

Evidence collected by SAMSHA and other major public health organizations suggests that medication-assisted therapy (MAT), which includes both opioid-replacement medication like methadone or buprenorphine and behavioral therapy—typical talk therapy that helps people identify and change self-destructive behaviors—is the most effective form of treating people. It’s supported by the U.S. Department of Health and Human Services because it reduces drug cravings while helping people deal with underlying mental or emotional problems that led to their addiction. Federal agencies like the National Institute of Health support expanding methadone’s availability across the country to be used in MAT.

In September, the U.S. Government Accountability Office (GAO) compiled a report on access to MAT at the request of Senate Majority Leader Mitch McConnell (R-Kentucky). Kentucky and other predominantly rural states have been hit especially hard by opioid addiction.

One issue, the report found, is how opioid drugs, and those used to treat addiction to them, are regulated. For example, certain opium preparations—including cough syrups containing codeine—are rated Schedule V by the Drug Enforcement Agency (DEA), meaning access to them is moderately restricted. But drugs to treat addiction, like methadone and buprenorphine, are more tightly controlled at Schedule II and III, respectively. This means they’re more highly regulated and can carry criminal penalties for people using them outside of a methadone clinic or doctor’s office. Naloxone, however, is not a controlled substance, meaning it is lawful for anyone to carry.

The GAO report stated that compared to many abstinence-based treatments preferred by some medical practitioners, MAT is better at reducing opioid use and preventing people from dropping out of treatment. Still, as of 2012, at maximum 1.4 million people had access to MAT therapy while 2.3 million Americans abused opioids or were dependent on them, meaning “access to MAT has not kept pace with the increasing problem of opioid addiction in the United States,” the report states.

Insurance is another problem. Many people lack private health insurance that would help them get MAT services. And even those whose insurance covers critical care may not get follow-up services. A report released in February from the Center for Behavioral Health Statistics and Quality examining health insurer data found that from 2010 to 2014, about 40 percent of patients who were hospitalized for opioid abuse received no follow-up services, even if they had private health insurance. Of those who did, 43 percent were therapeutic services without medication—or abstinence-based services—and only about 11 percent received MAT-centered therapy.

Since access to MAT is difficult for most people addicted to opioids, groups like OPEND instead pursue a strategy called harm reduction—preventing death and the spread of disease among people who are still using drugs. Naloxone works for their purposes because it’s easy to use and can immediately save a life.

“People need to survive whatever they’re going through,” O’Neil says. “If our goal is that people heal and recover and a have a different life, they can’t do that if they die along the way in their addiction.”

Organizations that offer needle exchanges, like HEPPAC, were the main early adopters of naloxone distribution. Today, those groups include veteran’s healthcare facilities, pharmacies, primary care clinics and substance abuse treatment facilities. Several states, including California, have passed laws increasing access to naloxone to those outside of the medical field, namely drug users, their family members, and others in direct contact with those at risk of an opioid overdose. It’s even available over-the-counter in select pharmacies in California.

The Harm Reduction Coalition study—based on data collected from people like O’Neil—found drug users received more than 80 percent of the naloxone kits distributed to laypersons, performing more than 80 percent of the reversals. Nearly 82 percent of those reversals involved heroin.

***

As the OPEND team distributes clean needles and other supplies at the West Oakland encampment, there’s Bruce Walter, who takes a juice box and sips on it slowly but intently. Walter had been living there for 45 days. During that time, he says, he’s helped several people through overdoses, including some by using naloxone. Those include “friends, family,” he says, pausing to glance over his shoulder at the dozens of tents behind him. “Look at this situation.”

When an overdose is occurring, he says, keeping a calm head is vital. “The one thing I’ve learned about all emergencies is that panic kills more than anything else. Shock takes lives,” he says.

Walter says the group’s services are greatly appreciated, namely because living at a homeless camp carries an increased risk of exposure to HIV and hepatitis C, which can be passed through blood, shared needles and sexual contact. “You have to be careful, you have to be smart,” he says. “You’ve got to use the common sense as well as street smarts.”

Denise Lopez, a HEPPAC outreach coordinator, and Mike Snow, control coordinator for the group, both wear black hoodies with the words “Clean needles save lives” on the back. Snow distributes clean needles, while Lopez tapes signs on garbage cans warning people to not trash used needles.

“When you have a dirty needle, put them in here,” Snow says to people gathered around him, holding up a red sharps container the size of a Big Gulp cup.

“No more in the garbage, or they’re going to stop garbage pickup,” Lopez warns.

Meanwhile, O’Neil clutches a clipboard with a naloxone kit underneath it, looking around the camp to see if anyone else could use training or more naloxone. A man in a faded black hat and insulated canvas jacket says he does, so O’Neil begins his training, collecting data as she goes. Has he ever witnessed an overdose? How many times? What was the drug involved? Was naloxone used in the reversal?

The man nods, yes, he has witnessed an overdose.

O’Neil has, too. The most recent occurred while she was working at a methadone clinic and a patient overdosed in her office. The woman survived because HEPPAC, the organization O’Neil works for now, provided the naloxone that saved her life.

O’Neil says naloxone is not, as some would suggest, a safety net that encourages drug users to try larger and more frequent doses. Using it is actually a horribly painful experience.

As an opioid antagonist, naloxone immediately blocks the brain’s opioid receptors. A person undergoing an overdose goes from being extremely high—perhaps so high they stop breathing—to immediately experiencing withdrawal symptoms. These can include leaving a person disorientated, angry and with nausea and chills. Depending on the strength of the naloxone and a person’s opioid dependence, this withdrawal can last up to 90 minutes.

“It’s not something anyone I meet wants to go through, but it can keep someone alive … so they can make different choices about their lives,” O’Neil says. “I have a lot of people I am close to who do not use drugs anymore, who would have died if they didn’t have access to naloxone.”

U.S. Surgeon General Dr. Vivek Murthy focused his latest report, released in November, specifically on drug and alcohol addiction, their prevalence in the country, and the problems with how they are treated. “Most Americans know someone with a substance use disorder, and many know someone who has lost or nearly lost a family member as a consequence of substance misuse,” the report states. “Yet, at the same time, few other medical conditions are surrounded by as much shame and misunderstanding as substance use disorders.”

Viewing addiction as a moral flaw or a form of resistance to societal norms is backlash from the unsuccessful war on drugs, the Surgeon General’s report states. Instead, those treating the epidemic of addiction need to follow sound scientific knowledge—not a moral authority—and understand how addiction is affected by genetic and environmental factors, and how addiction reshapes a person’s brain in response to stress, leaving them unable to cope with daily stressors without using drugs.

In his report, the Surgeon General endorsed the use of naloxone and other harm-reduction strategies, defying criticisms that they enable addiction and drug use. “Similar attitudinal barriers hinder the adoption of harm reduction strategies like needle/syringe exchange programs, which evidence shows can reduce the spread of infectious diseases among individuals who inject drugs,” the report states. “To reverse these trends, it is important to do everything possible to ensure that emergency personnel, as well as at-risk opioid users and their loved ones, have access to lifesaving medications like naloxone.”

Eliza Wheeler, manager of the Drug Overdose Prevention and Education (DOPE) Project with the Harm Reduction Coalition, has been running naloxone programs for about 15 years and has heard fears that naloxone enables drug use. Now, her ears are deaf it.

“At this point in my life and career, I don’t pay that much mind to it anymore,” she says. “Nothing has shown that to be true.”

Advocates say access to naloxone is also a first-line defense against black market drugs—made using ingredients drug dealers order from China via the “dark web”—which are increasingly relying on synthetic materials like U-47700 and fentanyl, an opioid 100 times stronger than oxycodone. Fentanyl is responsible for the highest rates of fatal overdoses in recent years, mostly in East Coast and Midwestern states. From 2013 to early 2014, there were more than 700 fatal overdoses in the U.S. related to fentanyl—which continued to rise in 2015—but those estimates are considered to be low, since most coroner’s offices do not test for fentanyl unless its immediately suspected, according to a 2015 report from the National Drug Early Warning System.

“People are taking one thing and finding out it’s another. It’s actually something that’s way stronger,” O’Neil says. “So getting naloxone into the community at those points of really potent drugs is crucial.”

In September, Louis J. Milione, deputy assistant administrator at the DEA, told a U.S. House of Representatives committee on the opioid epidemic that black-market fentanyl mixed in pills and heroin from China helped drive a 1,392 percent increase in fentanyl-positive drug samples from 2013 to 2015.

In March and April, counterfeit pills meant to replicate Norco tablets—a painkiller containing acetaminophen and hydrocodone—resulted in seven hospitalizations in Alameda, San Francisco, and Santa Clara counties. Lab testing later showed these pills actually contained fentanyl and promethazine, a strong sedative that may increase the opioid effect. All patients survived their incidents. At least two had been administered naloxone, according to a CDC report.

In Sacramento, nine people died as a result of fentanyl-laced drugs during the same time period. Special Agent Casey Rettig, a Bay Area DEA spokesperson, can’t say whether the Sacramento and Bay Area overdoses were related because of how easily counterfeit drugs can be made.

About $3,500 worth of fentanyl ordered from China over the internet can make $1 million in profit for dealers if they use a pill press that can give these fake pills the same markings as legitimate ones. Some users buy the pills thinking they’re getting real Norco, while others seek out pure fentanyl for a greater high, Rettig said.

“It’s like they want to go to the brink of death, or as close as they can to get it,” she said.

***

After being at the camp at 35^th and Peralta for about a half hour, the OPEND group gets back into the RV, slowly pacing their way through Bay Area rush hour traffic back to East Oakland. The interns will be late to their next obligations.

Francisco Noriega and Gabby Silva are seniors at LIFE Academy in Oakland. When it comes to their required internships, they make some of their classmates jealous. Earlier in the day, they were untwisting copper Chore Boy scrubbing pads to make safer filters for people who smoke drugs like crack cocaine. The experience of working at HEPPAC and going out to the camps, they say, gives them a better understanding of the drug problems they’ve witnessed in their own neighborhoods.

“Doing drugs is dangerous, but the way they were doing them…” Silva says.

“… we’re not here to judge. We’re here to help,” Noriega finishes.

Back at HEPPAC’s office, Snow said the avid response they receive each time the RV rolls up to one of their sites shows the need for naloxone as well as training on how and when to use it. “It’s a vital piece of what we do, because we’re able to bring back people and have people administer the Narcan,” he said. “It gives them almost the cachet or accountability and the know-how to use that information.”

Harm reduction advocates say there’s been progress on understanding and treating addiction as a mental illness, with focus on rehabilitation, treatment and overdose prevention instead of jail or other punishments.

Following the last “really good eight years,” some like Wheeler feel the new presidential administration could affect how drug addiction is treated across the country, possibly shifting back to a more law enforcement-focused approach. Regardless, Wheeler says, her group’s priorities will not change, including making sure people who need naloxone have access to it. “We will continue to advocate for the same things we’ve always advocated for,” she says.

Just this year, Alameda County funded a naloxone-specific program, creating OPEND with $250,000 in funding from the one-half cent sales tax voters passed in 2004. The health department next plans to expand those services to the southern part of the county. Earlier this month, Congress passed a heath-related bill, which includes $1 billion to be dispersed to states and used to prevent and treat drug addiction.

And HEPPAC plans to keep on doing needle exchanges, along with naloxone distribution through OPEND, too. Despite the changing market rate cost of the kits, the majority of the naloxone kits they give away are purchased through a direct-buy program from drug makers. Others are donations, like the sought-after auto-injectors O’Neil eagerly gave to people at the encampment.

In addition to their work at outdoor sites, HEPPAC runs Casa Segura, or “safe house,” their East Oakland center that offers anyone who needs help a wash of clothes, a hot shower, toiletries, and other necessities. After the sun had set and everyone else has gone home, one of those clients knocks on the window of Snow’s office. Snow tells him he’s unable to do anything for him right away, but they’ll be back tomorrow to help.

Then Snow smiles and laughs to himself because it’s just another normal part of a normal day. His normal.

Leah Rosenbaum contributed to this report.