When North Carolina nurse Chad Sanders lost his younger sister, Shelly, to a heroin overdose in November 2005, he was 21, she was 19, and they were college students at different schools in their home state. Chad found out only after her death that Shelly had been diagnosed with bipolar disorder a few months prior and that she'd experimented with “skin popping”—injecting heroin subcutaneously—while away at a residential high school. “It gave her a relief she hadn't had before,” Sanders said recently.
Gifted in science and math, Shelly did well in her classes as a college freshman. She was involved in an outpatient drug-rehabilitation program and had signed a no-drugs contract. She began dating a man with a history of addiction who had just been paroled, and when she had a hard time breaking it off she told her mom she was coming home for a while. Five days before her scheduled return, though, she and the man injected heroin in her dorm room. When he saw that Shelly was unresponsive he fled, terrified he'd be arrested for drug possession. Twelve hours later he called the police and made an anonymous report. By then Shelly was dead.
Because Shelly “didn't have the appearance of an addict,” as Sanders said, the family revealed the cause of her death to few friends until Sanders and his mother went to a meeting of GRASP—Grief Recovery After a Substance Passing—and decided to help others. In 2012, Sanders became an outspoken advocate of North Carolina's Good Samaritan/Naloxone Access bill, which became law in April 2013.
Had the law been in effect in 2005, Shelly's friend could have called emergency services without fear of prosecution. Perhaps he would have had the opioid antidote naloxone (Narcan) on hand, which might have saved her life. Sanders said he tries not to dwell on the what-ifs, and it comforts him to think that Shelly would have been pleased by his advocacy work. “Her spirit would have wanted to help,” he said.
CHANGING LAWS, SAVING LIVES
Most states have reported a dramatic rise in heroin overdoses, although more deaths result from overdoses of prescription opioids than heroin, according to the White House Office of National Drug Control Policy. According to the Substance Abuse and Mental Health Services Administration, between 2002 and 2012 heroin use more than doubled among young people ages 18 to 25, from 122,000 to 272,000 users, and the number of people of any age who reported using heroin in the year prior climbed from 373,000 in 2007 to 669,000 in 2012.
Contributing factors include easy access to more potent and cheaper forms of heroin and efforts to curb prescription opioid abuse through drug-monitoring programs, harder-to-abuse formulations of opioids such as the abuse-deterrent formulation of the oxycodone brand OxyContin, and stricter laws limiting “pill mills.”
The debate over how best to respond to the complex problem of heroin use has become ever more polarized. In many states the controversy centers on whether and how to make the opioid antagonist naloxone available at the community level. Naloxone works by adhering to opioid receptors, immediately (but only temporarily) reversing an opioid's respiratory-suppressing effects. Currently, 17 states and the District of Columbia have passed laws permitting naloxone distribution and training for police officers and firefighters, as well as family members and friends of heroin users.
Studies have shown that many witnesses to heroin overdoses say that “fear of police involvement” prevents them from calling for help. To address that, 16 states and the District of Columbia have passed Good Samaritan laws, which offer protection from criminal prosecution to anyone who calls for help for an overdose.
Two New England states show a range of perspectives on the heroin problem and the viability of naloxone programs in addressing it.
- In January, Vermont governor Peter Shumlin devoted his entire State of the State speech to Vermont's “full-blown heroin crisis.” The state's Opioid Overdose Prevention and Reversal Project involves distributing rescue kits containing nasal naloxone to those at risk for overdose or to their family or friends. The law also protects clinicians who prescribe or distribute it from criminal or civil liability.
- On the other hand, in Maine, where deaths from heroin overdose quadrupled from 2011 to 2012, Governor Paul LePage vetoed a bill last year that would have expanded naloxone availability, because the drug “would make it easier for those with substance abuse problems to push themselves to the edge, or beyond.”
A 2012 survey of 48 naloxone training-and-distribution programs nationwide (http://1.usa.gov/1myqMME) found that such programs save lives. Between 1996 and 2010, more than 53,000 people received naloxone and were trained in its use, and more than 10,000 “overdose reversals” were achieved.
BREAKING THE CYCLE
Nurses working in harm reduction in two of the states most affected by heroin understand that such laws are just one aspect of an effective approach to preventing overdose and treating addiction.
In Massachusetts, ‘we've been at high alert for so long,’ said Donna Beers, a nurse and a researcher at Boston Medical Center. She worked in addiction treatment in the 1980s and early 1990s, took a few years off to rear her children, and returned to practice in 1999. She was stunned to see the upsurge in heroin use among young people in Massachusetts, a state she now refers to as “ground zero of the heroin epidemic.”
Beers isn't the only one saying so. In late March, Governor Deval Patrick declared opiate overdose a public health emergency and used his emergency powers to make naloxone more widely available statewide and to direct $20 million to treatment programs.
In the early 2000s, cheap heroin became readily available—it was easy to “buy coke and get some heroin for free,” Beers said—and because it alters the brain's reward centers, relapse is an expected part of recovery. That's why Beers unequivocally supports Good Samaritan and naloxone-distribution laws. Some states distribute the injectable form of naloxone, but Beers said it's much more effective to train laypeople in nasal administration. An atomizer allows the drug (available only in a liquid, injectable form) to be administered as a nasal spray. But in her state insurance doesn't cover the cost of the atomizer, the costliest part of the $50 kit—“a huge barrier” to widespread use, according to Beers. Massachusetts is working with other states to get Medicaid to cover the cost of the atomizer, she said.
Beers emphasized that there is one important message that nurses, regardless of where they practice, can impart to patients: don't use heroin alone, when nobody can help you.
“It doesn't cost anything to say, ‘I see you have a history, and you're saying you're not using. But if you do relapse, it's important not to use by yourself. I just want to make sure you're as safe as possible.’ It's nonjudgmental and it could save lives.”
In North Carolina, ‘the budget was cut for treatment centers,’ said Leilani Attilio, the medical and advocacy coordinator at the North Carolina Harm Reduction Coalition. As a public health nurse, Attilio is aware of the many interlocking factors that affect drug use and relapse rates. For example, although her state has led the way in passing a model Good Samaritan and naloxone-access law, there are fewer beds dedicated to treating addiction.
“You get busted for drugs, detox in jail, want to start your life over again,” Attilio imagined. “And then you try to get a job. Every application asks if you've ever been convicted of a felony or misdemeanor. If you have, you're less likely to get a legal job.” This might lead someone to start using again, and since there are fewer resources allocated for treatment, the person reenters what Attilio called “the cycle of mass incarceration” for drug offenses. Such “nonmedical” issues are high on the nursing agenda in North Carolina, Attilio said, because the cycle can be broken with a holistic approach.
And to those who think that naloxone-access laws enable addiction, Chad Sanders urges compassion. We all know someone who's died in a car accident, he said, and soon we may all know someone who's died of an accidental overdose. “No one deserves to die because they made a bad choice and then became addicted. We aren't going to stop drug use, so maybe it's important to learn about addiction and how to save lives.”—Joy Jacobson