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Sunday, May 24, 2020

Fighting the addiction

This story is the final piece of a three-part collaborative report on the opioid epidemic by Melissa McCarthy, Rahwa Hailemariam and Katie Meier. They collectively obtained and analayzed data and interviewed sources.

By Katie Meier

In a motel room on Samish Way, the body of a man lies still on the ground, heroin coursing through his veins. He is in the middle of an overdose.

His girlfriend had tried desperately to wake him up before reaching out for help, dousing him in cold water and attempting to breath for him.

First responders flood into the room: police, firefighters, and EMTs all preparing for the worst, but hoping for the best.

He has just minutes before he will succumb to the effects of the drugs in his system. His heart rate is dangerously low and they cannot get air into him.

He is going to die.

Bill Boyd, a 38-year-old engine medic, grabs a syringe from his bag and leans down toward the patient. Opening up his mouth, Boyd inserts the needle underneath the patient’s tongue and injects its contents into the patient.

The drug: naloxone.

Naloxone is an antidote to opioid overdoses. Used in the form of a syringe or nasal spray, it has the ability to stop an overdose in its tracks. The effects are almost immediate, causing it to be a very effective tool in the fight against addiction.

“What are you doing?” a police officer asks.

Boyd explains the actions that he has taken to the police officer. During an opioid overdose, the central nervous and respiratory systems become suppressed, leading the body to shut down if it does not get enough oxygen.

Naloxone directly battles the lack of oxygen by restoring normal respiration for a short period of time, giving time for medical professionals to perform life-saving actions. It is not a cure for an overdose, but can help in the short term.

“I’m out of here, I can’t even watch this,” the uncomfortable police officer mutters in the background.

It takes about a minute for naloxone to kick in, but once it does the patient starts to breath on his own and eventually starts to wake, even before the medic unit arrives on scene.

This is the reality of opioid overdoses.

Lucky saves and near misses have become the reality for first responders in Whatcom County as opioids are becoming more prevalent.

Narcan: The Basics

Infographic by Sophia Greif

Naloxone has become one of the top tools in fighting opioid overdoses.

In Bellingham, first responders use Narcan, which is a brand of naloxone produced by Adapt Pharma Inc.

Originally created in 1960 and used in a syringe form, Narcan was injected intravenously beneath patients’ tongues, in strong veins in their arms and in other common sites where an IV would be started, according to Bill Boyd, fire chief of the Bellingham Fire Department from 2003-12.

“Take a piece of cloth and pull the tongue up and there are blood vessels. All you do is you take that needle and you shove it under the skin because it’s very vascular there, and the Narcan is rapidly absorbed into the bloodstream,” Boyd said.

It takes about 30 seconds to one minute for the effects to appear when used with an IV.

Flash forward to 2018 and the most common method of administration now is nasally, EMS supervisor Scott Farlow said.

Syringes preloaded with Narcan are connected with a mucosal-atomizing device at the tip. The mucosal atomizing device causes the Narcan to become a mist, which is a more effective method of administration. The greater the surface area that it mists, the greater the body’s capacity to take the medication in faster.

In a scenario where time is of the essence, methods like this can make all the difference. Administered correctly, it can take up to five minutes to see the effects.

“That five minutes can seem like it’s really long for people who are not used to looking at someone who’s not breathing for five minutes,” Farlow said.

Five minutes without oxygen can also have a huge impact on the quality of life a person has when they wake up. The brain needs oxygen and when it does not receive it, cells start to die off, which causes brain damage. Patients can wake up with memory loss, impaired vision and hearing, communication impairment or the loss of coordination.

This practice of using Narcan was implemented in Bellingham about 20 years ago to both keep the first responders safe by avoiding exposing them to untested blood, and to make it more efficient, by avoiding scarred-over veins.

Fairly quick to act, the drug also has a short time span once injected, lasting only about 30-90 minutes. While in the patient’s system, it keeps the patient awake and breathing, but once it leaves their system they can end up right back into an overdose.

If a patient took a lethal dose of an opiate, some might have worn off in the timeframe, but if not enough has worn off, the patient could start overdosing again. There is no way to know how severe the overdose is, which is why it is important for first responders to persuade patients to go to the hospital.

Overdose symptoms include a variety of characteristics including sweating, nausea, difficulty breathing and vomiting which can span from a few minutes to a few hours.

After being pulled out of their high and pushed into withdrawals, patients sometimes become violent and angry. Some patients refuse to go to the hospital, instead choosing to stay under the watchful eye of a friend or family member.

Unless a person is going through an opioid overdose, Narcan has no effect on the body. For this reason, Narcan can be used as a diagnostic tool, injected into people whose ailment is unknown to first responders.

“If we got on the scene and somebody was unconscious and the history we were given was kind of unknown, we would give Narcan as a diagnostic tool,” Boyd said. “You could have somebody that had an accidental overdose, slipped a mickey or something where somebody spiked a drink, we would use Narcan as a way to rule out a narcotic overdose.”

Such a response is part of the basic training paramedics receive. In the field they are operating under standing orders by a physician. In standing orders medics react based on the information they gather on the scene and how the patient presents. Since the introduction of the nasal spray, training on how to react and treat opioid overdoses has not changed.


Emotional impact on first responders

The impact of an overdose and the lasting effects it can have is not lost on the first responders of Bellingham.

Narcan has had the ability to make a huge difference in changing the attitudes of some of the officers like Dante Alexander. Before, all they could do was offer CPR and wait for EMS to arrive.

“It’s not fun to see a person turning blue and realizing that especially before Narcan, there wasn’t a whole lot that you could do,” Alexander said.


Before Narcan officers like Sgt. Dennis James of the Bellingham Police Department, struggled with the lack of control they had at their job.

“Most officers do this [job] because they want to help people and most officers hate the feeling of helplessness,” James said. “When you are dealing with those kinds of things you have things you can do, and you can try and help but there is only so much you can do.”

Officers attempt to do first aid and CPR up until the medics get there and try to save someone, but often times it is not enough.

“The ones [where] they don’t survive are hard, you know, because you’re seeing someone that was just right before that was alive and had potential and hope,” James said. “Then when they’re gone you just think about the families, the loss that they are going to have.”

For former Bellingham Fire Chief Bill Boyd, and many first responders, it is the impact that it has on families that is the hardest.

“What we are finding is that we are rolling up to a car where there is a mom and dad unconscious, not breathing in the car, and a kid strapped in the back seat. That is really hard on first responders, like fire and police, to see that sort of thing,” Boyd said. “I can’t imagine that it doesn’t have a negative impact on first responders, because they see the impact that it has on families.”

This is the reality of first responders, but they still work tirelessly to help those in need.


Narcan spending in Bellingham

Narcan can now be found in almost any police car, ambulance and firetruck in the United States.

The same can be said for first responders in Bellingham, both fire and police personnel have access to the life-saving drug.

The fire department has been carrying Narcan for more than 20 years, but for the police department it is a relatively new development, having been purchased for the first time Oct. 18, 2016. The only other purchase of naloxone by the police department was May 2017, for $450.

Originally purchased for police officers for interdepartmental use when accidentally exposed and dosed with opioids, officers like Sgt. Dennis James have started using Narcan on the public.

“The reason we bought the Narcan was actually for officers because fentanyl has become popular,” James said. “Because an officer has no resistance to it they end up passing away right away and so we bought the Narcan for the officers, but no officer wants to see someone lose their life so they are using them on people as well.”

Narcan is available to each police officer in packs of two four-milligram intranasal doses.

The fire department, however, spends a significantly larger amount on the drug. In 2008, the fire department was spending $2,269.37. Spending peaked in 2016 when it increased to $11,722.37 and by 2017, the spending was at $7,967.43. In a nine-year period that is an increase of 251.08 percent on spending on Narcan.

This spending could greatly increase in the coming years if Narcan follows the trend of other naloxone manufacturers.

According to a study done by Dr. Nilay D. Shah in The New England Journal of Medicine, Amphaster produces a one milligram-per-milliliter vial of naloxone that cost $20.34 in 2009, and has risen 91.69 percent in cost to $39.60 in 2016.

Perhaps the most dramatic price raise has been Evzio, a two-pack of single-use prefilled auto-injector, whose cost has risen 552.17 percent, from $690 in 2014 to $4,500 in just two years.

In fact, of six naloxone products on the market, three have had a price increase, and for two of them it has been a rise of over 100 percent.

Previously these products have been available by prescription only, but states are making the drug more available to the public now. In 44 states, you can buy a naloxone product without a prescription at CVS and in 46 you can buy it at Walgreens. In Washington state it can be purchased at both.

In Whatcom County the drug can be purchased inside of a kit from Hoagland’s Pharmacy. The kit includes two doses of naloxone, a nasal atomizer and easy directions on how to use the kit. The kit currently costs $100 without a prescription but is cheaper when purchased with one.

For the past year Whatcom County Health Depart has been part of a pilot plan to provide people at risk of witnessing an opioid overdose to obtain Naloxone for free and Narcan for a fee. To obtain the prescription those who want to carry it must go through a 30 minute training session. Most recently, this pilot plan has been approved to continued for five more years through a federal grant.     


Even with the public access to Narcan, first responders are seeing increases in overdoses around Bellingham.

“Our use of Narcan is pretty excessive now, and when you add to that the public’s ability to access Narcan and the fact that Narcan is being used in a public access format without us knowing about it, and yet we are still seeing an uptake in the use of our Narcan medication,” Farlow said.


As the accessibility for this drug increases, first responders like Farlow believe that this could be a good thing in fighting the new influx in opioid overdoses.

“We have come across a lot of cases where people, civilians [and] residents have given Narcan to their family members and then called us,” Farlow said. “The intent is to get as many people exposed to Narcan as we can… I don’t have a problem with other people in the public sector having it as long as if they have to use it, they call us.”


If it is not reported or recorded, the demographics for the depth of the problem is not recognized.

“We need to make sure that law enforcement and fire is always kept abreast of these instances, that we are always called to mitigate them in the end,” Farlow said. “We need to be able to have the information available to us, so that we can go take those demographics and use those to help create legislature that hopefully fixes the problem.”

It is the legislature that will provide a lasting fix to this ongoing problem.

In 2017, Washington state released an Interagency Opioid Working Plan, and one of the goals was to prevent deaths from overdose, which is one of the major roles Narcan plays. It would be hard to keep prescribing Narcan though, if it follows the same trend as some of its equals.

“Naloxone coprescribing and expanded availability represents only one of many potential strategies for reducing the number of prescription-opioid and heroin overdose deaths in the United States. But when governments promote naloxone use, they have a responsibility to ensure the drug’s affordability. Taking action now is essential to ensuring that this life saving drug is available to patients and communities,” Shah wrote.

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