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In the 2017 documentary, Heroin(e), Fire Chief Jan Rader speaks
to a crowd gathered to learn about the opioid epidemic that has ravaged their
small industrial town of Huntington, West Virginia (McMillion-Sheldon & McMillion-Sheldon, 2017). At
41.5 deaths out of 100,000, the rates for drug overdose deaths in West Virginia
are the highest in the nation (Centers for Disease Control and Prevention, 2017-b).
As a 22 year veteran and leader of the local fire department, she witnessed the
huge influx of overdoses each year and cannot speak highly enough about the
life saving drug naloxone, also known by its brand name, Narcan or Evzio. One
gentleman in the audience asked Chief Rader how she would respond to those who
believe having naloxone available only empowers addicts to continue using.
Without hesitation, she replied, “The only qualification for getting into
long-term recovery is you have to be alive. I don’t care if I have to save
someone 50 times. That’s 50 chances to get into long term recovery” (McMillion-Sheldon &
McMillion-Sheldon, 2017).

            Although
the opioid epidemic has hit the communities like Huntington, West Virginia in the
‘rust belt’ region of the United States particularly hard, this problem transcends
state lines and has become part of our national discourse. According to data
provided by the Centers for Disease Control and Prevention (CDC), heroin use
has surged in most demographic groups from 2002 to 2013, with significant
increases emerging in groups with “historically low rates of heroin use: women,
the privately insured, and people with higher incomes” (CDC, 2017-a, para. 1).
Opioid misuse and addiction affects all ages, ethnicities, gender, and
socioeconomic backgrounds, and as of August 2017, the CDC estimates that
approximately 91 Americans die every day from an opioid overdose (CDC, 2017-d).

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The use of heroin
by adolescents, aged 12-17, and young adults, aged 18-25, has also increased at
an alarming rate. The CDC reports that between 2002 and 2013, heroin use jumped
109% in young adults aged 18-25 (Centers for Disease Control and Prevention,
2017-a). Data provided by the National Center for Health Statistics (NCHS), a
subdivision of the CDC reveals an increase in fatal drug overdoses of
adolescents aged 15-19. These results which are highlighted in Figure 1
(Curtin, Tejada-Vera, & Warner, 2017) show that from 1999 to 2007, fatal
overdose rates peaked at 4.2 deaths (per 100,000). The period from 2007 to 2014
saw a 26% decline of overdose deaths (3.1 deaths), but by the end of 2015 that
trend reversed course, resulting in a 19% increase in overdose deaths (3.7
deaths). The majority of fatal overdoses in 2015 were identified as
unintentional, and were mostly attributed to opioid use, specifically heroin
(Curtin et al., 2017).

Figure 1: Fatal overdose rates for
adolescents aged 15–19, by sex: United States, 1999–2015

One reason we are
seeing high figures in opioid related overdoses and deaths is because of the
relatively new development of drug manufacturers and distributers adding
illicitly manufactured fentanyl and/or carfentanil to “improve potency” in batches
of heroin (Bond, A., 2016). Fentanyl and carfentanil are synthetic opioids that
are lethally stronger than heroin. Fentanyl is 50-100 times more potent than
morphine (CDC, 2017-c). Carfentanil, a variant of fentanyl is reportedly “100
times more potent than fentanyl, 4,000 times more potent than heroin, and
10,000 times more potent than morphine” (Carfentanil: The Latest Deadly Opiate,
n.d.). To put it into perspective, carfentanil has been historically used as an
elephant tranquilizer and it is so powerful that first responders must use
“gloves, facemasks, and even goggles to avoid accidently ingesting even the
smallest amounts” (Carfentanil: The Latest Deadly Opiate, n.d.).  The CDC calculates that from 2010 to 2015, deaths
attributed to synthetic opioids rose 219% from 3,007 to 9,580, highlighting the
severity of the epidemic (CDC, 2017-c, para. 1).

Naloxone (aka
Narcan) is a drug that is used to quickly and effectively treat opioid
overdoses. Because it is fast-acting, non-addictive, and can revive an
individual within minutes of being administered, it has been promoted as a
“miracle drug” (Seeyle, K.Q., 2016). Timely administration can also help
decrease some of the medical complications and consequences of overdosing, such
as heart problems and brain damage. As the opioid epidemic increasingly
devastates communities in the United States, naloxone has rapidly become a
well-known and recognized drug to fight against drug overdoses. It was approved
by the United States Food and Drug Administration (FDA) for opioid overdoses in
1971.

When an individual
consumes an opioid such as heroin, fentanyl, or oxycodone, the opioid binds to
receptors in the central nervous system (CNS) producing various effects such
as, “pain relief, mood changes, drowsiness, strong feelings of elation or
unease, decreased respiration, cough, constricted pupils, decreased peristalsis
in the gastrointestinal tract, and stimulation of the chemoreceptors that
control nausea and vomiting” (Calás, T., Wilkin, M., & Oliphant, C.M., 2016).
A consequence of “decreased respiration” in opioid users is the slowing down or
“complete cessation of breathing”, which results in an overdose (Calás et al.,
2017). Naloxone works as an “opioid antagonist” and does this by preventing
opioids from binding with receptors in the brain. It can be administered intravenously
through an IV, as a shot which is injected into muscle, or as a nasal spray.
When the medication is administered, the effects of the overdose are reversed,
and the user will go into immediate withdrawal. They may be feel irritable and
anxious as they experience symptoms of withdrawal such as diarrhea, body aches,
stomach pain, nausea, runny nose, and dizziness (Calás et al., 2017).

One afternoon in
August 2016, 26 overdoses were reported in a span of about 5 hours, completely
overwhelming Huntington, WV emergency medical services (EMS) which typically
respond to about 18-20 overdose calls in a week. All 26 individuals were
revived with the assistance of Narcan (Pearce, M., 2016). It was later
determined that the heroin had been cut with fentanyl. Even though there is
much cause to celebrate the rescue of 26 people, the opioid crisis has taken a
huge toll on the community and psyches of first responders. Gordon Merry, the
Director of Cabell-Huntington EMS holds monthly support group meetings at his
office to help Emergency Medical Technicians (EMTs) and paramedics deal with
the emotional impact of having to respond to this tragedy on a daily basis
(Iden, A., 2017). For Merry and other first responders, the ‘hardest thing to
deal with’ is the disquieting belief that the damage has already left its mark:
‘I think we’re losing a generation, maybe two generations. The adults are
having children, and the children, unfortunately, don’t have much of a chance
because of the environment they’re growing up in’ (Iden, A., 2017). Sadly, his
statement echoes the beliefs of many within the first responder community.

While firefighters
and paramedics routinely carry and administer naloxone in a prehospital
setting, the debate to equip non-medical first responders such as law
enforcement officers has been more divisive. Many local authorities have
expanded access of naloxone, but some departments have taken the opposite
stance. No one denies the effectiveness of naloxone, but many reject the idea
that it is a “cure” or a “fix-all” for the heroin epidemic (Stoffers, C.,
2015). There are concerns that naloxone has simply become a “safety net” which
has emboldened addicts to continue using and recklessly endangering their lives
(Stoffers, C., 2015).

Recently, Sheriff
Richard Jones of Butler County, Ohio came under fire for his unpopular decision
to not allow his deputies to carry naloxone (Wootson, C.R., 2017). He has
become the face or unofficial spokesman for law enforcement agencies that argue
against expanded access. Sheriff Jones made his sentiment clear in a July 2017
post on twitter: “Narcan not the answer. Wrong approach. Need a plan that is
proactive. Prevention.” He defends his position by arguing that providing
medical intervention could put his deputies in danger when an overdosed patient
wakes up “agitated and combative.” (Wootson, C.R. 2017). Although many law
enforcement agents counter argue that any physical risk due to “combative”
behaviors are minimal. Sheriff Jones also points out that law enforcement
agents “are not the hospital, not paramedics” and don’t carry other medical
supplies such as EpiPens for allergic reactions, or insulin for diabetics; the
fundamental argument being that life-saving interventions should be carried out
by emergency medical personnel (Wootson, C.R. 2017). Data presented by the Ohio
Department of Health (2015) indicates that in 2015, 2,590 deaths were
attributed to opioid related fatal overdoses, a staggering 775% increase from
296 opioid related deaths in 2003 (p. 8). With these shocking figures, it’s no
surprise that many organizations in and outside of the state of Ohio have
criticized Jones and other law enforcement administrators for not requiring
officers to stock up on naloxone.  

Starting in the
early to mid-1990s drug recovery advocacy groups began to promote the use of
naloxone as a harm reduction strategy to reduce opioid related overdose
fatalities. Harm reduction is a compassionate and strengths-based approach of
reducing the harmful consequences of drug use. It emphasizes choice, treating
individuals with dignity, and pursuit of treatment without defined outcomes. Van
Wormer and Davis describe harm reduction, as “decidedly optimistic and
strengths-based because it draws on positive possibility and hope” (2016, p.
81). Well before the implementation of harm reduction practices through
officially sanctioned, and federally backed policies, drug recovery advocacy
groups started distributing and educating on the use of take home naloxone kits
(Wheeler, E., Burk, K., McQuie, H., & Stancliff., S., 2012). Because it can
be administered by “minimally trained” non-medical personnel, it is regarded as
an “ideal” method for reversing overdoses, particularly within groups “who have
been prescribed opioid pain medication and in people who use heroin and other
opioids” (Wheeler et al., 2012).

Mirroring the
argument against law enforcement agents carrying naloxone, there are those that
are opposed to distribution of take home naloxone kits. As noted earlier, one
of the objections is the fear that distributing naloxone to drug users will
encourage or enable their drug use. Bazazi, Zaller, Fu, and Rich reported that
the current, existing data does not support this assertion, and in fact, two
separate studies of naloxone distribution sites, confirmed a “reduction in self-reported
drug use” (2010). Another argument is that providing naloxone allows addicts to
keep using drugs without having to seek treatment and care at a medical
facility, and without “facing some of the negative consequences of opiate
misuse” (Bazazi, A.R., Zaller, N.D., Fu, J.J. & Rich, J.D., 2010). As with
the first opinion, there is was no evidence to support this claim. Individuals
who are afraid to call 911 may risk facing death in the event of an overdose,
so having interventions readily available is an important part of minimizing
harm and reducing consequences. The most recent news to splash the headlines is
the availability of Narcan in big name pharmacy chains such as Walgreens and
CVS. These pharmacies are joining the effort to expand access to naloxone and
combat the consequences of drug abuse. Presently, it is available prescription
free in 41 states (Daily News, 2017).     

Riding the tsunami
wave of President Nixon’s war on drugs campaign, for many years, lawmakers
shied away from harm reduction strategies, preferring zero tolerance policies
and practices. Des Jarlais argues that part of the resistance to supporting and
implementing a harm reduction model of treatment is “rooted in historical
demonization of particular psychoactive drugs that were associated with
stigmatized racial/ethnic groups” (2017). Negative social perceptions and
“moralistic intolerance” of use of drugs created a situation where “abstinence
was seen as the only acceptable policy towards drug use” (Des Jarlais, 2017). Severe
sentencing laws punished drug users instead of offering them treatment and
help.

During President
Obama’s administration, lawmakers moved towards a more lenient stance regarding
criminalization of drug use. This is evident in the shift of laws regarding
marijuana possession and use. As of 2017, 29 states have adopted laws allowing
either recreational and/or medical marijuana use (Governing the States and
Localities, 2017). According to Van Wormer and Davis, recent opinion polls
indicated that “87% agree with the statement that we are losing the war on
drugs” and that more people are in favor of a “compassionate approach” in
dealing with drug users (2016, p. 513).

More lawmakers are
beginning to accept harm reduction as a sensible strategy for treating
addiction. One positive example involves the shift of policies outlined by the
Office of National Drug Control Policy (ONDCP). As recent as 2010, ONDCP was
firmly against the distribution of naloxone to drug users – prevention was the focus and main goal.
(“How ONDCP changed”, 2014, p. 4). Stirred by the FDA’s 2012 recommendation
that naloxone should be made available over the counter, the ONDCP made quick
strides to actively change their stance. Two years later, in 2014, the ONDCP was
on the “front lines” working closely with local law enforcement and first
responders to promote the use of naloxone (“How ONDCP changed”, 2014, p. 4).

In October 2017,
President Trump declared a public health emergency to help combat the opioid
crisis. While this declaration is a step in the right direction in building
more awareness, some saw the news as ‘disappointing’ and falling short of his
original promise to declare the opioid epidemic a national emergency (Allen,
G., & Kelly, A., 2017). The significant difference between a declaration of
a “public health emergency” and a “national emergency” involves access to
funding sources. A declaration of public health emergency only provides a “mere
$57,000 in funds to cover everything from telemedicine to naloxone distribution
expansions” – a drop in the ocean compared to the estimated $394.2 million
spent treating opioid addiction in 2016 (Goodnough, A., 2017). So far, despite the
Republican’s frequent attacks, they have been unsuccessful in their attempts to
repeal the Patient Protection and Affordable Care Act (ACA). But the fear is
that if the ACA is repealed and Medicaid expansion eliminated, it would disrupt
or even remove funding for opioid addiction treatment altogether. Many
advocates are also concerned about the current administration’s seemingly
ambivalent position on drug policy in general. While Trump has stressed the
importance in addressing the opioid crisis, he also promised a big ad campaign
that many feel is troublingly reminiscent of the “golden age of war on drugs”
when Nancy Reagan’s “Just Say No” message dominated national dialogue (Brico, E.,
2017). In a rejection of Obama era reforms, Trump’s attorney general, Jeff
Sessions aims to bring back criminalization of non-violent drug users, and
apply the harshest sentencing available (Brico, E. 2017).

To find a current
solution to the opioid epidemic we need a comprehensive strategy that looks to transform
and revolutionize various policies, while continuing to embrace a strength’s
based, harm reduction model of treatment. Efforts to educate and bring
awareness to this epidemic will help address the stigma associated with having
an addiction that often prevents people from admitting their problem and
seeking treatment. If people have a better understanding of addiction as a
chronic disorder, there will be greater willingness to help those that are in
need. Transformation can be a slow process, but hopefully the pendulum
continues to swing in the direction of compassionately helping drug users in
their journey to recovery.  

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