The patient’s sharp appearance made him an oddity in a Baltimore emergency room. He was fit and tanned, neatly groomed and dressed like a young banker on holiday. The staff noticed a membership card to the local athletic club dangling from his keychain. Heroin overdoses can be unsightly affairs: Disheveled patients with open sores and soiled underwear, littering vials and used needles beneath their stretchers. But not this gentleman.
He was alert now, following a hit of the overdose treatment Narcan, and a doctor had transferred him upstairs for observation. Narcan might save an addict’s life, but it kills their buzz, and the sudden withdrawal can provoke combative behavior. This guy stayed calm though. With the staff preoccupied, he started rummaging through his wallet. When a nurse returned to the room, he found the patient slumped over and blue. The young man had salvaged and snorted the remainder of his heroin, and had overdosed again, in his hospital bed. The staff was now as embittered as they were dumbstruck: They had just revived him. Orders were made for more Narcan.
Narcan, or naloxone, is a relatively new weapon in the war on opioids. It is one component of a new opioid bill that Congress passed this week, which will set up a state grant program to address opioid abuse. Some officials and supporters are expecting the drug to be a part of their campaigns against addiction, and the drug will undoubtedly save many people. But a brush with death doesn’t make you any less addicted to a drug like heroin. Narcan alone isn't enough to prevent fatal overdoses.
The opioid bill included language about some effective drug-based programs, ones that directly address addiction, but lacked adequate financial support. Efforts by Democrats in Congress to secure more money were unsuccessful. “We continue to believe this bill falls far short,” explained President Obama in a statement. The truth is that even with the funds proposed in Congress, the country will remain incapable of dealing with the problem. More resources are needed, and there may be only one place left to get them: the drug companies that enabled the country's opioid epidemic.
Narcan is a fine place to start, but it’s not a solution. Opioids can inhibit the body’s response to the accumulation of carbon dioxide, suppressing our incentive to keep breathing, and Narcan works to reverse the drugs' effects. The treatment started as an injection used in clinical settings, but now friends or family members can use it as a nasal spray or a simple, EpiPen-like injection. In the fall of 2015, the city of Baltimore launched a coordinated effort to distribute the drug to police officers and addicts alike.
Despite its efficacy, not everyone supports the indiscriminate distribution of Narcan. Some fear that the drug will act as an insurance policy for addicts, emboldening them to shoot up even more recklessly. Since Narcan became widely available in Baltimore last year, some ER providers say they have not witnessed a concurrent drop in overdoses. That's supported by data from the Maryland Department of Health and Mental Hygiene: Over the first three months of 2016, 383 people died of overdoses in Maryland, up from 318 at the same point last year. "The numbers are still going up,” said Mike Gimbel, former director of Baltimore County's substance-abuse office. “This harm-reduction model is obviously proving to be unsuccessful."
Some argue that those numbers could be because more and more people are using opioids, not because Narcan is failing to save people. It’s possible that consistently high overdose rates are attributable to the rise of fentanyl---the drug that killed Prince---which can be 50 to 100 times more powerful than morphine. Used as a cutting agent on the street, addicts don’t always know what they’re injecting.
But even supporters agree that Narcan is no substitute for treatment. It's a life-saving intervention, and that's it. Treating an addict is extremely difficult, and sometimes impossible when someone doesn’t want to quit. And even when an addict does want to quit, providers in the ER are frustrated with the lack of options.
For the uninsured, medical providers can only prescribe Narcan and maybe recommend a rehab facility somewhere out in the city. They're used to seeing repeat offenders, but are helpless to deal with the psychological roots of addiction. Emergency room staffers must assume the roles of psychiatrist, social worker, and parole officer all at once.
Baltimore is a good example of how ill-equipped ER providers can be to empathize with addicts. The city maintains an “eds and meds” economy, in which large medical and academic institutions supplanted manufacturing as a fiscal engine. You won’t find any Fortune 500 companies in Baltimore, but you will find the world renowned Shock Trauma center, as well as Johns Hopkins Hospital. Experts at these institutions are imported, and rarely cultivated from within the city. The ER is where the old and new worlds collide, a setting for awkward interactions between hyper-educated imports and the impoverished remnants of the city’s industrial past. In these situations it becomes even harder to provide everything the addicts who walk through the door need.
Responders at every level have seen this failure in action, and they're doing something about it. Local funds have been set aside for needle exchanges. Federal funding through Obama’s Affordable Care Act will be available in Baltimore to support a combination of therapy and medication-assisted treatment---the “whole patient” approach. Even politicians in Washington are crossing the aisle to help. And yet drug companies are still content to sit and watch.
In 2007, Purdue Pharmaceuticals pled guilty to charges that it had misled doctors and patients about the addictiveness of OxyContin. They were forced to pay roughly $600 million to the state of Virginia to settle the lawsuit, which amounted to a speeding ticket for a company that has earned over $31 billion from the sale of that drug alone. Prior to the settlement, Purdue had spent over a decade working to put legalized opioids in the hands of as many American patients as possible. Purdue witnessed the creation of pill-mills and black markets as they emerged across the country, and did virtually nothing to stop them. It is Purdue’s responsibility to at least provide the funds demanded by the President.
Years ago, heroin replaced painkillers as a drug of choice, and overdoses multiplied. During 2007---the year of the settlement---Baltimore City had the highest rate of drug-related deaths among all metropolitan counties. Since then, heroin-related deaths have skyrocketed in Maryland, as they have across the country. Of course, heroin predated pills in places like Baltimore, but as a distribution hub the city’s endemic problem grew along with America’s expanding clientele. Significant resources are still desperately needed to plug the capability gaps in our emergency rooms, and reach addicts the moment they regain consciousness. Narcan brings people back from the brink of death, but what is there to help them get their life back on track?
