Addicts Treat Others’ Overdoses

In the newest twist in harm reduction among users of dangerous drugs, a controversial study conducted here suggests that heroin addicts can be trained to treat fellow junkies against potentially fatal overdoses.

The project, co-funded by the San Francisco Department of Public Health, turned 24 longtime heroin users into enterprising street doctors, organizers say.

Supplied with syringes containing the anti-overdose drug naloxone and trained in cardio-pulmonary resuscitation, the users were able to take timely lifesaving measures with a drug now available only to physicians and paramedics. The moment a companion had an overdose reaction, the trained addict injected the drug into the victim’s leg or shoulder.

Researchers from the Urban Health Study will release their naloxone study results Monday at the National Harm Reduction Conference in Seattle. The group is composed of health-care experts who specialize in such efforts as needle exchange programs for drug users.

They also want San Francisco officials to consider becoming the first major city in the West to distribute naloxone. The drug is available to addicts in New Mexico and Chicago, and Baltimore officials plan to start dispensing naloxone next year.

Proponents say naloxone is a legal, nonaddictive drug that does not produce a high or sense of euphoria. When injected into a major muscle, naloxone, commonly known by its brand name Narcan, sends overdose victims into an instant acute withdrawal.

The drug works by binding to the brain receptors that normally attract opiates such as heroin, morphine or methadone. Without naloxone, heroin overdose victims often die from respiratory failure.

“This drug has been shown to save lives,” said Karen Seal, a physician and lead author of the 2001 study.

But critics say dispensing naloxone to addicts as a harm reduction technique is really harm promotion. “You’re putting a very serious medication into the hands of untrained people,” said Eric Voth, an addiction medication specialist and chairman of the nonprofit Institute on Global Drug Policy.

“The answer to heroin addiction is aggressive outreach, not an end-around against modern medicine. City officials should beware of the serious liability issues if someone dies after being administered this drug by another addict.”

Seal, an assistant professor of family and community medicine at UC San Francisco, said a citywide dissemination of naloxone would improve the lives of an intravenous drug population estimated to be as large as 14,000 to 17,000.

Each year, San Francisco hospitals see more than 100 heroin overdose deaths, many of which Seal believes could have been prevented. Doing her time in the emergency room, she saw the culture of heroin while responding to as many as half a dozen overdose victims a day.

She knows the futile result of street techniques used by junkies to stop a heroin overdose: everything from injecting victims with salt water or milk to immersing them in an ice bath.

A bigger problem is that many addicts, when witnessing an overdose, are reluctant to call 911 or summon help, for fear of arrest.

Two years ago, Seal set out to discover “why people could stand by a heroin overdose victim and not intervene.”

For six months, her study employed 12 teams of heroin addicts -- users so dependent that they no longer take the drug to get high, but rather to avoid the agony of withdrawal. After eight hours of training, participants were given kits containing vials of naloxone, latex gloves and alcohol wipes.

Half were homeless. Their median age was 40 and one-third were women. The goal was for each team member to look out for the other and be on hand with naloxone if one of them overdosed.

In all, the participants witnessed about 20 overdoses and used naloxone in 14 cases, resorting to CPR in the others. One participant died after injecting heroin while alone.

Seal said researchers initially feared that they could harm addicts by giving them naloxone. “We didn’t know whether they’d become vigilantes and use more heroin because they felt they had this magic anti-overdose antidote,” she said.

But researchers found that whereas in the six months before the study the group reported 68 overdoses, in the six months after the study only five occurred, although naloxone was no longer available.

Seal said their participation led many study subjects to seek referrals to methadone clinics, although there is no evidence that the drug itself does anything to discourage heroin use.

One participant was William Bowden. The 51-year-old Philadelphia native and longtime junkie said carrying naloxone gave him a new take on San Francisco’s back-alley heroin scene.

“When you’re a junkie, nobody cares about you; you don’t even care about yourself,” he said. “But this study made me look at things differently. By being concerned about others, I became more concerned about myself.”

Seal said addicts showed researchers even more enterprise: In more than half of the 14 cases in which naloxone was used, it was administered not to the participant’s addict partner but to strangers they encountered on the street.

Many offered mouth-to-mouth emergency treatment to strangers who were violently ill. “They took a risk of being arrested to save somebody else,” Seal said.

San Francisco officials aren’t exactly lining up behind a naloxone program for addicts.

Joshua Bamberger, medical director of the housing and urban health section of the city’s Department of Public Health, said other outreach efforts helped drive the city’s heroin overdose deaths to a 10-year low of 101 in 2001.

“It’s undoubtedly worth exploring,” he said of the naloxone plan. “But I don’t know the political lay of the land.”

Critics remain disturbed by the image of addicts cast as lifesavers. They might mistake alcohol or cocaine overdoses and inject naloxone, delaying proper medical help.

“To receive naloxone is a hellish experience,” said Voth of the Institute on Global Drug Policy. “People go into instant withdrawal and often suffer vomiting, diarrhea and extreme agitation. I don’t think other addicts could ever be trained to manage such an ordeal.”

Seal said study participants were trained for just such a result. “People who’ve been given naloxone wake up angry, and we told our participants the victim might look at them like ‘Hey, you just ruined my high,’ ” she said.

“People don’t understand that they’ve basically died and have just been saved.”

Despite such drawbacks, public distribution of naloxone has worked in New Mexico, where a state law passed in 2001 legally protects people who inject an overdose victim with naloxone. San Francisco researchers say they would push for a similar liability law.

Chicago also has seen dramatic effects since the drug began being dispensed through private clinics. “Not long ago, 466 people died in Cook County alone from heroin overdose in a single year,” said Dan Bigg, executive director of the Chicago Recovery Alliance. “The people bitten by the snake of heroin addiction couldn’t cope.”

Last year, the county saw a 20% drop in heroin-related deaths, its first. Bigg attributed that to getting naloxone onto the streets. “It works,” he said.

In contrast, Portland, Maine, has backed away from a plan to give naloxone to heroin users. “We got flak from law enforcement and the community -- letters and e-mails,” said Gerald Cayer, the city’s director of Health and Human Services.

But drug policy experts say naloxone’s time may have come.

Ricky Bluthenthal, a social scientist in the health program and drug policy research center at the Rand Corp. in Santa Monica, said the federal government should encourage study of naloxone use among heroin addicts.

“If you give drug users the tools that lead them to be healthy, they’ll use them as intended,” he said.