More potent drugs raise stakes in Ohio’s fight against opioids

What is naloxone?

Naloxone, also known by the brand name Narcan, is a medication that can reverse an overdose caused by an opioid drug (heroin or prescription pain medications). When administered during an overdose, naloxone blocks the effects of opioids on the brain and quickly restores breathing. Naloxone has been used safely by medical professionals for more than 40 years.

If naloxone is given to a person who is not experiencing an opioid overdose, it is harmless. If naloxone is administered to a person who is dependent on opioids, it will produce withdrawal symptoms. Withdrawal, although uncomfortable, is not life-threatening. Naloxone does not reverse overdoses that are caused by non-opioid drugs, such as cocaine, benzodiazepines (e.g. Xanex, Klonopin and Valium), methamphetamines or alcohol.

Naloxone must be administered by a third-party because the overdose victim is unconscious or otherwise incapable of administering the medication personally. Due to a 2015 change in Ohio law, a pharmacist or pharmacy intern under the direct supervision of a pharmacist can dispense naloxone without a prescription..

Source: Ohio Department of Mental Health & Addiction Services

Recognizing an overdose

If someone takes more opioids than their body can handle, they can pass out, stop breathing and die. An opioid overdose can take minutes or even hours to occur.

A person who is experiencing an overdose may have the following symptoms:

Source: State of Ohio Board of Pharmacy

How to respond to an overdose

1. Try to wake the person up by yelling their name and rubbing the middle of their chest with your knuckles (sternum rub).

2. Call 9-1-1. Indicate the person has stopped breathing or is struggling to breathe.

3. Make sure nothing is in the person’s mouth that could be blocking their breathing. If breathing has stopped or is very slow, begin rescue breathing.

Rescue Breathing

4. Use naloxone and continue rescue breathing at one breath every 5 seconds.

5. If the person begins to breathe on their own, put them

on their side so they do not choke on their vomit. Continue to monitor their breathing and perform rescue breathing if respirations are below 10 breaths a minute. If vomiting occurs, manually clear their mouth and nose.

6. Stay with the person until EMS arrives.

Source: State of Ohio Board of Pharmacy

Overdose risk factors and prevention

Opioids include both heroin as well as prescription medications used to treat pain such as morphine, codeine, methadone, oxycodone (Oxycontin, Percodan, Percocet), hydrocodone (Vicodin, Lortab, Norco), fentanyl (Duragesic, Fentora), hydromorphone (Dilaudid, Exalgo), and buprenorphine (Subutex, Suboxone). The following are some common risk factors for opioid overdose as well as some prevention strategies:

Mixing Drugs

Many overdoses occur when people mix heroin or prescription opioids with alcohol and/or benzodiazepines. Alcohol and benzodiazepines (Xanax, Klonopin, Ativan and Valium) are particularly dangerous because, like opioids, these substances impact an individual’s ability to breathe. Avoid mixing opioids with other drugs or alcohol. If prescribed an opioid and a benzodiazepine by a prescriber, take only as directed.

Tolerance

Tolerance is your body’s ability to process a drug. Tolerance changes over time so that you may need more of a drug to feel its effects. Tolerance can decrease rapidly when someone has taken a break from using an opioid. When someone loses tolerance and then takes an opioid again, they are at-risk for an overdose, even if they take an amount that caused them no problem in the past. If you are using opioids after a period of abstinence, start at a lower dose.

Physical health

Your physical health impacts your body’s ability to manage opioids. Since opioids can impair your ability to breathe, if you have asthma or other breathing problems you are at higher risk for an overdose. Individuals with liver (hepatitis), kidney problems and those who are HIV-positive are also at an increased risk of an overdose.

Previous overdose

A person who has experienced a nonfatal overdose in the past has an increased risk of a fatal overdose in the future. To prevent a fatal overdose, teach family and friends how to recognize and respond to an overdose.

For help, dial the Ohio Department of Mental Health and Addiction Services toll-free at (877)275-6364 to find an addiction services provider near you.

Source: State of Ohio Board of Pharmacy, Ohio Department of Mental Health and Addiction Services

Skyrocketing costs

Naloxone is now carried at more than 1,000 Ohio pharmacies and is available without a prescription. Some private insurers will also pay for some of the cost. Many of those purchasing naloxone are now covered by Medicaid, which will reimburse the entire cost for some variants of the drug.

In 2015, Ohio Medicaid reimbursed pharmacies $212,047 for 778 naloxone claims. That number has skyrocketed. During the first eight months of this year, 2,262 claims totaled $782,796, according to Ohio Medicaid records.

Many still view naloxone as a double-edged sword, including pharmacist Dr. Kindy Ghussin, who dispenses the drug at the Heartland Pharmacies he owns in Kettering and Moraine.

“On one side you can help with saving lives. If someone does overdose they have this life-saving syringe. They can inject themselves and come back from the dead,” Ghussin said. “But there are those users who think that now they have this life-saving ticket that they can go crazy with abusing street drugs because they now have in their pocket this magical syringe that’s going to bring them back from the dead. And that’s not necessarily true. Once you go down that route there’s no guarantee you’re going to come back.”

Ghussin sells generic naloxone at $40 for the medicine and an additional $7 for the atomizer. He can order other versions including naloxone in an already pre-packaged nasal spray for around $700, or two single-dose auto-injector devices for a mind-boggling $3,500.

“It has to be covered by insurance for the patient to get it, otherwise they’re not going to get it, Ghussin said. “Nobody’s going to cough up that much money.”

Free generic naloxone kits are available to Montgomery County residents at noon each Wednesday through Project DAWN at Samaritan Behavioral Health.

Recognizing an overdose

If someone takes more opioids than their body can handle, they can pass out, stop breathing and die. An opioid overdose can take minutes or even hours to occur.

A person who is experiencing an overdose may have the following symptoms:

Source: State of Ohio Board of Pharmacy

How to respond to an overdose

1. Try to wake the person up by yelling their name and rubbing the middle of their chest with your knuckles (sternum rub).

2. Call 9-1-1. Indicate the person has stopped breathing or is struggling to breathe.

3. Make sure nothing is in the person’s mouth that could be blocking their breathing. If breathing has stopped or is very slow, begin rescue breathing.

Rescue Breathing

4. Use naloxone and continue rescue breathing at one breath every 5 seconds.

5. If the person begins to breathe on their own, put them

on their side so they do not choke on their vomit. Continue to monitor their breathing and perform rescue breathing if respirations are below 10 breaths a minute. If vomiting occurs, manually clear their mouth and nose.

6. Stay with the person until EMS arrives.

Source: State of Ohio Board of Pharmacy

Overdose risk factors and prevention

Opioids include both heroin as well as prescription medications used to treat pain such as morphine, codeine, methadone, oxycodone (Oxycontin, Percodan, Percocet), hydrocodone (Vicodin, Lortab, Norco), fentanyl (Duragesic, Fentora), hydromorphone (Dilaudid, Exalgo), and buprenorphine (Subutex, Suboxone). The following are some common risk factors for opioid overdose as well as some prevention strategies:

Mixing Drugs

Many overdoses occur when people mix heroin or prescription opioids with alcohol and/or benzodiazepines. Alcohol and benzodiazepines (Xanax, Klonopin, Ativan and Valium) are particularly dangerous because, like opioids, these substances impact an individual’s ability to breathe. Avoid mixing opioids with other drugs or alcohol. If prescribed an opioid and a benzodiazepine by a prescriber, take only as directed.

Tolerance

Tolerance is your body’s ability to process a drug. Tolerance changes over time so that you may need more of a drug to feel its effects. Tolerance can decrease rapidly when someone has taken a break from using an opioid. When someone loses tolerance and then takes an opioid again, they are at-risk for an overdose, even if they take an amount that caused them no problem in the past. If you are using opioids after a period of abstinence, start at a lower dose.

Physical health

Your physical health impacts your body’s ability to manage opioids. Since opioids can impair your ability to breathe, if you have asthma or other breathing problems you are at higher risk for an overdose. Individuals with liver (hepatitis), kidney problems and those who are HIV-positive are also at an increased risk of an overdose.

Previous overdose

A person who has experienced a nonfatal overdose in the past has an increased risk of a fatal overdose in the future. To prevent a fatal overdose, teach family and friends how to recognize and respond to an overdose.

For help, dial the Ohio Department of Mental Health and Addiction Services toll-free at (877)275-6364 to find an addiction services provider near you.

Source: State of Ohio Board of Pharmacy, Ohio Department of Mental Health and Addiction Services

Skyrocketing costs

Naloxone is now carried at more than 1,000 Ohio pharmacies and is available without a prescription. Some private insurers will also pay for some of the cost. Many of those purchasing naloxone are now covered by Medicaid, which will reimburse the entire cost for some variants of the drug.

In 2015, Ohio Medicaid reimbursed pharmacies $212,047 for 778 naloxone claims. That number has skyrocketed. During the first eight months of this year, 2,262 claims totaled $782,796, according to Ohio Medicaid records.

Many still view naloxone as a double-edged sword, including pharmacist Dr. Kindy Ghussin, who dispenses the drug at the Heartland Pharmacies he owns in Kettering and Moraine.

“On one side you can help with saving lives. If someone does overdose they have this life-saving syringe. They can inject themselves and come back from the dead,” Ghussin said. “But there are those users who think that now they have this life-saving ticket that they can go crazy with abusing street drugs because they now have in their pocket this magical syringe that’s going to bring them back from the dead. And that’s not necessarily true. Once you go down that route there’s no guarantee you’re going to come back.”

Ghussin sells generic naloxone at $40 for the medicine and an additional $7 for the atomizer. He can order other versions including naloxone in an already pre-packaged nasal spray for around $700, or two single-dose auto-injector devices for a mind-boggling $3,500.

“It has to be covered by insurance for the patient to get it, otherwise they’re not going to get it, Ghussin said. “Nobody’s going to cough up that much money.”

Free generic naloxone kits are available to Montgomery County residents at noon each Wednesday through Project DAWN at Samaritan Behavioral Health.

Recognizing an overdose

If someone takes more opioids than their body can handle, they can pass out, stop breathing and die. An opioid overdose can take minutes or even hours to occur.

A person who is experiencing an overdose may have the following symptoms:

Source: State of Ohio Board of Pharmacy

How to respond to an overdose

1. Try to wake the person up by yelling their name and rubbing the middle of their chest with your knuckles (sternum rub).

2. Call 9-1-1. Indicate the person has stopped breathing or is struggling to breathe.

3. Make sure nothing is in the person’s mouth that could be blocking their breathing. If breathing has stopped or is very slow, begin rescue breathing.

Rescue Breathing

4. Use naloxone and continue rescue breathing at one breath every 5 seconds.

5. If the person begins to breathe on their own, put them

on their side so they do not choke on their vomit. Continue to monitor their breathing and perform rescue breathing if respirations are below 10 breaths a minute. If vomiting occurs, manually clear their mouth and nose.

6. Stay with the person until EMS arrives.

Source: State of Ohio Board of Pharmacy

Overdose risk factors and prevention

Opioids include both heroin as well as prescription medications used to treat pain such as morphine, codeine, methadone, oxycodone (Oxycontin, Percodan, Percocet), hydrocodone (Vicodin, Lortab, Norco), fentanyl (Duragesic, Fentora), hydromorphone (Dilaudid, Exalgo), and buprenorphine (Subutex, Suboxone). The following are some common risk factors for opioid overdose as well as some prevention strategies:

Mixing Drugs

Many overdoses occur when people mix heroin or prescription opioids with alcohol and/or benzodiazepines. Alcohol and benzodiazepines (Xanax, Klonopin, Ativan and Valium) are particularly dangerous because, like opioids, these substances impact an individual’s ability to breathe. Avoid mixing opioids with other drugs or alcohol. If prescribed an opioid and a benzodiazepine by a prescriber, take only as directed.

Tolerance

Tolerance is your body’s ability to process a drug. Tolerance changes over time so that you may need more of a drug to feel its effects. Tolerance can decrease rapidly when someone has taken a break from using an opioid. When someone loses tolerance and then takes an opioid again, they are at-risk for an overdose, even if they take an amount that caused them no problem in the past. If you are using opioids after a period of abstinence, start at a lower dose.

Physical health

Your physical health impacts your body’s ability to manage opioids. Since opioids can impair your ability to breathe, if you have asthma or other breathing problems you are at higher risk for an overdose. Individuals with liver (hepatitis), kidney problems and those who are HIV-positive are also at an increased risk of an overdose.

Previous overdose

A person who has experienced a nonfatal overdose in the past has an increased risk of a fatal overdose in the future. To prevent a fatal overdose, teach family and friends how to recognize and respond to an overdose.

For help, dial the Ohio Department of Mental Health and Addiction Services toll-free at (877)275-6364 to find an addiction services provider near you.

Source: State of Ohio Board of Pharmacy, Ohio Department of Mental Health and Addiction Services

Skyrocketing costs

Naloxone is now carried at more than 1,000 Ohio pharmacies and is available without a prescription. Some private insurers will also pay for some of the cost. Many of those purchasing naloxone are now covered by Medicaid, which will reimburse the entire cost for some variants of the drug.

In 2015, Ohio Medicaid reimbursed pharmacies $212,047 for 778 naloxone claims. That number has skyrocketed. During the first eight months of this year, 2,262 claims totaled $782,796, according to Ohio Medicaid records.

Many still view naloxone as a double-edged sword, including pharmacist Dr. Kindy Ghussin, who dispenses the drug at the Heartland Pharmacies he owns in Kettering and Moraine.

“On one side you can help with saving lives. If someone does overdose they have this life-saving syringe. They can inject themselves and come back from the dead,” Ghussin said. “But there are those users who think that now they have this life-saving ticket that they can go crazy with abusing street drugs because they now have in their pocket this magical syringe that’s going to bring them back from the dead. And that’s not necessarily true. Once you go down that route there’s no guarantee you’re going to come back.”

Ghussin sells generic naloxone at $40 for the medicine and an additional $7 for the atomizer. He can order other versions including naloxone in an already pre-packaged nasal spray for around $700, or two single-dose auto-injector devices for a mind-boggling $3,500.

“It has to be covered by insurance for the patient to get it, otherwise they’re not going to get it, Ghussin said. “Nobody’s going to cough up that much money.”

Free generic naloxone kits are available to Montgomery County residents at noon each Wednesday through Project DAWN at Samaritan Behavioral Health.

Officer Joe Sheen flies down Keowee Street in his Dayton Police cruiser, makes a hard left turn and then throttles upward of 60 mph on East Third Street.

He doesn’t say a word, dodging other drivers, before jamming the vehicle into park sideways in front of a house on Irwin Street. He bounds past the toys in the yard and the Halloween decorations on the front door and races up to a second-floor bedroom where an unconscious man is on the carpet.

As heroin and its many substitutes course through the underbelly of the city, Sheen’s main weapon is in the right front pocket of his cargo pants: the drug that reverses an opioid overdose.

“The telltale signs are the agonal breathing — that snoring thing — and then pinpointed eyeballs,” says Sheen, an 11-year veteran of the force.

But neither he nor the medics who would soon join him in that room had ever encountered anything quite like this.

‘Lazarus drug’

The nation is now painfully familiar with the opiates that cause death: prescription pain pills, heroin and fentanyl. But the raging opioid epidemic has also introduced Americans to a drug that literally brings people back to life from an opioid overdose.

Naloxone — often called by the brand name Narcan — is known as the “Lazarus drug.”

So often used to reverse overdoses, its trade name has morphed into a verb used by first responders and those familiar with addiction. Thousands of Ohioans each year now get “Narcaned.”

While 2,590 Ohioans died of unintentional opioid overdoses last year, an untold number have been saved — sometimes over and over again. Emergency Medical Services (EMS) providers in the state administered at least 20,000 doses of naloxone in 2015.

Beat cops like Sheen are each armed with naloxone and are often the first to respond to an overdose. But Dayton EMS providers who work for the fire department burn through the majority of the naloxone used in the county, according to data reported to the state. The drug is administered intranasally, by injection or, in some cases, intravenously.

The cost of naloxone raises a chilling question: How much is a life worth?

The Dayton Fire Department will administer an estimated 4,663 doses of naloxone to 1,300 people by year’s end, roughly double the number of doses from last year. At about $40 a dose, the 2016 projection would exceed $187,000 — and that’s just for the fire department. Add in the costs to the various other jurisdictions throughout the county — as of Sept. 12, Dayton Police had used Narcan on 361 people since the program started a little more than two years ago — and heroin is extracting a numbing toll on taxpayers.

Police and fire get their funding and supply of naloxone from different sources. A central naloxone repository has been set up at the Dayton Police Department to supply the drug to Montgomery County law enforcement agencies. It operates through a mix of funding by the Alcohol, Drug Addiction and Mental Services board of Montgomery County (ADAMHS), Public Health – Dayton & Montgomery County and state grants. Entire funding for this year amounts to $80,748, according to ADAMHS.

The fire department is supplied Narcan by the Greater Miami Valley EMS Council, which is administered by the Greater Dayton Area Hospital Association. The EMS Council provides the drug to 99 area fire and EMS agencies in Butler, Champaign, Clark, Darke, Greene, Miami, Montgomery, Preble, Shelby and Warren counties.

Stronger opioids arrive

It is a distressing outcome of the opiate crisis that while Narcan has unquestionably saved lives, the number of overdose deaths continues to climb. At least 400 people will die from unintentional drug overdoses this year in Montgomery County if the pattern from the first six months continues. Not only would that eclipse any previous high, it would shatter the previous record of 264 overdose deaths in 2014.

“We’re in the midst of an overdose epidemic,” said Daniel Raymond, policy director of the national Harm Reduction Coalition. “If community members, health departments and first responders can’t afford naloxone they cannot save lives.”

Some versions of naloxone have doubled or quadrupled in price the past three years. Compounding the costs to public health agencies and the state are newer and stronger synthetic opioids that require more medicine to pry opiates from brain receptors,” said state Rep. Jeff Rezabek, R-Clayton, who co-sponsored a successful Ohio law that took effect last year allowing pharmacists to dispense naloxone without a prescription.

“The problem that we’ve seen lately is the carfentanil and fentanyl itself coming in because it’s requiring more doses of naloxone to save those individuals,” Rezabek said.

Fentanyl and, more recently, carfentanil feed a demand from users seeking ever-more-potent street drugs. Fentanyl is up to 50 times more potent than heroin while carfentanil — a tranquilizer used to sedate elephants — is up to 100 times the strength of fentanyl.

Carfentanil is so potent a dose no larger than a grain of salt can kill a human being.

Still breathing

When Sheen arrives at the Irwin Street house the man on the floor is breathing but barely able to maintain an ominously slow guttural snore.

The opioid is closing in.

Police know the house. They were called here two months earlier because three people were overdosing.

“What’s his name?” Sheen asks the man who dialed 9-1-1, an occupant of the house.

Sheen calls out the name of the man OD’d on the floor several times and strains to lift him by his left arm to re-position him in the room. The man was wet, as was the floor around him.

“Did you soak him in water?” Sheen asks the 9-1-1 caller, knowing that’s what happened. Often doing so is counterproductive, though witnesses frequently use water to try to revive someone who is overdosing.

With gloved fingers, Sheen pries open the man’s eyes. His pupils are tiny, further confirming to Sheen the man is in the throes of an opioid overdose.

He pulls his Narcan kit from the pocket and affixes an atomizer to a syringe. He bends over and sprays a first dose — half into each of the man’s nostrils.

A TV in the room continues to play an infomercial as Sheen waits an excruciating two minutes for the naloxone to kick in.

It has no effect.

He administers a second dose, the last he has.

Nothing.

He yells the man’s name over and over to no response.

“Wake up!” he hollers. “Wake up!”

A ‘ton of Narcan’

Dayton Fire Department medics enter the room. The furniture, including the uncovered mattress on the floor, leaves little space for five to work so Sheen steps out.

The Medic 18 crew gives the man more naloxone. But they are having difficulty finding a vein to start an IV, a faster and more efficient way to deliver the medicine.

Another policeman asks the caller if the dog that wandered upstairs will cause a problem.

“No, he’s friendly,” the man says, but the dog is taken to another room as a precaution.

With three doses of Narcan — going on eight minutes since the first — speculation begins that there’s more than heroin at work on the man’s brain.

“Usually by now, two doses of Narcan will make them come to,” Sheen says. “My two have had no effect yet.”

One EMT looks for a vein in the man’s foot while another checks his pupils.

“They’re still a little small but after six they haven’t changed,” announces the medic checking the man’s eyes, not a foot away from an ashtray filled with cigarette butts.

“If that elephant tranquilizer stuff is in there it takes a ton of Narcan,” answers another.

Magic doses

“Let’s do two more,” says one medic hovering over the still lifeless body in the upstairs bedroom.

They administer doses 11 and 12 via IV.

“We’re out. That’s the last of the Narcan for us,” says another.

“Maybe these will be the magic two,” the other responds.

A ‘monstrous drug’

One dose of naloxone would typically revive a person overdosing on heroin but that’s not the case with the synthetic opioids hitting the street over recent years, said Tim Erskine, chief of Trauma Systems and Research for the Ohio Department of Public safety’s Ohio Emergency Medical Services. Erskine oversees the state database of naloxone uses.

“With this new carfentanil — the elephant tranquilizer — that takes many, many, many doses,” Erskine said. “When you stop to consider the strength of carfentanil … you are talking about a monstrous drug.”

Looking at EMS data, the climbing ration of doses per patient indicates use of much stronger drugs, Erskine said.

“One dose of naloxone generally works,” Erskine said. “With fentanyl it takes more.”

‘You overdosed’

At 2:37 p.m. a medic spots the first sign of life.

“We got an eye open,” he announces. “Are you waking up?” he says to the man.

“He’s waking up after 12 of Narcan,” another radios in.

The final two doses did the trick.

The man sits up but is dazed and begins half spitting, half vomiting. One of the EMTs holds a plastic cup under his mouth.

“Try to cough. There you go. You OD’d,” the medic says.

“Really?” the man slurs.

“It took us a bunch of Narcan. The most I’ve ever given,” the medic tells him. “Try to stand, alright buddy.”

“What happened?” asks the man still trying to comprehend.

“You overdosed. Come on partner, let’s get downstairs. Put your feet under you.”

The man is helped down the stairs but walks under his own power.

‘Pink’s not normal’

Outside the house Sheen chats with an EMT who tells him the man said he took one cap and the drug looked pink, a color that led them to believe the drug the man took was carfentanil.

“Pink’s not normal,” Sheen says.

‘The Racetrack’

The area between Xenia Avenue and East Third Street from Keowee Street to Smithville Road is what Dayton cops call “The Racetrack.” It’s where a majority of the city’s overdoses occur.

Sheen says if he patrols too far north he inevitably ends up back here. The number of doses of naloxone given the man on Irwin Street was unusual, but rolling up on someone who is overdosing is, sadly, an almost daily fixture of police work for him.

Sheen reported for duty at 2 p.m. After reviving the man he still had most of his shift left.

He swings by an East Dayton police station to replenish his naloxone supply and resumes patroling.

In an alley he stops to talk to Wendell Farmer, who says he had a $100-a-day heroin habit before recently entering treatment.

“We dealt with someone earlier,” Sheen tells Farmer. “They’re saying the stuff was like a pinkish color. It took 12 (naloxone) doses to revive him. It’s more potent than the fentanyl.”

Farmer says he’s heard of the elephant tranquilizer, but adds, “I don’t think I’ve had any of that stuff.”

He says a girl he liked first introduced him to heroin. “It’s kind of hard to explain,” he said. “It just takes you to another place. I fell in love with it the first time I did it.”

Sheen shows Farmer his naloxone kit and tells the 36-year-old he should keep some handy.

He offers to help him if Farmer stumbles.

They bump fists and part.

‘I’m sorry’

A dispatcher announces a man is down at Monument and Riverside near Fifth Third Field. Sheen steps on the gas and is there within minutes, lights on, siren blaring.

He arrives about the same time as an EMS medic, and they talk to the man as he sits up and is helped to a park bench.

“I’m sorry,” the man says, admitting he had taken drugs, including heroin.

“There’s nothing to be sorry about,” Sheen says before transporting the man to the hospital.

The man protests but Sheen gives a practical reason for getting medical help.

“What I’m afraid of, if we leave, you’re going to nod off and hit your pumpkin right there on the ground,” he tells the man.

When his shift ends the Narcan is still in his pocket.