HEROIN HASSLES

MEDICAL AND LEGAL ISSUES KEEP OVERDOSE ANTIDOTE OUT OF USERS' HANDS

Valerie S. was getting high in her Brooklyn apartment when a friend "went
out." She says, "I wasn't really close to the guy. He was a neophyte, a
married, college-educated professional, about 30. I made connections for
him and he sampled the product at my house. "It happened in stages. I was
nodding also, but I looked back and I saw that his legs were in a weird
position, spread on the floor. Something got my attention, maybe the
syringe falling. The first thing I saw when I looked closely was that he
was on the floor and blue.

"There wasn't time to think," she says."I tried mouth-to-mouth, I tried
CPR, but I realized, 'Wow, he's going.' By the time I realized I should
have called [an ambulance], it was too late. I had the naloxone in the
house, so I found a vein and injected him. He took a sharp inhalation of
breath and sat up."

Valerie's experience using naloxone, a prescription drug, to save a fellow
user from opiate poisoning makes a strong case for training others to do
the same and making the antidote more widely available.

Raising awareness is just what the Lindesmith Center, a drug policy think
tank in New York City, and 19 other agencies and organizations intend to
do. Later this month, they are sponsoring an international conference in
Seattle, "Preventing Heroin Overdose: Pragmatic Approaches." Attendees will
include scholars, service providers, outreach workers, and others who deal
with or are affected by heroin overdose.

Unfortunately, the need for naloxone is growing. Nationwide, according to
statistics from the U.S. government's Substance Abuse and Mental Health
Services Administration, there were 217,868 admissions to treatment
facilities for heroin addiction in 1997, up 24 percent from 1992. Between
1988 and 1997, heroin-related emergency room visits nearly doubled, from
18,100 to 36,000, according to the government-funded surveillance study
Drug Abuse Warning Network (DAWN). In New York, DAWN trends are confounded
by the HIV epidemic, but approximately 700 people die from opiate overdose
annually, according to the study's figures, which are compiled by local
medical examiners.

With heroin use up, inevitably, the incidence of overdosing rises. Among
those who take heroin, an overdose experience is the rule, not the
exception. Valerie has overdosed at least three times over the last several
years. Research studies from several countries consistently show that about
two-thirds of long-term heroin addicts report that they've overdosed at
least once. Nearly 80 percent have seen someone else do it. At least one
overdose a week is reported to New York's Positive Health Project needle
exchange. Though most overdose episodes aren't deadly, they can be.

It is impossible to overdose on naloxone, and there is no potential for
abuse. The drug can, however, produce unpleasant withdrawal symptoms if
given to an opiate addict in high doses. These symptoms are not
life-threatening. The medication is far more likely to cause dysphoria than
euphoria.

While conceivably adrenaline, cocaine, or speed could be used to treat
overdoses, each of these drugs has a significant chance of doing more harm
than good. About two-thirds of opiate overdoses involve a mixture of drugs,
according to DAWN, so adding a stimulant is risky because an "up" drug like
cocaine might be the real cause of the overdose. Unlike stimulants,
however, naloxone isn't likely to do harm. And if heroin is one of a
cocktail of "downs," removing the opiate effect alone is usually enough to
save the person's life.

So why aren't service providers handing out naloxone at needle exchanges
and training addicts in CPR and other aspects of overdose treatment? One
obstacle, according to naloxone advocates, is that the medical profession
is wary of allowing those with no medical training to treat overdoses.
Although naloxone generally is not dangerous, it's certainly medically more
prudent to take anyone who is unconscious and not breathing to a hospital
where doctors can deal with any complications.

In ordinary circumstances, if the poison weren't an illegal drug, almost no
one would disagree with such a recommendation. But expecting addicts to
risk arrest and the contempt often meted out to them by medical
professionals is naive, according to Dr. Karl Sporer, an emergency room
physician at San Francisco General Hospital.

Sporer says that even in Australia, which has a much more humane attitude
toward addicts, only 14 percent of users call an ambulance first. "We can't
get the police to promise not to arrest them, and the police often need to
be there," he says. A recent article in the Santa Cruz County Sentinel
cites needle exchange officials who report that 65 percent of participants
in the Santa Cruz Needle Exchange Program who have overdosed or witnessed
an overdose "did not call 911 because they feared criminal charges."

"[Naloxone will] work," says Dr. Clifford Gevirtz, chief of anesthesiology
at New York's Metropolitan Hospital and a leading addiction specialist.
"But our society is a little too litigious." Family members of addicts who
died despite naloxone might sue prescribers, claiming that the addict would
have gone to the hospital and had a greater chance of survival if the
naloxone hadn't been available.

A related concern is that making naloxone more accessible could encourage
users to take more drugs. Dan Bigg, of the Chicago Recovery Alliance, which
has trained several dozen users in administering naloxone, says this is
unlikely. "Using naloxone is always unpleasant even for those without
opiate tolerances," he says. "I have never seen nor heard of such increased
reckless reactions to its availability. This is similar to the myth that
sterile syringes incite more use."

Around the world and in small underground programs in San Francisco and
Chicago, people have begun to research (albeit, somewhat informally,
sources say) whether naloxone can actually reduce deaths. Italy has the
most experience. In 1987, the Italian health ministry decided that naloxone
could be sold without a prescription. In 1995, researchers in Torino began
distributing the drug with instructions on its use at needle exchange
programs. Susanna Ronconi, coordinator of the Torino Outreach Project, says
that there is no data yet showing a decrease in the number of deaths, but
naloxone is widely accepted and no problems have been reported.

ER physician Sporer believes the advantages of providing naloxone far
outweigh the disadvantages. When naloxone works, an addict's return to
consciousness is dramatic and almost instantaneous. However, he mentions a
final potential complication. "Narcan [the brand name for naloxone] is not
totally benign," he says. "There are a small number of people, about 1
percent, who have seizures. They are short-lived and not fatal. Compared to
near-certain death, it's an easy choice."

The mother of one 16-year-old girl, who found her daughter dead of a heroin
overdose this summer, says it best, her voice shaking: "Never give up on
your child. Never." She insists, "I don't think [providing naloxone] would
encourage people to use drugs, but it would help families to save the lives
of drug users. I think it's a great idea.'

Valerie has decided to give up heroin. As of late December, she had gone 48
days drug free.