ISIH S2 E10 / The Opioid Overdose Crisis: What comes after naloxone?

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Jonathan Goyer: To be quite honest, I was sort of appalled when I did find out about it ...saying, where was this medication in 2009? And where was this medication in 2004? And had it been more readily available or accessible, would that have made a difference in the lives of my father and brother?

Celine Gounder: Jonathan Goyer is an opioid overdose survivor. In 2004… when Jonathan was 17… his father passed away from a fatal heroin overdose… and two years later… in 2009... his brother also passed away from complications of drug use.

Jonathan Goyer: I had never heard of naloxone in 2004 or 2009. I only heard about it in 2013 when it was used on me. And being somebody who had struggled with addiction for 10 plus years, who's been to over 30 detox and treatment facilities… I was never educated on naloxone, or what it was, or how to use it, or how it works… So that sort of mentality definitely propelled me into advocating for just a wide-scale expansion of Narcan.

Celine Gounder: Welcome back to “In Sickness and in Health,” a podcast about health and social justice. I’m Dr. Celine Gounder. In this series, we’re trying to better understand the opioid overdose epidemic... how the crisis is evolving… and how we’re responding to it. In this episode, we’re taking a closer look at the drug naloxone… also known by the brand names Narcan or Evzio. Naloxone is a medication that helps save lives by reversing the effects of opioids… and reviving people from a potentially fatal overdose.

Celine Gounder: It isn’t a new drug. Naloxone has been around since 1971. But for years, naloxone was only available by prescription... or administered by EMTs.  But… in the past few years, it’s become easier to get naloxone. You can now get it over the counter in 46 states… Yet… many pharmacies don’t stock it. And many pharmacy workers don’t understand it can be dispensed without a prescription… or to someone other than the person having an overdose. The ongoing lack of access to naloxone… led the U. S. Surgeon General, Dr. Jerome Adams, to issue a national advisory… recommending that more Americans carry naloxone on them… and learn how to use it.

Celine Gounder: Although we’ve made significant strides, efforts to make naloxone more available are still ramping up… many police departments and first responders now carry naloxone… and, there’s a push for free, public distribution of the the medication… so that family, friends and members of the community can respond to an overdose… and save lives… without having to wait for the help of a medical professional.

Celine Gounder: Access to naloxone… is very much on Jonathan’s mind. He’s the former drug user we heard from at the top of the show… For Jonathan, it’s really personal… not just because his father and brother died from opioid overdoses and other complications related to drug use… but also... because he... himself... nearly died from an opioid overdose.

Jonathan Goyer: So the circumstances of my overdose were that I actually had six months clean and sober at the time. I had gone to jail, then I completed a 90 day residential rehab and I was actually living in a safe, sober, transitional recovery house at the time. ...One day I was feeling a way that I didn't want to feel. And I just--I reverted back to--to opioid use. And I did get high in that in that house I was in, which shame on me for that. But also thank God I was in that house because the individuals that were in that house were all in recovery and they were trained on what Narcan was and how to use it, and it was available in the house and that's what actually saved my life.

Celine Gounder: Naloxone, or Narcan, works by essentially kicking the opioids out of the brain… This stops a fatal overdose… and brings people back from the edge of death. And… naloxone can work fast. It can take someone from unconscious and barely breathing... to awake and talking... within minutes. At the time of Jonathan’s overdose, fentanyl… which is 50 times stronger than heroin… had begun to surface in Rhode Island, where Jonathan lives.

Jonathan Goyer: Having been a heroin user for 10 plus years, on and off at times. ... I've never sort of dropped on the floor immediately like I did that time… I do suspect that it was… tainted with some level of fentanyl, just due to the immediate overdose.  

Celine Gounder: Because of the potency of the drug that caused Jonathan’s overdose… he needed several rounds of naloxone.

Jonathan Goyer: I was administered a dose of Narcan from somebody in the house. They called 911. Meanwhile they administered a second dose to me. ... Ambulance arrived. Administered a third dose to me… And it was very sort of confusing to me [00:39:49] I was very groggy and… It took more Narcan after that to really set me out of it.

Celine Gounder: After about an hour… Jonathan started to come to in the hospital… and piece together the gravity of what had happened.

Jonathan Goyer: My initial thought of waking up from… after receiving Narcan and coming to from the overdose... my initial thought was that I messed up again, that I can't, I can't get my life straight. Why do I bother? ... And I need to go get high again to sort of forget about this guilt and shame.

Celine Gounder: This was a familiar pattern for Jonathan. Although he hadn’t overdosed before… Jonathan had already been in and out of 38 detox programs… and had relapsed numerous times. For Jonathan, quitting drug use… was a really hard, scary process.

Jonathan Goyer: And when you get clean and sober… reality really sets in… and you almost begin remembering all the horrible things that you've done to people. The ways that you've harmed people. The money that you owe. ... it can become very, very overwhelming.

Celine Gounder: For Jonathan, relapsing was always about escaping the feelings of anxiety and emotional overload… that come with stopping drugs.

Jonathan Goyer: I think anytime anybody relapses, it's really just to feel better than what they're currently feeling, and somebody that doesn't have very good recent practice of dealing with their feelings and reality are sort of, you know, you step back and say, well, of course they got high. I mean, they don't know how to... They haven't built any coping skills or things like that to get through some of these feelings of overwhelm that come with sobriety.

Celine Gounder: Right before overdosing, Jonathan had been abstinent for 6 months… For the first time in a long time, he was starting to trust people and build real friendships.

Jonathan Goyer: What I was able to do in that six months of time was really sort of solidify and build this network of peers in recovery that really sort of changed my life and changed my outlook on life. And really just gave me a lot of hope that maybe -- I can get better and maybe all of these compounded problems that my active addiction had created for me in my life, maybe I could get through all of those, like one day at a time.

Celine Gounder: Jonathan had built up his emotional reserves and his support network… so when he really needed the help, people were there for him. These relationships… and the naloxone… that’s what saved his life.

Jonathan Goyer: A few friends that I had made in recovery as I was going in and out of of recovery... and 12 step support groups, and things of that nature. Two friends actually came to visit me in the hospital.

Jonathan Goyer: And having those people in my corner... quite literally I should say having those people on the side of my bed when I woke up from the overdose definitely made all the difference in the world. They didn't... they didn't judge me. They didn't push me away. In fact, they just sort of moved closer. And as it appeared, they still cared about me, clearly more than I cared about me, and that sort of... they sort of loved me until I can love myself. ... And I think that made all the difference in the world for me.

Celine Gounder: Jonathan knew that it was time to quit using… and this time… for real. While Jonathan was in the hospital, his friends called the Providence Center in Rhode Island… Jonathan was transferred to the center’s crisis stabilization unit.

Jonathan Goyer: I really sort of realized that I'm at this fork in the road, and… Next time I get high, I'm not going to end up in jail and I'm not going to end up back in treatment. I'm going to end up dead. And it was really this opportunity that I had sort of just realizing that. And I just sort of made a decision at that moment in time, that I was... I didn't want to die.

Celine Gounder: For Jonathan, his near-death experience… that’s what he says saved him. Naloxone brought him back to life… and then… that experience… helped him live. But… others… even after they’ve been revived by naloxone… will still go on to die from an opioid overdose.

Julie Donohue: I'm Julie Donohue and I'm an associate professor of Health Policy and Management at the University of Pittsburgh.  

Celine Gounder: Julie studies what happens to people after they’ve lived through an overdose.

Julie Donohue: ... we looked at about 6,000 individuals… who experienced an overdose either from heroin or prescription opioids. And then we looked... to see if there was a change... in treatment for addiction, and specifically we looked at medication-assisted treatment... ...And here we see overall pretty low rates of treatment before overdose, it's about 13 and a half percent among those with prescription opioid overdose and it went up just to 15 percent.  ...in the six months after the overdose.  

Celine Gounder: Before they had an overdose, very few of these people were getting treated with medications like methadone or buprenorphine… and the needle barely shifted after they survived an overdose. And that’s why many first responders… often revive the same people over and over again… Overdosing… getting naloxone… that experience on its own… doesn’t cure addiction. It doesn’t cure the problems that led someone to use drugs in the first place. So… what’s next? What should happen... after... naloxone?

Julie Donohue: We hear a lot about the overdose deaths that have been rapidly rising in this country. But we hear less about the non-fatal overdoses, which are about 30 times more common than the fatal overdoses. And oftentimes, people who have a non-fatal overdose are at increased risk of future overdose and death because of the chronic nature of addiction.

Celine Gounder: For Julie, a non-fatal overdose… often when someone has survived because they got naloxone… that has the potential to be a point of intervention. In an ideal world, it would go down like this: a drug user would be saved from an overdose by naloxone… brought to the hospital to stabilize… and then be connected to services and drug treatment… including medications like methadone or buprenorphine. But, often… it’s a lost opportunity.

Julie Donohue: There is an inadequate supply of providers to meet the treatment needs in our country. Not all communities have an opioid treatment program where someone could be treated with methadone, or if they do have such a program it's operating at capacity. And medications like buprenorphine, which can be prescribed in any setting… by a provider who has gone through the appropriate training… unfortunately only about 4 percent of physicians in the U.S. have completed this training and are certified to prescribe this kind of medication-assisted treatment to their patients. So there's, there's a real shortage. So inadequate supply of providers is one factor.

Celine Gounder: And the second factor which is quite longstanding is the lack of integration of substance abuse treatment with the rest of health care delivery. And I think the opioid crisis is shining a bright light on what has historically been a very fragmented system for people with addiction.  And that’s an important point. We’ve got to do more than just ramp up access to naloxone… and medication-assisted treatment like methadone and buprenorphine.

Julie Donohue: ...it's really comprehensive care. It's not just about prescribing the medication. It requires good quality treatment requires active follow up especially in the beginning to motivate patients to make sure they stay engaged in treatment. ...medication treatment is is often most effective when it's delivered with psychosocial supports which could include group therapy family counseling, individual counseling...  

Celine Gounder: So the point here is that naloxone… like many harm reduction strategies… needs to be a bridge to somewhere if it’s going to help prevent deaths from opioid overdoses... in the long-run.

Celine Gounder: When harm reduction strategies are used in isolation… naloxone without addiction treatment… law enforcement assisted diversion... away from jail to non-existent social services… well… that just doesn’t work. It’s sort of like a car… you can’t drive it if you’ve got a flat tire… but four brand new tires and no car? ... that won’t get you far either. You need the whole car to drive. The same goes for harm reduction. People need to be alive to move forward. And there need to be medical, mental health, addiction treatment and social services to help them take the next step. Our current piecemeal approach… offering bits and pieces… not the whole menu… it’s also made it hard for researchers to study… to measure impact.

Celine Gounder: In March, two economists--Jennifer Doleac at the University of Virginia and Anita Mukherjee at the University of Wisconsin--published a controversial study looking at whether naloxone enables more opioid abuse. I’ve heard many argue that harm reduction enables addiction by giving drug users a safety net… by taking away deterrents… like incarceration… infectious diseases… or death. Economists call this phenomenon “moral hazard.”

Celine Gounder: That study--which still hasn’t been fully vetted by other experts in the field--found that naloxone access laws failed to prevent overdose deaths. There were a number of problems with the study… but perhaps the most important is related to what Dr. Julie Donohue was explaining to us earlier. That people who’ve had one overdose... remain at very high risk for another overdose… if they don’t get treatment for their drug addiction. And… Doleac and Mukherjee’s study found that where drug treatment was widely available… deaths from opioid-related overdose… may in fact… have gone down. In other words… naloxone alone won’t turn the tide on the opioid overdose crisis… but it can save lives in the long-term… if after someone’s saved from overdose… they get the treatment they need.

Celine Gounder: Jonathan… who we heard from earlier in the episode… got treatment after his overdose... and has now been clean for almost four years. BUT, before getting clean… there were many years when Jonathan struggled to get treatment. Here’s Jonathan again....telling me... when well before his overdose... he called up a center to see if he could get treatment.

Jonathan Goyer: And one day, I mustered up the courage to call. I was just ready. I was-- I was just-- I was completely defeated by addiction and the time was now. So I picked up the phone, which weighed about 200 pounds at the time, or so it felt, and then it rang. And it just seems like it took forever for somebody to answer the phone and answer the phone, and they did a quick assessment, and they said, "Well, it sounds like you need treatment, but there's no beds available today. Can you call back tomorrow?" ... And I hung that phone up, and I just said to myself, This is why I don't bother. Like, I knew there was a reason why I didn't. It took me this long to call, and this is why. And nobody's willing to help me. And then the next thing, you know, the disease of addiction is sort of, you know-- And I don't want to say misinterpreted, but sort of skewed all of my-- any bit of logic that I had at that time. And I was able to sort of use that as fuel to go out and continue to get high. So to answer your question, I think the access to recovery is definitely a factor.  

Celine Gounder: Nowadays, Jonathan is an advocate for the recovery community and runs the Anchor More program at the Providence Center… the same center where he got treatment after his overdose. The Anchor More program is the first of its kind in the country… they have contracts with all 12 hospitals in Rhode Island… If somebody overdoses, the hospital can call Anchor, and Anchor will dispatch a peer recovery coach to arrive onsite at the hospital within 30 minutes to talk to the overdose survivor. For Jonathan… offering naloxone is an essential first step… it quite literally gives people another shot at life… but it’s just a first step… and should be used as a tool for engagement… to connect people to treatment services… so they don’t overdose again.And he believes peer recovery coaches, like the ones in his Anchor More program... have a unique ability to connect with drug users in these moments… because… they’ve been through it themselves.

Jonathan Goyer: So in my personal experience and my professional experience, peers are not meant to replace any form of treatment but rather complement it. The difference of waking up in a hospital bed and having a doctor with a white coat walk up to me and tell me that I need to get help-- I don't receive that very well as as a person with addiction. It just doesn't go over well for me. I get very defensive. Combative. I go into denial, but when I'm approached by somebody that comes and sits next to me in this hospital bed, and says, I know exactly how you feel. Just four years ago, I actually overdosed and was brought to this very, very hospital. But I was able to-- I was able to find recovery, and here's how I did it. Taking that different approach, really greatly increases individuals receptivity to what the individual is saying because they can they can identify with it and it's somebody that's talking to them on an equal level on a peer level. It's just one human being to another. One Addict helping another. One alcoholic helping another.

Celine Gounder: The Anchor More program has been really successful. Out of all the drug users they’ve reached out to in the emergency room after an overdose… over 86 percent of them have sought addiction treatment after their session with a recovery coach. That’s real impact. Like many of the solutions we’ve looked at in this season… there isn’t one silver bullet to solve the opioid overdose crisis… but rather several solutions working together… complementing each other.

Celine Gounder: Over the last few episodes, we’ve been talking about about the here and now… what we’re facing… and what needs to be done. But in our next episode, we’re going to shift gears a bit. We’re going to go back in time… and examine how our nation’s attitudes about race… put us on a different path… influencing how we think about drugs… and shaping the history of drug laws and enforcement in this country. That’s next time… on “In Sickness and in Health.”

Celine Gounder: Today’s episode of “In Sickness and in Health” was produced by Nora Ritchie and me. Our theme music is by Allan Vest. You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com, that’s insicknessandinhealthpodcast.com. If you like what you hear, please leave us a review on Apple Podcasts. It helps more people find out about the show!

Celine Gounder: If you or a loved one needs help, you can reach out anonymously and confidentially to SAMHSA’s National Helpline at 1-800-662-HELP, that’s 800-662-4357. SAMHSA stands for Substance Abuse and Mental Health Services Administration. You can also find information online at www.findtreatment.samhsa.gov, that’s www.findtreatment.samhsa.gov.

Celine Gounder: I’m Dr. Celine Gounder. This is “In Sickness and in Health."