Jonathan Goyer would be dead today, were it not for a few chance occurrences.
For some reason, he left the door to his room ajar that day last June. Another resident of the Pawtucket “recovery house” where he lived just happened to come upstairs and glanced into his room.
What she saw threw her into a panic: Goyer on his knees, face on the floor, skin turning blue, syringe at his side.
By some stroke of luck, the manager of the house — a transitional home for people in recovery from addiction — had just returned, and the frightened roommate alerted him. Michael J. Rossi, who is also a registered nurse, called 911, ran upstairs and gave Goyer an injection, and then a second shot a few minutes later.
Goyer was being carried to the ambulance on a stretcher when suddenly he lifted his head, looked around and asked, “Do I have time for a cigarette?”
As Rossi tells it, “all those little coincidences would have gone to waste” if he hadn’t had one important tool on hand: a drug that acts so quickly to reverse an opiate overdose it seems to bring the dead back to life. That drug is naloxone, also known by the trade name Narcan.
For decades, emergency medical technicians have used naloxone to treat overdoses. But in recent years, as overdoses from prescription opiates and heroin increase nationwide, public health officials are pushing to make naloxone more widely available.
On Friday, the Rhode Island State Police announced plans to carry naloxone in every cruiser. And last week Boston Mayor Martin Walsh called for all that city’s first responders to have the drug on hand.
But first responders aren’t always summoned in time. So a number of laws and programs are also trying to get naloxone into the hands of relatives, friends and neighbors of people who use opiates.
Rhode Island has a program that may be unique in the nation: an agreement among the Board of Pharmacy, a Miriam Hospital doctor and the Walgreens pharmacy chain that allows anyone to walk into a Walgreens in Rhode Island and obtain naloxone. Under this “collaborative practice agreement,” Dr. Josiah D. “Jody” Rich, of Miriam Hospital, has essentially written a prescription for anyone who requests the drug, and Walgreens has agreed to dispense it, along with some training.
Opiates are a group of drugs that includes heroin and methadone as well as prescription painkillers such as OxyContin or Vicodin. When a person takes too much of an opiate, breathing gradually slows and, if the person doesn’t get help within one to three hours, respiration stops altogether.
Naloxone interrupts this process by quickly binding with the receptors in the brain that opiates affect. If you imagine the opiate as a key stuck in a lock, naloxone yanks out those keys and fills all the keyholes, preventing the opiate from working.
“It blocks all those receptors almost immediately. It’s really dramatic,” says Jeffrey Bratberg, a University of Rhode Island pharmacy professor. People go from being unconscious and blue “to awake and angry. All the symptoms of withdrawal happen immediately.”
Naloxone is available only by prescription, but it is not a controlled substance and has no potential for abuse. It also won’t have any effect on a person who hasn’t taken an opiate, so there is virtually no risk in giving it to someone who passed out from another cause (allergic reactions are rare). The drug can be administered through an intramuscular injection or a nasal spray, although the nasal spray is currently in short supply.
The Walgreens program started a year ago at four pharmacies and was expanded to all 26 Walgreens in Rhode Island after a spate of overdoses last summer. It got off to a slow start, with a just a few doses distributed, but demand picked up after the Health Department reported a spike in overdose deaths in January, says Leo J. Lariviere, pharmacy supervisor for Walgreens in Rhode Island.
Naloxone costs about $25 for the injectable form and $40 for the nasal spray, and insurance companies have been paying for it, Lariviere said.
He estimates that fewer than 100 doses have been dispensed so far. Clearly, the naloxone agreement hasn’t drawn legions of new customers into the store, but that wasn’t the point, says Lariviere, who worked for 14 months to win corporate approval and iron out the legal details. Drug dependence “is a complex problem,” he says. “Any part that we can play to help alleviate that we’re happy to do.”
Health officials are urging anyone who knows someone who uses prescription painkillers or heroin to keep some naloxone on hand in case of an overdose.
But you can’t walk into a Walgreens and just grab a vial of Narcan off the shelf. You must go to the pharmacy window and request it. The pharmacist will require the same basic identifying information needed to dispense any prescription. Additionally, the pharmacists will spend 10 to 15 minutes training you in how to recognize and respond to an overdose and how to dispense the drug.
Walgreens has developed its own naloxone kits, with either the injectable or nasal-spray versions. (It includes a patient information sheet developed by one of Bratberg’s URI pharmacy students, with advice from experts.) People are advised to call 911 first and give rescue breaths if the person is not breathing. They are taught how to draw the drug into the syringe if giving an injection or how to assemble the nasal spray if using that version. And they are also advised to stay with the person until help arrives.
Lariviere said that Walgreens dispenses at least two doses with each prescription, because naloxone can wear off quickly and a second shot may be necessary. People will go into immediate withdrawal and may try to use more drugs, heading into a double overdose.
Jody Rich is an infectious disease specialist at Miriam Hospital who has seen the toll of drug abuse on his HIV patients. He worked to legalize needle exchanges and then to legalize the needles themselves, and also championed Rhode Island’s 2012 “good Samaritan” law, which ensures that someone who calls 911 to rescue a person from an overdose won’t face charges for drugs found at the scene.
All those laws required years of work. The naloxone project didn’t require legislation, but it, too, has been a long-term effort. It dates back a decade, Rich says, when researchers Michelle McKenzie, of Miriam, and Traci C. Green, of Rhode Island Hospital, launched PONI — Preventing Overdose and Naloxone Intervention — a pilot effort to train people at needle-exchange sites, drug-abuse treatment centers and homeless shelters in the use of naloxone.
Dozens received this training, and some had occasion to save lives with it. In fact, Mike Rossi had undergone the training at the Anchor Recovery Center in Pawtucket, a support program for people in recovery from addiction, just a month or two before he used it to save Jonathan Goyer.
Hoping to expand access to the drug, the Miriam group asked the state Board of Pharmacy about making naloxone available through a collaborative prescription agreement.
“We invited all the big pharmacies,” Rich said. “Walgreens stepped up to the plate.” (Rich said he has also had conversations with CVS Caremark, and spokeswoman Carolyn Castel said the company is “evaluating the potential benefits of Naloxone and ways in which CVS Caremark may become involved in providing this therapy.” Rite Aid did not immediately have a comment.)
While the agreement was being hammered out between Walgreens and the Health Department, Bratberg’s student intern at URI developed an online training course that all Walgreens pharmacists took to prepare for the program.
Since then, Rich says, pharmacists are learning that some people will run in fear when asked for an ID. And some will break down in tears, like the mother who came into a Providence Walgreens and told the pharmacist that her 20-year-old daughter shoots up heroin every time she leaves the house.
Bratberg says he’s getting calls from other states looking to emulate Rhode Island’s program.
But Rhode Island is not alone in trying to get naloxone into wider distribution. In recent years many states have passed laws making it easier for laypeople to obtain and administer the drug. For example, 14 states passed laws allowing “third-party prescriptions,” in which a doctor prescribes the drug to someone other than the person who will take it — such as the spouse or parent of a user. Fifteen states have naloxone-distribution programs, including Massachusetts, where the public health department distributes the drug and provides training at centers statewide.
Jonathan Goyer, the young man who was rescued by naloxone last June, says he hasn’t used any drugs or alcohol since the overdose, despite battling addiction to heroin for a dozen years. He works at a cafe on the East Side and as a peer educator for Project Weber, a program to improve the safety and well-being of men at risk of HIV infection and addiction.
And he’s been trained in administering naloxone.
“Sometimes it takes a catastrophe or some tragic event for people to be willing to get clean and live a better life,” says Goyer, 26, of Providence. “Since then, I’ve just really been motivated to help others and be of service to others. …
“My story is one that shows it’s worth saving lives.”
On Twitter: @felicejfreyer