As the opioid crisis claims more lives, Narcan — the medication that can quickly counteract the life-threatening effects of heroin or opioid overdose — is becoming more directly available to the public through pharmacies across the state, and across the country, including on Martha’s Vineyard.
Statewide, the Department of Public Health (DPH) estimates that 2,000 lives have been saved by Narcan. There are currently two ways for private individuals to obtain the opioid antidote — by taking a doctor’s prescription to a pharmacy that stocks the drug, or by going directly to a pharmacy that has a standing order for Narcan, also known as Naloxone.
A standing order is a blanket prescription that is written by a doctor for a particular pharmacy. After a state mandated training session for the pharmacy staff and DPH review, Narcan can be sold over the counter at the pharmacist’s discretion.
According to DPH records, the Conroy Apothecary stores in Oak Bluffs and West Tisbury are currently the only pharmacies on the Island dispensing Narcan by standing order. “No pharmacies have rejected the idea, we’re just at the beginning,” Martha’s Vineyard Youth Task Force (MVYTF) coordinator Theresa Manning told The Times. Ms. Manning said discussions are ongoing and that one other pharmacy has verbally committed to the program.
Tamara Conroy, owner/pharmacist of Conroy Apothecary, said the decision to dispense Narcan by standing order began with a phone call from Ms. Manning. “She asked if I would be interested in collaborating with a substance abuse doctor in Boston, Dr. [Alex] Walley, who is really passionate about the opiate crisis and saving lives,” Ms. Conroy told The Times. “He created the standing order for our pharmacies, and then our staff from both locations went through a training program in collaboration with him.”
Dr. Alex Walley has an extensive resume in addiction medicine. He’s an assistant professor of medicine at Boston University; an addiction medicine specialist at Boston Medical Center; the director of the Boston University Addiction Medicine Fellowship program, which trains addiction medicine specialists, and he’s the medical director for the Massachusetts Department of Public Health’s Opioid Overdose Prevention Program.
Dr. Walley also has a personal connection to Martha’s Vineyard — he was a seasonal resident growing up and he now owns a home in Oak Bluffs, where his parents are year-round residents. His sister lives in Edgartown.
In 2005, state officials asked Dr. Walley to head a new program with a mandate to get Naloxone overdose kits directly to active users and their family members. According to a 2014 interview in The Atlantic magazine, there were more experienced physicians and researchers than Dr. Walley at the time, but they were either unable or unwilling to take on the enormous professional and legal risk. But Dr. Walley agreed immediately. “There had been a spike in overdoses, and it seemed like a no-brainer to get these kits in to the people most likely to be on the scene, which was other users,” he said.
Over the counter
The “Standing Order” regulation that enables Massachusetts pharmacies to dispense Narcan directly was passed by lawmakers in March 2014.
Last August, the Boston Medical Center received a $1.3 million grant from the Agency for Healthcare Research and Quality to evaluate the effectiveness of standing orders in Massachusetts and Rhode Island. The results were encouraging.
CVS now dispenses Narcan without a prescription in 14 states. Last month, Walgreens, which dispenses Narcan in all of its Massachusetts pharmacies, announced it would begin dispensing in 35 additional states.
Conroy Apothecary began dispensing Narcan over the counter in early February. So far, only a handful of Narcan rescue kits have been sold.
“I think part of the reason is that people don’t know it’s available,” Ms. Conroy said. “Theresa [Manning] is getting the word out. It’s not something I want to advertise, but I think the people that need it will find out that we have it.”
Ms. Conroy said that it’s usually a relative or a friend of the addict who purchases the opiate antidote, which can be administered by syringe or nasal spray.
“I write up a prescription with Dr. Walley’s name and dispense two syringes with two nasal atomizers,” she said. “I show them how to use it and let them know that they need to call 911 when they administer it.”
Ms. Conroy said pharmacists also have to weigh their risks before dispensing Narcan rescue kits. “I gave it a lot of thought and talked to my staff about it. It really came down to the fact that we dispense opioids here, so I feel like we’re responsible and we need to help educate people and help them overcome addiction.
“Some people feel this is just a band-aid approach, that you’re somehow encouraging an addict to take as much heroin as they want because they have a rescue kit,” Ms. Conroy said. “Maybe there’s some of that, but I think it’s more important that we’re saving lives.”
Narcan is covered by most insurances and the co-pay varies, depending on the person’s drug benefits. MassHealth covers two doses with nasal atomizers, with a zero copayment.
Tisbury EMS director Tracey Jones said paramedics in her town have been using Narcan for at least 12 years, with increasing frequency. “It’s always been in our protocols, but we’re definitely using it more often now,” she said. “In 2014 we had seven overdose calls, one of which Narcan was used. In 2015, we had 14 overdose calls, seven of which Narcan was used.”
Tri-town EMS chief Ben Retmier said the up-Island first responders also had a doubling in overdose calls between 2014 and 2015, three and six respectively. In the 10 years Tri-town has been administering the drug, he’s seen a wide range of responses. “Sometimes people look like they’re slowly waking up, or they can react violently and sit up start swinging at you,” he said. “It’s really dependent on the person and what they have in their system.”
Mr. Retmier said it’s imperative, even if someone appears revived by Narcan, that the individual gets medical attention immediately. “Narcan has a shorter half-life compared to what’s in their system,” he said. “Once they’re awake, they can think they’re going to be fine, but when the Narcan expires, the opiates kick back in and they can overdose a second time.”
Mr. Retmier said that people who don’t call for medical attention because they are also using are making a potentially deadly and unnecessary mistake. “The Good Samaritan law covers drug users who call for help,” he said. “There’s no reason not to make that call.”
The Massachusetts Good Samaritan Overdose Prevention Law protects people who overdose or seek help for someone overdosing from being charged or prosecuted for drug possession.
Half of all heroin drug users report at least one nonfatal overdose during their lifetime, according to a survey published in the Journal of Urban Health in January 2007. The survey also found that a majority of doctors said they “would never consider prescribing [Narcan] and explaining its application to a patient,” over concerns that it would further enable their drug use and encourage risk taking.
Tisbury EMS director Tracey Jones said she had mixed feelings about enhanced Narcan availability, which she described as a “potential double-edged sword.”
“If it’s available to friends and family, I feel it’s a good thing because it could save somebody’s life,” she said. “But at the same time, does it make it easier for people to ignore the idea that they may overdose?”
Drug Enforcement Agency (DEA) spokesman Agent Tim Desmond said that saving lives is always a top priority for a DEA agent. “If it can save a life, we’re all for it,” he told The Times. But he also expressed ambivalence about over-the-counter Narcan. “We have intel that addicts have gravitated to places where they know Narcan is used by police and EMT’s,” he told The Times. “We also know that some have gone to places where there’s been a string of overdoses, because they think it’s where they can get the strongest potency.”
Mr. Desmond said DEA agents carry Narcan for their own safety as well. “Fentanyl is so poisonous it can seep through your skin,” he said. “If one of our agents is undercover and a bag breaks in his pants, he could easily receive a lethal dose.”
Not an easy way out
Dr. Charles Silberstein, psychiatrist and substance abuse specialist at Martha’s Vineyard Hospital, asked recovering addicts with whom he works if they thought Narcan could be viewed as a safety net and induce addicts to increase their drug intake. They unanimously rejected the idea.
Their answers included:
“Do you know how painful it is when you get Narcan? No one would plan to take Narcan.”
“When people are using heroin they aren’t thinking about what is a safe way to do it. They just want their fix.”
“It saves lives! How can that be a bad thing?”
“This is about bigotry toward people who have this disease.”
“Plain and simple, it is a lifesaver,” Dr. Silberstein wrote in an email to The Times. “Increased access is crucial.”
What to look for
Dr. Silberstein said the following are symptoms of a possible opiate overdose:
- Awake, but unable to talk.
- Body is limp.
- Face is pale or clammy.
- Fingernails and lips turn blue or purplish black.
- For lighter skinned people, the skin tone turns bluish purple, for darker skinned people, it turns grayish or ashen.
- Breathing is very slow and shallow, erratic, or has stopped completely.
- Pulse is slow, erratic, or not there at all.
- Choking sounds, or a snore-like gurgling noise (sometimes called the “death rattle”).
- Loss of consciousness.
- Unresponsive to outside stimulus.