‘Reversal fatigue’ – Narcan and needle exchanges have saved thousands of lives, but not everyone is on board

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A safety kit provided by North Carolina Harm Reduction Coalition. The group has helped save thousands of lives, and take tens of thousands of needles off the street. But not everyone agrees with their methods. (Photo Benjamin Schachtman)
A safety kit provided by North Carolina Harm Reduction Coalition. The group has helped save thousands of lives, and take tens of thousands of needles off the street. But not everyone agrees with their methods. (Photo by Benjamin Schachtman)

Author’s note: This series has explored questions about the opioid epidemic in Wilmington. It has focused on the basics: what are opioids, who are the people using them? Some questions remain: what is at the root of epidemic? Why is this epidemic hitting our area so hard – harder than nearly anywhere else in the nation? What can we do?

Those questions won’t have easy answers. But the picture will be clearer for those who understand the current efforts to address the epidemic. Again, a complicated picture emerges. Every group involved agrees our area is facing a crisis without parallel. Not everyone agrees on what to do about it.

This part of our series will show you the crisis through the eyes of the people fighting it. These are the many front lines against the opioid epidemic. By knowing where these groups stand now, we hope to provide a better sense of where the fight can go next.

Part V – The power and potential risk of ‘harm reduction,’ AKA, needle-exchange

On a chilly Wednesday evening in December, Mike Page was standing in the Game Stop parking lot between Market Street and Walmart. Page, and two other volunteers, had answered a text message and were there to exchange clean needles for used ones. Port City Daily had been invited for a ride along to learn about “harm reduction.”

Page hands a 'care package' to an opioid user who texted him. The package contains clean needles, Narcan and information about substance abuse programs. (Photo Benjamin Schachtman)
Page hands a ‘care package’ to an opioid user who texted him. The package contains clean needles, Narcan and information about substance abuse programs. (Photo by Benjamin Schachtman)

“This guy just recently came to town, he heard about us through another user,” said Page, an outreach worker for North Carolina Harm Reduction Coalition (NCHRC). “This is pretty much what needle exchange looks like, what harm reduction looks like. Us being out here.”

Page stored the used needles in a biohazard container, giving the young man about a dozen fresh needles. Page asked if the man had heard of any batches of heroin containing fentanyl. He also offered him an intramuscular Naloxone kit that could be used to reverse an overdose.

Page had the user fill out a brief survey and took down some key information, part of NCHRC’s protocol for accepting needle exchange clients. The group has had at least 450 clients since starting the program. Some of these clients, in turn, act as ambassadors to other users.

Page said, “they’ll collect needles from other people, or deliver naloxone kits to places where people are shooting up.”

[cp_messagebox align=”left” color=”#ffffff” shade=”noshade” border=”#000000″ font_color=”#000000″]Opiates or opioids? Narcan or Naloxone? What’s what in the world of opiates and opioids? Check out our appendix of terms[/cp_messagebox]

Over the next few hours, Page drove to Greenfield Lake to retrieve a cache of used needles, and then to a parking lot in Mayfaire to drop off a naloxone kit and clean needles.

This is how harm reduction works, Page said, “one call at a time, one person at a time.”

“I’ll make jokes about particular needles or a place I used to score, and someone will say, ‘oh, hey, wait, you used to use?’” he said. “It puts a face on outreach, now we’re two people talking. It also puts a face on recovery, it’s a reminder that it’s possible.”

Page was an active intravenous heroin user who survived three naloxone reversals before “retiring” from use. But neither Page or NCHRC push detox or rehab.

“I’m out there to offer help to my community. I think to bait and switch – to try and force it on someone – would be inappropriate,” he said.

NCHRC does provide information about local services – like detox and treatment at Coastal Horizons, RHA’s The Harbor and others – but it does not require,  nor overtly push them.

Robert Childs, director of NCHRC, said, “we give that information in every naloxone kit, and we hope that someone has that ‘golden moment,’ that lucid moment and gets help. But usually it’s more complicated than that, and we can’t force it.”

That method allowed the NCHRC to take 36,000 needles off the street in its first six months, considerably more than the 24,000 it gave out. North Carolina passed a law allowing needle exchange programs in July of 2016.

Critics of needle exchange

Recent efforts have been successful, but not without its detractors.

“Critics argue that we’re in essence sanctioning or encouraging drug use, but we’re focused on reducing infectious disease and infection,” Childs said. “We provide Hepatitis-C and HIV testing. We’re not condoning drug use, we’re taking care of people.”

Childs said that, despite the clear public health benefits of the program, the only way to overcome moral objections in Raleigh was for the law to prohibit public funds for purchase of needles or other “safe shooting” supplies (like alcohol swabs, tin cups to make solutions of heroin in, etc.).

From left: Mike Page and Robert Childs. (Photo Benjamin Schachtman)
From left: Mike Page and Robert Childs. (Photo by Benjamin Schachtman)

Childs said that the low-pressure approach “is critical to building trust.”

“We don’t preach and we don’t judge,” he said. “We build their trust and they’ll reach out to their mates. That’s how we build a peer-to-peer network. That’s how we can help. That’s just the old-school way we’ve always done it.”

NCHRC uses that network to distribute several types of naloxone medication throughout the community. Childs has also helped convince local law enforcement to carry Narcan.

A frequent complaint about this practice is the expenditure of public money on repeat offenders, something called “reversal fatigue.”

Those on the front lines of the epidemic feel this fatigue too. As District Attorney Ben David said, “a lot of first responders get frustrated, they’ll revive someone they just saw a week ago. You have to understand how they feel, that reversal fatigue, that their resource are being wasted.”

Childs helped cushion this by providing a supply using grants and “end of life” donations (i.e. medication with limited remaining shelf-life). This has earned him the praise of law-enforcement leaders.

Wilmington Deputy Police Chief Mitch Cunningham said, “Robert is a force of nature, what he’s been able to do, with no state funding and a tiny staff, it’s incredible.”

Carolina Beach Police Chief Chris Spivey echoed these comment, saying, “Childs is a game-changer. He changed the way we’re fighting the heroin crisis. He’s helped us save lives.”

But it is the 38,000 naloxone kits distributed by outreach workers like Page, and used by opioid users and members of the community, that have saved the most lives. The number of overdoses reversed with NCHRC naloxone kits is more than 6,000 state wide, over 1,500 in Wilmington (in both cases, more than 10 times the number of reversals by law enforcement).

The overwhelming majority of naloxone reversals in North Carolina have been through harm reduction's efforts.
The overwhelming majority of naloxone reversals in North Carolina have been through harm reduction’s efforts (in orange) versus police departments and Sheriff’s offices. (Data from Wilmington PD and www.nchrc.org/programs-and-services/nc-od-reversals/)

But while Childs is respected by cops, the district attorney’s office and medical health professionals, not everyone agrees with the strategies employed by NCHRC. As with needle exchange and naloxone, NCHRC’s “hands off” policy is sometimes accused of failing to deter – or even encouraging – opioid users.

The victims' vehicle was pulled away from the scene hours after a pick-up struck the family from behind. Photo by Christina Haley.
The victims’ vehicle shortly after the Nov. 1 accident. (Photo by Christina Haley)

A common touchstone in the conversation about opioids in recent months has been the tragic car accident in November. In that crash, a man under the influence of opioids crashed into another vehicle killing a two-year-old child. It was widely reported that driver had been administered naloxone on several previous occasions.

While this was one opioid user out of thousands of reversals, the emotional impact is still deeply felt throughout organizations facing the opioid crisis. The question has to be asked: could something more have been done?

District Attorney David discussed the increasing use of involuntary holds after overdose reversals, citing this incident as an example of the broader danger opioid users pose to others and themselves. David explained he’s looking into working through civil courts, where the burden of proof is less extreme, to try and get more opioid users into treatment as quickly as possible after an overdose.

“A reversal shouldn’t be the end of the story,” David said. “I’ve been at those scenes, I’ve seen it, to have someone who has just overdosed essentially get up and walk away … I say, ‘you’ve got to be kidding me.’”

Kenny House, clinical director at Coastal Horizons, put the question in perspective.

“I’ve got the Chief and Ben David on one side, talking about involuntary holds and court ordered treatment, and I’ve got Robert on the other side, who doesn’t want that, who wants a hands off approach,” House said. “I think, for me, it’s a question of when personal safety becomes the question of public safety. When you have something like that tragic car accident on Independence, it’s too late. We need to decide when a person’s recklessness goes beyond their own behavior into the public sphere.”

House said this would be one of the issues addressed as plans for a proposed multi-agency opioid response force, discussed during last week’s legislative breakfast in Wilmington, move forward.

Next: Everyone agrees, treatment is the goal for opioid addiction – but first comes detox, and maybe “rock bottom.”

Read more of our opioid series:

Part I – The epidemic, by the numbers

Part II – Opioids: from heroin to prescription pills to and ‘psycho synthetics’

Part III – The many changing faces of opioid addiction

Part IV – Mental health and opioid abuse

Opioids: An appendix for readers

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