It was a summer morning like most other normal mornings in Chicago, people stopping for coffee, rushing to get to work on time, catching the crowded “L,” searching for empty seats, and dealers selling heroin.
After one such exchange, a young man named Nick injected the drug with his friend in the passenger seat of his Honda. It took one shot, and Nick immediately lost consciousness, body slumped, breathing stopped — and his friend knew. He was overdosing. He was going to die. He had just minutes before he would be brain dead.
Nick’s friend opened the glove box of his car and pulled out another drug. This one could save his life. He injected the opioid overdose antidote into Nick’s outer thigh. Nothing. He was still unconscious. He tried again. Another dose of naloxone—and this one worked. Nick sat straight up and began sweating like he was just woken up from a ghoulish nightmare.
Naloxone, also known as Narcan, quickly reverses an opioid overdose by attaching to opioid receptors and effectively reversing and blocking the effects of other opioids. Nick, my brother-in-law, is clean and sober now, thanks, in part, to naloxone. My sister, who also is recovering from substance use disorder, is clean, too. I’ve seen her heart break as her friends passed away from the disease of addiction. I’ve seen with my own eyes the way addiction can ravage families. But I’ve also seen how people with addictions can recover and lead productive lives.
Even though Nick’s overdose resulted in him getting clean, the Centers for Disease Control and Prevention report that more than 70,000 Americans died from drug overdoses in 2019. And, in 71 percent of those deaths, opioids were involved. Such overdoses only surged in the US during the pandemic: more than 96,700 Americans died from drug overdoses in a 12-month period from April 2020 to March 2021, 72 percent opioid-related. That’s more than twice the annual number of traffic fatalities. It’s clear that opioid use disorder is far from going away, and we need to think big picture to find solutions.
The woman who provided Nick with his lifesaving dose of naloxone, Laura Fry, spends her days educating people about substance use disorder and training folks on how to use naloxone. “I always tell people: you’ve got to have a heartbeat to do anything,” Fry said. She leads a Chicago-area harm reduction agency called Live4Lali, named after a boy who died from an opioid overdose. “The biggest hurdle we face is stigma.”
In 2015, the Illinois Legislature passed Lali’s Law requiring law enforcement officers to be trained on how to use opioid antagonists such as naloxone and that first responders, including all ambulances, carry them at all times. By 2018, all Chicago Fire Department vehicles were equipped with Narcan, and by 2019, almost three-quarters of Illinois Police Chiefs surveyed report that all of their officers bring with them naloxone while on duty. This mindset change from punitive to therapeutic or rehabilitative measures is, in turn, empowering public health advocates.
“The way we use naloxone may be changing—higher doses administered more quickly,” said Beth Dunlap, an addiction specialist in the Chicago area and an Assistant Professor of Family and Community Medicine in the Northwestern Feinberg School of Medicine. This is apparent with the recent news of FDA approval of a higher dose naloxone nasal spray. One source claimed to know of cases where seven or eight doses were required.
So why did Nick’s revival take two doses of naloxone, not one? The drugs were never tested, so the drug potency and type remain unknown. A big problem has taken hold in the US: Dealers get their hands on pill presses, and they can put whatever they want in these pills, including fentanyl, a colorless, tasteless, and odorless synthetic opioid that is 50 times stronger than heroin. Even other drugs, like cocaine, and LSD, have tested positive for fentanyl. Dealers will do this so that the drugs are not only stronger but also more addictive.
Fry noticed this trend taking effect in the Chicago area. In addition to distributing naloxone to the community, she distributes fentanyl test strips. When drugs are purchased on the street, the origins are unknown. If people are going to be using a drug anyway, they should at least be testing for an agent, like fentanyl, that can prove lethal.
In meeting people where they are, Fry and her colleagues give people tools, such as those fentanyl test strips, naloxone, transportation to community recovery centers, and community support groups, for free. This is important because the opioid crisis is a problem affecting all Americans: while Black Illinois residents’ opioid overdose death rate is twice that of white residents, in the United States as a whole, non-Hispanic white Americans are the most likely to die of an opioid overdose. Furthermore, people living below the poverty line are more likely to die of an opioid overdose than their affluent counterparts, according to a 2020 study. To add to the problem, the risk of opioid overdose increases for people without health insurance. This means the poor and uninsured face the greatest risk, but they also encounter some of the greatest obstacles, such as the cost of getting naloxone from the pharmacy, or staying at a residential treatment center without insurance: As of January 2022, the average marked price of a single box containing two one-time-use nasal sprays is $72.99. For comparison, that is about seven to eight hours of work for someone making minimum wage in Illinois.
“I’ve had people turned away from the pharmacy,” Fry said.
Advocates agree: to unlock naloxone’s lifesaving potential means making it accessible. One way to build upon the work of groups like Live4Lali, which try to lessen the burden on the groups at greatest risk, is always dispensing high-dose opioid prescriptions with naloxone in the pharmacy. Lowering costs, reducing barriers, and educating people about naloxone laws in their state will save lives.
Bioethicist Travis Rieder is the director of Johns Hopkins University’s Master of Bioethics program and the author of In Pain: A Bioethicist’s Personal Struggle with Opioids. He himself became dependent on opioids after sustaining serious injuries in an accident. He was able to overcome his addiction even in a medical system that is vastly underprepared for getting people off an opioid regimen. Rieder now applies what he knows to people with substance use disorder.
He touts the harm reduction philosophy of groups like Live4Lali: “Basically, it requires that we meet people where they are, recognizing that they are agents with dignity, worthy of respect, despite their choices and values,” he said. “People don’t deserve respect because and only if they act in accordance with our own values; they deserve respect because they are people.”
“People don’t deserve respect because and only if they act in accordance with our own values; they deserve respect because they are people.” — Travis Rieder, Director, Master of Bioethics Program, Johns Hopkins University
During the pandemic, I have seen my family fewer times than I would have liked. Still, we all met one night for dinner the first week of the new year. My sister is very close to graduating with a bachelor’s degree in finance from DePaul University in Downtown Chicago. She is overjoyed to be starting a banking internship in the summer. My brother-in-law Nick is studying to be an electrician. He’s optimistic about the future. They live with their Yorkshire terrier, Rocco, in a Chicago suburb. When Nick looks back on his experiences, he expresses gratitude for the people who fought for his recovery. “I would not be alive today without them.”
I am grateful, too.