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'Use of Opioid Overdose Antidote Expanding in Knox County Area'

Around 30 times a week, Rural/Metro paramedics in Knox County administer naloxone to people overdosing on opioids.

The ambulances have carried the drug for around 20 years now. It works by blocking the effects of opioid drugs on the respiratory and central nervous system. In minutes, it can restore normal breathing, potentially saving the life of someone dying of an overdose.

There's always been a place for it in the paramedic's bag of tools — but over the past three to four years, Rural/Metro personnel have seen the need to use it rise steadily, said Chris McLain, clinical manager for the ambulance service. Over the last six months, he said, Rural/Metro's first responders have been using it 100-120 times a month.

And they're no longer the only ones carrying the drug. Since Knoxville Police Department began carrying naloxone in September 2015, officers have used it 27 times on people overdosing on opioid pills like oxycodone and street drugs like heroin.

A little more than halfway through 2016, Knoxville Fire Department has already used it 46 times — compared to 54 times in all of 2015, said Capt. D.J. Corcoran. And 2015 more than doubled the number of times — 19 — KFD used the drug in 2014.

At the same time, it's becoming more common for private citizens to have naloxone on hand. Some pain clinics are requiring patients fill naloxone prescriptions along with their prescriptions for opioid drugs. Friends and family members of addicts are beginning to request — and fill — prescriptions for the drug to keep on hand, legal in Tennessee since 2014 and encouraged last year by Tennessee Department of Health Commissioner Dr. John Dreyzehner.

"Ask for it, prescribe it, keep it around," Dreyzehner said. "Relatively speaking, it is more effective at saving lives than CPR or an AED," the automated external defibrillator that can shock the heart back into rhythm.

But, like an AED, naloxone requires training to use correctly, McLain said. And like CPR, it's a temporary fix — something to do while waiting for paramedics to arrive, he said.

"I think it's kind of a misconception to say (naloxone) 'saves' somebody," point-blank, McLain said. Though effective, it's not fail-safe, he said. Some patients — especially chronic users — need more than one dose. Some patients also need to be ventilated, or they go into cardiac arrest.

And some patients get naloxone over and over again, and it can become less effective.

"We do have 'repeat customers,' " McLain said. "Sometimes you have communities and groups of people who just can't get off the (opioid) medication."

Fighting the epidemic

Public health officials are increasingly looking at naloxone — brand name Narcan — as an antidote to Tennessee's increasing overdose death rate. In 2014, the last year for which state numbers are available, a record-setting 1,263 Tennesseans died of drug overdoses — at least one in all but four counties in the state, including 133 in Knox County. The state expects to release 2015 numbers in a week or two.

Between Jan. 1 and June 15 of this year, 118 suspected overdose deaths happened in Knox County, said Sean McDermott, assistant district attorney general, though it's possible not all were Knox County residents. Exactly how many of them were opioid drug overdoses, he can't say — the numbers aren't broken down by types of drugs, he said.

Last month, U.S. Surgeon General Dr. Vivek Murthy, on a visit to Knoxville, announced increasing access to naloxone was one of his three primary areas of focus in the fight against the opioid epidemic. At a June 30 forum in Abingdon, Va., hosted by U.S. Secretary of Agriculture Tom Vilsack, Virginia Governor Terry McAuliffe touted that state's initiative to make naloxone available statewide to anyone without a prescription — a policy Tennessee may soon have also.

This year, the Legislature passed Public Chapter 596 allowing "any willing pharmacist," collaborating with the state's chief medical officer, to dispense naloxone over the counter "using their best clinic judgment, good faith and reasonable care." The collaborative practice agreement that would result in pharmacies having a standing order for the drug has been written and now will be reviewed by various state boards. At the same time, health departments — including Knox County's — have been working with pharmacies to make the easy-to-administer drug more available.

Last fall, pharmacy chain CVS announced Tennessee was among states where its pharmacists would dispense naloxone without a prescription. They could do so using a standing order already compliant with state law, Mike DeAngelis, director of public relations for CVS in Rhode Island, told the Tennessean.

But though DeAngelis said then the company would "reinforce" its change in policy to its 135 stores in Tennessee, calls to Knoxville CVS stores last week found some will prescribe naloxone without a prescription, while others won't.

Other Knoxville pharmacies varied on whether they would prescribe or even stock the drug, which can range widely in price. For those not filing the drug to insurance — for which a prescription would be required, even at CVS — cost could be a barrier.

Brandon Lock, head pharmacist for local chain Belew Drug's Broadway Shopping Center store, said his pharmacy keeps in stock both Narcan and generic naloxone, in two forms: injected through a needle into the muscle, and sprayed into the nostril through a syringe. (Paramedics also sometimes give the drug intravenously.)

Narcan with the kit that allows it to be injected averages about $4,000 for those paying cash rather than filing insurance, Lock said. By contrast, the Narcan nasal syringe kit averages about $159, and the generic naloxone nasal kit — which most people opt for — costs about $75, he said.

Lock said demand for the drug has increased.

The Federal Drug Administration didn't approve the nasal spray form of the drug until November 2015, though some agencies were using it before then. When the more affordable version of naloxone became widely available, that opened the door for many agencies to carry it, said Jessica Belitz, community outreach coordinator for the nonprofit Blount Memorial Foundation and staff coordinator for the Blount County Substance Abuse Prevention Action Team.

"We were interested in supplying it to our first responders, but at the time law enforcement felt it needed to be FDA-approved," Belitz said.

In February, the team provided the nasal spray kits to three law enforcement agencies and two fire departments in Blount County, Belitz said. It's been used at least a dozen times so far, she said.

In addition, the coalition provided the kits to middle and high schools in all three school systems in Blount County, she said, though she's not aware that they've yet been used in a school.

Belitz said both first responders and schools were eager to have the drug on hand, especially since Tennessee — like Virginia — has passed laws protecting people who administer naloxone "to a person reasonably believed to be experiencing an overdose" from being sued or criminally prosecuted.

"One of the No. 1 complaints I hear is access," Belitz said. "Family members who may be living with someone or close to someone who's addicted call me, and they want to access this medication. … But even with a prescription, it's still a challenge for some to be able to get ahold of it."

Call 911 first

McLain, of Rural/Metro, urges anyone who might give the drug to become educated on its proper use — and its limitations. He worries people may grow overly reliant on the drug, thinking they can continue using opioids and "self-medicate," rather than seeking medical help.

He warned that people given naloxone suffer withdrawal as the drug blocks the opioid drugs already in the body, which can make them combative. Some initially respond to naloxone but then "rebound," especially if they're chronic users or there are large amounts of opioid drugs in their system.

Call 911 first, he said, then administer naloxone.

Dreyzehner said the drug can "prevent a mistake from being deadly or give more people a second chance at recovery instead of death."

And people should think of it as a second chance — not a long-term solution, McLain said.

"If you have a headache, you can take some Tylenol, but we still need to know what's causing the headache," he said.

"Prevention is the key, and getting into some kind of treatment plan to get people off the (opioid) medications."

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