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Nasal spray gives families the power to reverse overdose

The Foxborough woman could tell that her son had been using again. On that November day in 2011, he was hyper and overly affectionate. “Dear mother,” he called her.

She knew that he was at risk of an overdose. The weeks the 21-year-old had gone without heroin, as the family worked to get him into a treatment program, weakened his tolerance for the drug. When she awoke that night to screams, she was ready, as ready as she could be.

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Her husband had checked on their son and found that he was not breathing. As he dragged the young man’s limp body from the bed to begin rescue breathing, their daughter dialed 911, and the mother sprayed a heroin antidote called naloxone into each nostril. Then the family waited, as precious moments passed, for a breath or a groan, a sign that the drug was working.

Dina Rudick/Globe Staff

A member of Learn To Cope trained two other members in administering naloxone at Lowell General Hospital.

Since 2006, health officials in Massachusetts have been distributing intranasal naloxone to those most likely to witness an overdose: outreach workers, homeless shelter operators, drug users themselves, and, most recently, family members. The program, started in Boston and expanded by the state Department of Public Health, is credited with reversing more than 1,800 overdoses from heroin, prescription painkillers, and other opiates.

A recent study found that the rate of overdose deaths slowed in communities where the program was active.

Yet, in much of the country, access to naloxone, also known as Narcan, is limited. Few doctors prescribe the drug, which typically must be administered by syringe. Some communities and, in the past, federal officials have resisted, worried that people would perceive naloxone as a safety valve and use drugs without fear of an overdose.

But attitudes are changing, and leaders in addiction medicine have pointed to the Massachusetts ­pilot program as a model.

“The Massachusetts program is to be envied and emulated,” said Dr. Sharon Stancliff, medical direc­tor of the Harm Reduction Coalition, based in New York. “We’re getting the information that [naloxone] works. We’re getting the information that it’s not expensive for the level of effectiveness.”

Two features of the program have helped it gain a foothold in Massachusetts. The state packages the drug as a nasal spray, an approach first tried here by Boston Emergency Medical Services. With no needle required, the spray is easier for the layperson to use, though it has not been approved by federal drug regulators, so it is not widely available.

And, while naloxone requires a prescription, in Massachusetts one physician serves as the prescriber of record, so that the drug can be distributed by outreach workers at 15 groups that work in communities hard hit by the overdose crisis, including Lynn, Fall River, and Lawrence.

Dr. Alexander Walley, assistant professor of medicine at Boston University School of Medicine and medical director for the state program, said these workers and others connected to drug users can be the most effective ambassadors for naloxone rescue kits.

The US Centers for Disease Control and Prevention reported last month that fatal overdoses ­nationally grew for the 11th consecutive year in 2010, to 38,329, driven by prescription drug abuse. In Massachusetts, overdoses killed 738 people that year, twice as many as motor-vehicle deaths. That was fewer deaths than in 2006, but it is not clear to what extent the naloxone program contributed to the decline.

Members of Learn to Cope, a support group with chapters across Eastern Massachusetts for parents and other relatives of people addicted to opiates, began clamoring for access to naloxone in 2006, after members saw nine families lose people to overdoses within seven weeks.

At first, the parents worked through community groups already enrolled in the pilot program, learning how to administer the drug and how to recognize the irregular breathing and behaviors that signal an overdose.

“We couldn’t believe, when we finally got this training, how many of us were seeing these signs and didn’t even know it,” founder Joanne Peterson said.

Her group became part of the pilot program in November 2011, and parents began counseling other parents at the start of each chapter meeting on how to use the naloxone rescue kits to save their children.

The families’ eagerness surprised some state officials. Asking for naloxone meant tacitly acknowledging their child’s substance use, Walley said. But the drug became one tangible tool for parents ­unmoored by a disease beyond their control.

“It’s not a cure-for-all,” Peterson said, “but it’s a chance.”

In the past 15 months, the group has distributed hundreds of naloxone kits to members and recorded at least nine overdose reversals.

The Foxborough mother learned to use naloxone at her first Learn to Cope meeting in summer 2011, days after her son admitted to his parents that he was using heroin. She kept it close by, on top of her refrigerator, until the day they needed it.

When she first administered the drug, her son was not responding.

“We were all screaming and yelling at each other,” she said recently, tearing up as she sat in her living room in front of a portrait of her son. “He was just not waking up.”

But the naloxone did work. Later, after her son was revived by first responders and recovering at Massachusetts General Hospital, doctors told her the antidote had slowed the effects of the heroin in his system.

After several rounds of inpatient treatment, her son is still struggling with substance use and the law. She asked that her name not be used to protect his privacy.

In 2009, the rate of overdose deaths in communities where the state distributed naloxone was ­reduced between 27 percent and 46 percent, compared with those with no naloxone program, according to a study led by Walley and published in the BMJ medical journal in January. Communities with wider distribution of the rescue kits saw a bigger effect.

Walley said there are lots of ideas about how to control illegal drug use, including drug take-back events and prescription-monitoring programs. In terms of setting public priorities, Walley said, “distributing naloxone kits should be right up there, if not in front of these other methods, because we’ve shown an association with mortality.”

The state Department of Public Health spends about $300,000 per year on the naloxone program, mostly on purchasing the rescue kits. The program’s results, taken together with a recent study that found naloxone to be cost effective, could prove pivotal at a time when support for naloxone distribution seems to be growing, said Stancliff, of the Harm Reduction Coalition.

Federal agencies, led by the US Food and Drug Administration, hosted a meeting last spring to discuss what it would take to make the drug widely available in the intranasal form and over the counter. The latter is more complicated, requiring evidence that people can use the drug safely without a doctor’s advice.

Dr. Douglas Throckmorton, deputy director for regulatory programs at the FDA’s Center for Drug Evaluation and Research, said he has been talking with device makers about seeking FDA approval for a nose spray or an auto-injector similar to the spring-loaded devices used to deliver epinephrine to someone who is having a severe allergic reaction.

Ultimately it is up to the device companies to decide how to move forward, he said, but “they’ve asked the kind of questions I hear developers ask when they’re taking a program seriously.”

Meanwhile, Learn to Cope meetings — “sadly,” Peterson said — continue to grow, with a seventh chapter opening this month in Cambridge. At a recent gathering in Lowell, one mother counseled ­another about how, if needed, she should give naloxone to her 21-year-old son, who began using heroin soon after friends passed around Percocet pain pills while playing video games.

The instructor asked the Wilmington mother whether she had ever witnessed an overdose. “None,” the woman said.

“It’s going to stay that way,” the instructor told her, more as a prayer than a proclamation.

Chelsea Conaboy can be reached at cconaboy@boston.
com
. Follow her on Twitter @cconaboy.
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