Brandi Fincham had been drug-free for 82 days last year when she relapsed on heroin.
“I snorted some” and was passed out when friends found her, she said.
They called 911 and the Richmond-area ambulance crew that arrived gave her naloxone, a drug that can reverse a heroin overdose.
Fincham, 26, a Henrico County mother of a 5-year-old daughter, said she has been clean since May 20, 2014, the day after she overdosed.
Virginia officials want to make the drug that helped save Fincham’s life widely available to laypeople who may be around when a person accidentally overdoses on heroin or prescription opioids such as oxycodone.
A new state law allows pharmacists to dispense naloxone under more lenient rules. A pharmacist working with a doctor or other legal prescriber can collaborate on a “standing order” that allows the pharmacist to dispense naloxone without the patient having to see the doctor first. It’s similar to the arrangement that allows people to get flu shots at drugstores without getting a prescription from their doctor.
Pharmacists also can dispense the drug to people not at risk of overdose themselves but who worry that a friend or relative may overdose and who want to be able to save them if that does happen.
“It’s more or less a broad authority for the pharmacist to dispense naloxone under these specific circumstances to, really, anyone who requests it or is in need of having the naloxone dispensed to them,” said Caroline Juran, executive director of the Virginia Board of Pharmacy.
“It’s a vital tool for preventing overdose deaths, whether that’s from opiates that are legitimately obtained through prescriptions or whether it’s abused prescription drugs or whether it’s an overdose from heroin,” Juran said.
The new law went into effect July 1 and was one of dozens of recommendations from a task force appointed by Gov. Terry McAuliffe in September to examine how to stop a growing problem of prescription drug and heroin abuse.
Naloxone has been used for years by local emergency medical technicians and emergency room doctors to reverse opioid overdose emergencies, said Jim May, who oversees substance abuse services at the Richmond Behavioral Health Authority.
Recovery from addiction is seldom once and done, he said.
“More common are repeated, failed, brief attempts to get clean, sometimes without professional help,” May said. “If you are a parent, friend or a loved one to one of these people, you will want to access the naloxone quickly and conveniently if you are seeing signs of return to use. That’s why a standing order can be helpful, so you don’t have to make another appointment with your physician and get a new prescription every time this pattern emerges.”
May said there is no evidence people get the drug and skate closer to the edge.
“Most overdoses are accidental. Someone gets some particularly strong heroin on the street, uses the same amount as usual, and then slowly goes to sleep, for good. Some cases, recently, have involved heroin mixed with fentanyl, which is kind of like mixing dynamite with a small firecracker — way too strong,” May said.
“Other cases involve someone who has tried to go cold turkey or who has otherwise stopped using for several days, and then as the withdrawal symptoms continue, or the psychosocial drive becomes too strong, they go back out and use again, typically going for the same dose they had previously used, which is too much, if their tolerance has gone down.”
In Virginia in 2013, there were twice as many overdose deaths from the prescription narcotics fentanyl, hydrocodone, methadone or oxycodone — 386 deaths total — as there were from heroin, with 174 deaths. The numbers are from annual reports of the state chief medical examiner’s office.
Another new measure asks the Virginia Department of Health and the Virginia Department of Health Professions to develop guidelines for doctors to write a companion prescription for naloxone whenever they prescribe long-term use of a prescription opiate. That way, the naloxone would be on hand in case of an accidental overdose.
Naloxone is packaged to give by injection or by squirts in the nose.
The Virginia Pharmacists Association, which is holding its annual meeting in Williamsburg this week, is offering its members training on the new law, said pharmacist Tim Musselman, the association’s executive director. It’s not sure how many pharmacies will pursue standing orders.
“We need to throw every solution and tool possible in order to save lives,” said Whitney O’Neill Englander, spokeswoman and lobbyist for the national Harm Reduction Coalition.
“We are dealing with overdose rates that are unparalleled in our history,” she said, noting that overdoses have overtaken automobile accidents and homicides as the leading cause of injury deaths.
“Pharmacy access through a standing order is a really great access point that hopefully will help a lot of families,” Englander said. “What I would love to see across the country, however, is an investment in overdose education and naloxone distribution programs. Those programs have proven … to reach the highest-risk patients and people who are most likely to witness an overdose. It puts the tool directly in their hands.”
Last year, Virginia began a pilot project called Revive! to train laypeople how to use naloxone. People learn how to administer the drug but have to get a prescription from a doctor to get the drug.
Jason Lowe, Revive! program manager at the Virginia Department of Behavioral Health and Developmental Services, said the program has trained 536 people as lay-rescuers and an additional 448 as trainers who can pass on what they know to others.
“We ask people to report reversals, but we’ve received no official responses,” said Lowe, referring to cases where people who were trained have used the drug to save someone. “We have heard anecdotal reports of a handful of reversals in the Richmond area.”
Training on how to use nasal naloxone is needed because the drug does not come ready to squirt up the nose. Instead, a rescuer has to attach an atomizer to the tip of a pre-filled naloxone syringe.
An easier to use but more expensive option is Evzio, a device that auto-injects the medication. It was developed by the Richmond-based Kaléo pharmaceutical company, which also makes an epinephrine auto-injector for treating severe allergic reactions.
“Whereas there is a lot of activity throughout the nation on the pharmacist front to increase access through these collaborative practice agreements, where we really think that there’s going to be substantial progress made in reducing opioid-related deaths is in the medicine cabinet or co-prescription model,” said Dr. Eric S. Edwards, Kaléo’s chief medical officer.
In that model, patients prescribed long-acting opioids — for chronic pain, for instance — are co-prescribed naloxone to have on hand in case of breathing emergencies.
Kaléo has co-pay programs to help make the product more affordable for individuals, Edwards said, and its Kaléo Cares programs make the product available for free to nonprofit law enforcement and harm-reduction organizations.