To the sharply dressed crowd spilling past her at closing time last Sunday, the woman passed out next to the elevators appeared to have had too many $12 cocktails at Kabana Rooftop bar.

But a paramedic who rushed downtown within minutes knew this was something worse. He pushed back her eyelids, confirming her pupils were tiny. She was only taking about five breaths a minute.

“It takes about 15 seconds to recognize what’s going on,” said Tom Hudson of the Richmond Volunteer Rescue Squad, who was part of the team of paramedics who found her still in her dancing clothes and long, dangling earrings, cradled in the arms of a friend 20 floors below the bathroom where she’d nodded off.

This was an opioid overdose, the early stages of a slow bodily shutdown that kills more people in Virginia every year than guns or car wrecks. There have been 19 a week on average this year in the city, where ambulance crews are on pace to treat 40 percent more overdoses than last year and more than twice as many as in 2015.

The Richmond region trails only Roanoke for the highest rate of emergency room visits for opioid overdoses in Virginia over the past five months, according to figures compiled by the Virginia Department of Health. The local rate is more than two times the state average.

Across the state, 2017 is on pace to be the deadliest year yet.

In both a dire indicator of the scope of addiction and a silver lining if there’s one to be had, more overdose patients are being revived.

In a growing number of cases, it’s thanks to the increasing use of naloxone — often referred to by the brand name Narcan — to reverse the effects of opioids.

“It’s not a cure, but it can be a second chance,” said Jim May, who oversees substance abuse programs at the Richmond Behavioral Health Authority. “The general consensus here is more people have access to it, more people have been trained, and it’s having an impact.”

For front-line responders, Narcan is a tool of war. More than 9,000 doses have flowed to local health departments from the state so far this year.

The number of nonfatal overdoses is up more than 25 percent in the Richmond region compared with last year, according to local law enforcement agencies that track them. Deaths in the region are on a similar pace.

People are nodding out in front of their meatloaf and mashed potatoes at home, slumping over in bathrooms and bars. They’re dying in parking lots and alleys, alone or in front of their children.

Seven times this year, Richmond paramedics have had to use Narcan on a driver after responding to a car crash.

Local jails have been overrun with people locked up and in need of treatment and state morgues have been strained by an influx of bodies in need of processing, a spokesman said.

***

Drug overdoses killed 6,661 people in Virginia in the decade from 2007-2016, and are on track to snuff out nearly 1,200 more lives this year, according to the state’s chief medical examiner’s office. And it’s an epidemic without boundaries, affecting people of all ages and backgrounds.

Hours before the woman collapsed at Kabana, two people had overdosed in one of the motels along Midlothian Turnpike, where rooms go for about $40 a night. Another person had to be revived in Church Hill. This summer, a pregnant woman was found overdosed behind Franklin Military Academy. It was too late for her and the unborn child, as it has been for more than 1,000 others in Richmond and its surrounding counties in the past decade.

Prescription painkiller deaths have remained relatively flat during the past decade, hovering between 400 and 500 a year. But the painkiller epidemic has been surpassed by more potent street drugs such as heroin and fentanyl, a prescription drug most often seen manufactured illegally. Fentanyl killed more than 600 people in Virginia last year, nearly triple the count in 2015. In recent months, fentanyl deaths in the state have given way to more heroin overdoses.

The state’s top health official declared the crisis a public emergency last year. Last month, Richmond-area leaders announced an Oct. 26 summit called to foster regional collaboration.

“Getting better at preventing people from dying is a good thing, but it’s not the solution we seek,” Richmond Mayor Levar Stoney said Oct. 6 at a news conference designed to drum up interest in the event, scheduled to run from 8:30 a.m. to 3 p.m. at the Greater Richmond Convention Center.

He had just cited numbers from the Richmond Police Department that demonstrate a dramatic year-over-year increase in the number of nonfatal overdoses, up more than 50 from 245 at that point in 2016.

But those figures might not show the full picture: The Richmond Ambulance Authority had treated 662 overdose patients in the city with naloxone through August of this year, already double those reported by Richmond police through the middle of this month.

Many calls for help are routed straight to emergency services, and the ambulance authority does not contact police for every overdose due to federal patient privacy protections, said Koury Wilson, a police spokeswoman.

Agencies that track overdoses readily acknowledge that their figures are in some ways a low-ball estimate of the opioid epidemic. It’s impossible to track the untold number of times naloxone was used by people who bought the revival drug at a pharmacy, or the thousands who received free doses as part of a statewide program. Also unseen are the people who wake up without medical attention, only to continue a potentially deadly behavior.

Because of the lingering crowd outside Kabana, Hudson and his crew loaded the woman — identified by friends and family as a doctor — into a stretcher and hurried her toward the ambulance for treatment.

Inside, the paramedics worked quickly and calmly, attaching a heart rate monitor, checking blood pressure and breathing, finding a vein in her arm. They shouted her name to try to rouse her. The Richmond Times-Dispatch agreed not to identify the patient as a condition of shadowing paramedics.

As Hudson prepared to press the IV needle in her forearm, the people she came with insisted they hadn’t seen her with pills or heroin, just drinks.

Hudson pumped in half a milligram of Narcan, a sort of antivenin for opioids, and waited. One eye opened, then fell back closed. Another half milligram.

Narcan works by temporarily pushing opioids out of specific receptors in the brain. It’s not effective on any other condition. Here and across the state, naloxone usage by paramedics or emergency rooms jumped by more than 40 percent between 2015 and 2016.

People often never admit they took pills or heroin, Hudson would say later. But if the Narcan brought them back, there’s little question of what happened.

The woman receiving Narcan in the back of the ambulance in the middle of downtown Richmond was one of 10 opioid overdoses paramedics responded to last weekend.

“Wake up,” Hudson and others yelled repeatedly as they worked on her. “Wake up.”

Still groggy, the woman, who half an hour earlier had been drinking and dancing with friends overlooking the Richmond skyline, opened her eyes and mumbled a few words: “I’m gonna (soil) myself.”

That night wouldn’t be her last.

***

The potency of street drugs has increased in the past few years, according to paramedics and medical experts. Fentanyl can be up to 50 times stronger than heroin, so toxic that police wear gloves to avoid touching it.

Narcan wears off faster than narcotics, so patients need multiple doses depending on the strength of the drug. In some fentanyl overdoses, patients are connected to a Narcan drip for as long as 10 hours, said Virginia Poison Center Medical Director Dr. Kirk Cumpston, who also covers shifts in the VCU Medical Center emergency room.

VCU used to declare a critical medical alert, a sort of “all hands on deck” for the ER, for every suspected opioid overdose.

“There came to be so many that we just stopped doing them. ... It was overwhelming,” Cumpston said.

Often, he said, overdose patients today have been treated with Narcan and stabilized by the time they get to the hospital. The idea is to give patients just enough to improve their breathing and wake them up slightly, but not enough to trigger vomiting or aggression by waking them up too quickly.

“But the solution, the real solution beyond paramedics and doctors and naloxone and all that is treatment of addiction,” Cumpston said. “And that’s the thing that people don’t really talk about that they should. That’s the real treatment. The Narcan keeps them alive, but what’s missing is access and funding for addiction treatment.”

Treatment services have long been inadequate and underfunded, but state public health experts are working to catch up. Even as they do, the growing volume of overdose survivors means a host of new people whose needs can overwhelm the system.

May, of the Richmond Behavioral Health Authority, said the agency has seen a dramatic surge in the need for an array of services ranging from medication-assisted treatment to inpatient care.

The agency has already treated 756 people for substance abuse since July 1.

A few years ago, May said he could expect four or five people a day to trickle into the lobby seeking help for substance abuse. That number has soared to 25 and resulted in a triage designed to provide support while people are easing into longer-term treatment and case management.

Where they once hosted 20-30 people weekly, they now see upwards of 180, divided into separate groups that occasionally spill over into common areas and take up an employee lounge on the second floor.

“It’s unreal, the demand,” he said. “We’re working hard to keep up.”

The agency is part of a growing group of community services boards that form the backbone of public mental and behavioral health services in the state striving to provide people who walk in off the street with same-day screening, but the wait to receive treatment for men is between two and three weeks, May said.

Part of a $9.7 million federal grant to the state will put trained workers who’ve been through addiction in emergency rooms including VCU’s, Chippenham’s and Richmond Community Hospital’s as soon as December. They’ll be assigned to help guide overdose patients toward treatment so they don’t leave the ER and go back into the same environment that got them there.

About half of the money is going to expand access to addiction treatment.

“We’ve brought a whole new workforce and treatment capacity into the state,” said Dr. Hughes Melton, chief deputy commissioner of the Virginia Department of Health. “Is it enough? No. But I do feel comfortable saying that we’re going in the right direction and we’re gaining ground.”

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