Trish is shivering in her lime green polo shirt even though it's 70 degrees outside. The 42-year-old stands behind the Free Clinic's needle exchange van parked near Metro on W. 25th Street and admits she's a bit paranoid, her head on a swivel as she rubs her hands against her arms.
Trish is a heroin user and has been for 17 years, scattered around brief stretches of sobriety.
On this April morning, however, she is not at the van to pick up clean syringes for her habit, though she and her sister use the service. She's here to pick up a refill on her naloxone prescription from Dr. Joan Papp, a Metro emergency room doctor whose small pilot program aims to get the drug, which reverses opiate overdoses, into the hands of at-risk users.
"She was here a few weeks ago and said someone used it on her sister to save her life," says Chico Lewis, a 15-year veteran on the needle exchange van. "She said it was a miracle drug. She said she couldn't believe it worked."
Trish's sister is 40 and also a heroin addict of two decades. One afternoon her sister shot up and fell down. Overdose. She was purple, her breathing laboring to a near stop. Trish's 28-year-old niece found her mother and called Trish's nephew, a user himself who had access to Trish's naloxone. He rushed over the small distance on the near west side of Cleveland to administer the nasal spray.
"They said it worked right away," says Trish. "They said she just took this deep breath, this deep, deep breath, and shot up. Then she threw up, but she was fine."
Her sister had never ODed before, and without the drug might have ended up padding Ohio's already epidemic-level numbers of painkiller and heroin overdose deaths. In 2011, the last year for which data is available, there were 1,765 such deaths in the Buckeye State, a record.
"But everyone's overdosing," says Trish. "You read the obits, you have a friend die. My sister just had a friend die. That's just what happens.
"This, though, is a miracle drug."
Opiates – heroin, oxycodone, Vicodin, Percocet, etc. – latch onto the mu receptors in the brain. The drugs cocoon those receptors like warm magnetic blankets, producing the high in the user. An overdose, which usually includes mixing different drugs and alcohol, blasts those receptors with enough depressants to cause breathing to slow and stop.
Naloxone (brand name: Narcan) is an intravenous prescription drug that's been around since the 1960s. It is not a controlled substance, has no major side effects, and is not addictive. It does, however, have a stronger pull to the mu receptors than opiates. One dose knocks the opiates off the receptors, reversing the OD and restoring normal breathing. Quite literally, it's a 50-year-old miracle drug way past its time of being in the hands of users and those around users.
Dr. Papp sits in a conference room at the Free Clinic on Euclid waiting for just those users every Friday. With nominal seed money -- about $90,00 in all -- from Cuyahoga County, the Ohio Department of Health, and her hospital, she's brought Project D.A.W.N. (Deaths Avoided With Naloxone) to Cleveland as a pilot program that launched March 1. To date, she has registered 96 users, with ive refills of naloxone for documented overdose reversals, including Trish's sister. There are three additional reversals that have yet to come in for refills but that have been confirmed through verbal reports.
Naloxone is not FDA-approved for nasal use, but pilot programs around the country, like the D.A.W.N. project in Cuyahoga County and its Ohio-based inspiration, the D.A.W.N. project in Portsmouth, have begun supplying nasal adapters with naloxone for easier use – less training, equally effective.
"Users don't like to get it because it wrecks their high," says Papp. "But when they're in trouble, it knocks them right back. It literally lets them breath again. The need just hasn't been as great as it has been now. We're taking this drug that's worked really well for us in the hospital and making it widely available to people."
The restrictions on Dr. Papp's program are pretty strict. It's a prescription medication and must be given to someone who was or is an opiate abuser at risk of an overdose. One level of protection in place at D.A.W.N. is the requirement that to enroll, you must become a patient at Metro, and your medical records will indicate that you are an opiate abuser. Dr. Papp has had to turn away many parents and friends looking for the medicine for a loved one.
"This started about a year ago, the planning portion," she says. "We've noticed a lot more heroin users in the ER – estimated, about 20 percent of what I see has to do with opiates, whether it's infections or withdrawals or overdoses. And you're not seeing the lower rungs of society, you're seeing young, middle-class people from the suburbs."
Turning away those in the immediate vicinity of users is not acceptable, according to Papp, which is why she's working with State Rep. Michael Stinziano, a Columbus Democrat, on a bill that would expand access to users and their families and loved ones.
There are two other bills winding their way through the Ohio legislative process, with many more restrictions – families would have to bring users to the doctor to a get a prescription, etc. – that would do far less to curb the overdose epidemic.
And Ohio is far behind the curve and just responding to the staggering numbers – the fact that there's an increase in white, middle-class suburban users can easily be seen as a prod for action. There are already 188 programs nationwide to distribute naloxone, some with unfettered easy access, others with slight hoops to jump over. The point, however, is that from Boston to Chicago and D.C. to New York, cities have responded to the heroin and opiate epidemic through intertwined tentacles of education and prevention, treatment and law enforcement, and also accessible naloxone.
With 161 ruled cases of heroin-related deaths in Cuyahoga County in 2012, 72 of which occurred in the suburbs, there's been a delayed call to action that resulted in D.A.W.N.
"There was a meeting not too long ago where the FDA basically said they wouldn't mind a prescription medication of nasal naloxone," says Papp. "But we have to get a pharmaceutical company to do that, and there are only two companies in the United States that manufacture naloxone. There's someone working on it now, and hopefully sometime in the next year or two, it'll be on the market. But it has to wind its way through the FDA."
On this Friday morning in April, one user, an older black gentleman with a cane, a jean jacket and glasses, comes through the Free Clinic just after it opens. He'll watch a short DVD about the medicine and its administration. He'll receive two vials, as well as a packet of information. He declines to be interviewed for this story, though as with most addicts and users
Scene encountered over the course of this article, that's not a strange request. All that matters is that he showed up.
Brett, another recipient of naloxone who is a former addict of both Oxycontin and heroin, is forthright in his habit and desire to spread the word to his fellow users, though he's been clean for months now.
He started when he was 24, a nurse's aide out west in Elyria. He'd developed a back problem – softball-sized knots beleaguered his daily activities – and the pain grew too much to bear. His girlfriend's best friend was over his house one day; he was flat on the floor. An offer of Oxycontin arrived. Take a quarter of a 40-mg tablet, she said. It'll take away all your physical pain.
It did more than that.
"After 30 minutes, I felt nothing," says Brett, wearing a Tribe jersey and hat, tattoos covering his arms. "Then I felt like I was going to throw up, just sweating profusely. So, I took a shower. Just after that, I felt perfectly fine, like I was floating. Those drugs, they take away all your physical and mental pain."
He began to take Oxys supplied by friends and bought off the street. Soon, a habit formed. He lost his son, he lost his job, he started dealing and stealing to support his habit.
"I would steal candy from the dollar stores," he says. "And then go resell it to the convenient stores around town. I had a $450 a day habit. There would be times when I would be walking around in the dead of winter in shorts and a t-shirt. It's a full body orgasm."
Like so many pill users, Brett soon turned to heroin – it was cheaper and more readily available.
"Pills got to be a pain in the ass to find," he says. "Especially after they changed the formulations."
He overdosed five times alone in 2011. And like so many users and addicts, he used with friends, and has witnessed his fair share of overdoses and the ineffective ways in which users try to solve the problem. In fear of law enforcement, many don't call 911 or take ODers to the hospital. Instead, they throw them in a cold shower, toss ice on them, or give them a dose of Suboxone, an opioid withdrawal drug that contains a small bit of naloxone.
His best friend died in his arms two years ago. The Sunday before he talked with Scene, he attended a friend's funeral; he had another the Sunday after, both from heroin overdoses, and the latter of which was a friend whom he introduced to the drug.
"I remember the first time I got sick on the pills," he says. "I told my friend I couldn't come out because I was throwing up, I said I know when I have the flu. He asked if I had any pills around. I told him I had an 80 mg in the bedroom. He said take a quarter and call me back in half an hour. It only took 15 minutes. I called him back and I felt perfect."
"I've been clean eight months now after I fucked up briefly last year," he continues. "But I put a message out on my Facebook that I have this drug, just so people know I have it. It's a life saver."
"Thank God Dr. Papp had the fucking balls to do this," says Roger Lowe, the other half of the Free Clinic's needle exchange van team, along with Chico Lewis. Lowe's been on the crew for five years.
Like Chico, Lowe is a former user himself – first joint at the age of 8, just about every drug known to man until he was 22, clean for 18 years now – and can identify with the clientele.
"I didn't do heroin," he says, a low-slung hat over his reddish brown hair, looking very much like the musician that he is when he's not manning the white van on the west side in the mornings and the east side in the afternoons, Monday through Friday. "It was taboo: you're going to die if you do this. It wasn't that accessible."
Lowe's mom died of a heroin overdose two years ago; she, however, wasn't even a heroin addict. She started doing it after getting into pills.
On the streets five days a week, Lowe and Chico know just about every user in Cleveland on a first name basis. They know who disappears – "We maintain an informal death registry of sorts," he says. "Someone will ask about a guy, and we might be able to tell them, 'Yeah, we saw him,' or, 'You probably won't see him again." – and they provide HIV and hepatitis testing, as well as direct users to treatment facilities and social outreach programs.
Needle exchanges are illegal in Ohio – why and how is a whole other conversation – but cities can grant emergency actions, which is how the Free Clinic's program, the only legal needle exchange, began in Cleveland after Mayor Michael White declared an AIDS emergency in 1995. Still, it's a one-to-one exchange – bring a dirty needle, get a clean needle – and they can't work with minors or outside of Cleveland.
"If I had my way, and I've testified in Columbus on this, you know how you see food trucks going down the street?" he says. "You'd see my needle van following right behind. It works. We have people wanting us to go to Parma and we just can't."
Chico and Lowe have seen first-hand how the heroin epidemic has changed over the years, and they have endless stories to tell. There's the one about the former suburban high school football player who came to the van. They asked what the hell he was doing there. "I got hooked on painkillers, and when they ran out, I started using heroin," he told them.
Or the one about the grandma who came to the van and listened to them tell her about the D.A.W.N. project.
"I wish I knew about that a couple weeks ago," she confessed. "I came home to find my grandson dead in the bathroom from an overdose."
"These kids are driving up in nice cars – nice suburban white kids," says Lowe. "Parma is bad. You used to not see a piece of paper littered on the streets in Parma, now there are needles. Lakewood is bad, too. Years ago, you'd lose a guy here or there. This one time, some dope was going around that was cut with fentanyl and we had five drop in one week. But then word got around and people stopped using it. Not like now. Right now, especially after guys get out of treatment, you hear and see them drop two, three at a time. The county and the city are like, 'What the fuck are we going to do?' Well, Joan [Papp] is what they're doing. That's all Joan."
"The way drug policy changes is slowly and when young people die who are meaningful to policy makers," says professor Lee Hoffer, an anthropologist at Case Western who has studied heroin markets for a decade. "This happens to be suburban white youth now, but there were plenty of black and brown kids dying before."
It's not hard to coax officials in government, law enforcement, or the health care field to admit in plain language that they have a substantial problem on their hands. Unfortunately, they've been slow to come around to that conclusion and it's easy to infer that Hoffer is right at the motivation, though most talk around that point.
"Quite frankly, that's all we're seeing right now – heroin," says Jeff Capretto, special agent in charge with the Westshore Enforcement Bureau narcotics task force. "Between our unit, the Lorain County drug task force, the Cleveland police, and others, we're all pursuing heroin. It's the most sought after drug at this time. It's not really a matter of being forced to, but the amount of deaths, it's out of control."
There's more market supply -- users will tell you that sometimes, heroin is easier to find than marijuana – but Hoffer is cautious to pin the sky-rocketing overdose numbers on any one cause.
"It probably has many factors," he says. "In urban areas, there aren't that many anomalies in the product. But once you start getting out into rural areas, it's different. If everyone in the market is diluting the heroin, the market equalizes, so I don't think the purity here is any different, but if you go to different locations, the purity can be different."
Also, heroin is about ten-times more potent than pills, Hoffer says. And many times, when someone exits treatment or prison, they think they can go back to using the same dose they were before, but the body has lost tolerance, and they'll overdose quickly.
"What's amazed me, though, is that I run into these twentysomething users that I interview, and they didn't get started on heroin; they get started in benign ways, popping pills at a party or something. It doesn't take long for that to lead to heroin. That's why it's important for there to be peer education, to learn about use and potency. And D.A.W.N. is important and it's nice to give it away, but it's fucked up that family members and friends can't go get it."
"I think it's very clearly a public health epidemic," says Vince Caraffi, supervisor at the Cuyahoga County Board of Health and chair of the Cuyahoga County Opiate Task Force. "We recognized it through the medical examiner's review. His office, last September, put together a report. We've been dealing with the opiate problem in pills, and it just kind of leads to heroin. It's unfortunate, but it's easy, especially cost-wise. If you can't afford an 80 mg tablet, which is $80 on the streets, heroin is the other option."
The problem is: how do you get naloxone into those same hands?
A handful of organizations and entities form the poison control review board. The Cuyahoga County medical examiner, medical professionals, cops and others are reviewing overdose records on a case-by-case basis looking for commonalities and patterns. Which ones were preventable? Which users used socially? Could someone have been saved?
Judge David Matia, who runs the drug court in Cuyahoga County, is also part of the committee. He's been on the bench for 15 years, the last four of which have included work with high-risk, high-need offenders who roll through the judicial system.
"I thought I'd be dealing with crack addicts," he says. "But I took over the drug court just as the heroin epidemic was starting. I've talked with crack dealers who say they can't make any money anymore and have switched to heroin. And for the users, about half get started on legitimate medical treatments."
As part of the re-entry process, offenders spend 90 days in a residential treatment facility. As of March, Judge Matia also mandates that they visit the D.A.W.N. program to get a naloxone prescription.
"I think it's a reversible, treatable problem, but there needs to be education," he says. "And what we've found is that the window after being released from treatment or prison is the highest risk time for overdoses. They think they can go back to doing the same thing they were before if they slip up."
Like almost everyone interviewed for this story, Judge Matia believes naloxone should be readily available and accessible to those around users and users themselves. He relates a telling anecdote.
"There was someone not too long ago in a treatment facility who snuck in some heroin. They overdosed and the staff called 911. But the dispatcher screwed up and sent a fire truck, not EMS, so they didn't have naloxone. But thankfully, another resident in the facility had gone to D.A.W.N. and the drug was there to be used. They saved his life."
State Senator Eric Kearney is the sponsor of one of the competing naloxone bills in Ohio, Senate Bill 105. While his heart is in the right place after seeing opiates devastate counties near Cincinnati, and while he has a firm grasp of what naloxone can mean to communities – "It's fiscal responsibility," he says. "If you take someone to an emergency room for an overdose, it's approximately $10,500. Narcan is less than $40."
But Kearney's bill has red tape that is emblematic of Hoffer's claim that drug policy is slow to change. His version would require that non-users take an addict to the doctor, and only then would the non-user also get access to a prescription.
As for why there is fettered access, Kearney explains: "I think it's cautionary. It's a safeguard. I just wouldn't want to have a controlled substance be available over the counter or anything."
Except that naloxone isn't a controlled substance, and, once again, not addictive and produces no major side effects.
"It's unfortunate that people think it's a moral issue," says professor Hoffer. "The idea that access would translate to use or abuse or things like the senator said."
Or to put it another way:
"Everyone has a fire extinguisher under their sink or in their house," says Judge Matia. "That doesn't give them license to smoke in bed."
On a Sunday in early May, a 39-year-old Amherst woman found her niece, 17, and the niece's former boyfriend, 18, overdosing. The girl was unresponsive.
"There was some sense that they were both trying to get clean," says Amherst police Lt. Dan Jasinski. "The next thing you know, the lady's upstairs and finds the 17-year-old on the bed. She thought she was dead."
The woman had been to Dr. Papp's program and learned how to use naloxone. It's unclear whether she too was a user or lied to get the drug. Either way, she had it on hand and saved her niece.
"They said she would have died without it," says Jasinksi.
Dr. Joan Papp has had to turn plenty of people away who tell the truth – those concerned about a loved one or friend overdosing but wary of having medical records note a drug addiction.
A middle-aged man walks into the Free Clinic conference room not long after opening hours on a Friday and the staff begins their presentation. They come to the part about the Metro medical records and declaring yourself an opiate user.
The man is a social worker who wanted naloxone for a client's house. He leaves without naloxone but does grab a can of Mountain Dew on his way out.
"It breaks my heart," says Dr. Papp.