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Click the map above to explore where Direct Relief deliveries of naloxone have gone across the United States. The red squares signify naloxone deliveries to health centers and the state colors indicate overdose mortality rates. (Map by Andrew Schroeder/Direct Relief)
A patient at Avenal Community Health Center described watching his sixth friend die from overdose to Dr. Khuong Phui in May. He said the deceased had been confused, then unresponsive and had shallow to nonexistent breathing.
The patient, a heroin user, was at the federally qualified health center for treatment. Phui sent him home with naloxone, an overdose reversal drug, just in case. Two more patients with similar stories left the clinic the same week.
The overdose reversal drug was one of 50,000 doses sent across the United States through a four-year partnership with Direct Relief and Pfizer Pharmaceuticals. The pair have agreed to provide naloxone to combat overdose deaths in the opioid epidemic, as stories from patients like Phui’s have become more common.
(Chart by Andrew Schroeder/Direct Relief)
Though California is instituting new policies that emphasize community collaboration, doctor accountability measures and funding to combat the epidemic, many health clinics were financially unprepared for the influx of assistance needed. Funding from the federal government wasn’t guaranteed until the President’s National Drug Control Budget was released in May.
Even with federal dollars, additional resources to save lives and support treatment are needed from organizations like Direct Relief.
John Blaine, President of Avenal Community Health Center, said naloxone should be on every emergency crash cart in the country.
“It’s definitely something we need, we haven’t gone through the pharmacy, so having it from Direct Relief is a huge benefit,” Blaine said.
Though most opioid abusers were introduced to substances through prescription pills, heroin is a cheap alternative.
The price of heroin in the United States has fallen over time, even with the illegal drug’s resurgence in popularity after the millennium. In 2015, the Washington Post reported heroin was cheaper than a package of cigarettes in most states—the most expensive was about $10 a bag. An even cheaper, more potent synthetic opioid, fentanyl, is more commonly being mixed with heroin. The Centers for Disease Control and Prevention reported it is 50 times more powerful than heroin and 100 times more so than morphine.
Dr. Kimberly Johnson of the Substance Abuse and Mental Health Services Association confirmed fentanyl’s rise in popularity over the last three years. Its use is congruent with the jump in overdose death rates.
“People who don’t know the strength of what they are getting leads to a higher rate of overdose,” said Johnson. “They may be buying what they think is heroin. Heroin is never 100 percent pure, it’s always mixed with something.”
As the epidemic worsens, spurring national attention on prevention and recovery methods, naloxone is one treatment that has remained constant. The New England Journal of Medicine said the FDA first approved the life-saving medication in 1971 and generic brands have been available to the public since 1985. While generic brands can be found at a local pharmacy for about $30, name-brand products have experienced serious price hikes, but the product provided by Pfizer and Direct Relief retails for about $15 a dose.
But health clinics aren’t just trying to prevent death. In California, medically assisted treatment programs are encouraged to curve and control addiction. These programs provide patients who suffer from substance abuse disorder with therapy and a prescription of a weakened opioid to help with withdrawal.
Avenal Community Health has two waived physicians for their medically assisted treatment program and prescribes suboxone to patients who are trying to control their addiction. The clinic launched the program with a community partner who offers therapy and rehabilitation services.
The health center is in Kings County, California, which has yet to submit a county implementation plan with the state. California is encouraging local stakeholders to be proactive in substance use disorder prevention and recovery treatment. Under this initiative, Medi-Cal (California’s version of Medicaid) patients have more affordable access to treatment. According to the state’s Department of Health Care Services, 19 counties have implementation plans that have already been approved. Eight more, including a multi-county plan covering nine areas, are awaiting approval from the state.
Additionally, Avenal doctors are avid users of the California Controlled Substance Utilization Review and Evaluation System, also known as CURES. CURES database allows doctors to track patient prescriptions across medical systems, helpful for doctors who treat non-regular patients for pain. According to the California Department of Justice, the state was the first in the country to begin tracking this practice as a counter diversion tool for law enforcement. Almost every state in the country now has a similar system.
Anyone able to write a prescription in the state is required to register with CURES. However, DOJ representatives say those able to write prescriptions are not required to use the system for their patients. That may change in early 2018. CURES is currently state-funded, but in President Donald Trump’s National Drug Control Budget for 2018, a $12 million increase to state grants was approved for prescription drug monitoring programs. The budget also calls for increases in funding for medically assisted treatment programs and $103 million in drug enforcement efforts through organized crime.
(Editor’s note: This story is the third in a series. Earlier stories can be found below.)
