Al is about to graduate from the University of Minnesota. He also is an opiate addict, and has been for almost a decade. He asked that his name not be used because he is on probation for heroin possession.
Al spent a lot of time last summer with one young woman.
"We were running buddies, always using together, and obviously we'd use at my apartment a lot," Al said. "One time we'd got some powder dope and a $40 bag. I draw some out for myself. I do most of it, just give a fifth to my girl."
She went to the bathroom after shooting up. Al found her passed out on the toilet. He dragged her to his living room and grabbed two rigs of the anti-overdose drug Narcan, which he keeps prepped on his bookshelf. He muscled the needles into her shoulder and injected the antidote.
Narcan can take up to five minutes to bring someone back from an overdose.
"While that's working, I'm giving her CPR and slapping her even, and just yelling her name and just going through incredible hysteria," Al said. "I thought she wasn't coming back, really."
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The young woman's lips were turning blue.
Then the Narcan kicked in. She woke up like in a movie, Al said, gasping for air.
"It was incredibly intense, emotionally taxing, having this girl I care about just dying in front of me," Al said. "If I wasn't here with the Narcan, she would be 6 feet under."
THE OVERDOSE ANTIDOTE
The United States is in the midst of a prescription drug epidemic, according to the Centers for Disease Control and Prevention. The problem of opiate overdoses is compounded in Minnesota, which has some of the cheapest and purest heroin in the country.
The number of Minnesotans who have died as a result of prescription opiates and heroin has climbed dramatically in the last decade. In 2009, at least 191 people in Minnesota died, many of them from prescription opiate overdoses, according to the most recent data available from the CDC. That number of deaths from opiates is about five times higher than it was a decade before.
The overdose trend has driven some states to adopt Narcan, also known by its generic name naloxone, as one solution. A report issued in February by the CDC found that 48 active Narcan distribution programs in 15 states around the country reported more than 10,000 lives saved by the anti-overdose drug during a 14-year period.
In Minnesota, Narcan is legally available only by prescription. Public health workers and activists want the state to loosen rules governing prescription drugs to get Narcan more easily into the hands of those most at risk of overdose: prescription opiate or heroin addicts.
"What I would like to see is for this to not be underground, but for it to be mainstream and legal," said Gavin Bart, director of addiction medicine at Hennepin County Medical Center in Minneapolis. "It's such an important thing to get out there; we know it's saving lives."
As a prescription drug, Narcan is governed by state legal and professional laws.
A 2007 assessment of Minnesota's laws on Narcan by the Project on Harm Reduction in the Health Care System at Temple University found that programs that distribute Narcan to ordinary people without a prescription "would be legally vulnerable" under Minnesota law. Advocates who distribute the drug could be "found guilty of the crime of practicing medicine without a license," and recipients of Narcan could be charged with illegal possession of a prescription drug, although prosecution would be unlikely.
Scott Burris, director of the Temple Law School's Center for Health Law, Policy and Practice, said programs that allow lay people to distribute Narcan to addicts fall into a legal gray area, although they aren't explicitly banned. Burris said this fuzzy legal situation can intimidate donors and doctors who otherwise would support Narcan distribution programs.
Spokespeople for county attorneys in Hennepin and Dakota counties said Narcan isn't really on their radar. A spokesperson for the Hennepin County Sheriff's Department wouldn't rule out investigating the distribution or possession of Narcan but said an incident would likely need to pass a certain public safety threshold before the department investigated.
But in May, a 23-year-old man who administered Narcan to a woman overdosing on heroin was arrested by Minneapolis police. Charges have not been filed in that case, but the investigation is still open.
Other states have avoided this legal quagmire by changing their policies. Washington and at least four other states have passed laws to make it easier to get Narcan into the hands of addicts. Maryland clarified that distributors and doctors won't face prosecution. Still other states have sponsored Narcan distribution projects that train people to administer it.
The Washington law, which passed in 2010, is two-pronged, said Caleb Banta-Green, a research scientist at the University of Washington's Alcohol and Drug Abuse Institute.
It expands access to Narcan by allowing it to be prescribed to both people at risk for an overdose and those, like family members or friends, who might witness an overdose. It also institutes a "good Samaritan" law that gives people who call 911 during an overdose immunity from prosecution for drug possession.
"We also found that during that period where underground [Narcan] was being distributed, almost never was 911 getting called" during overdoses, Banta-Green said. "Because it's given in an underground way, people may feel, 'Oh, I really need to keep this hidden, I shouldn't be calling 911, I might have to give out my source of where I got my [Narcan].'"
The preliminary results of Banta-Green's study of the effects of Washington's law found that "other states should consider this legislative approach as an integral part of their plan to improve public health."
MINNESOTA'S NARCAN VOLUNTEERS
"Everybody's got something that they use to navigate life, whether it's heroin or overeating or booze. My thought is: Why should people have to die for that?"
The Morpheus Project is Minnesota's only distributor of Narcan. That's where Al got the Narcan that saved his friend's life last year. The volunteer-run group exists despite the foggy legal conditions about the drug in Minnesota. They give needles, Narcan and other equipment directly to injection drug users and teach them how to use them.
Sue Purchase helped start the Morpheus Project in 2009. Purchase said she has delivered clean supplies to people like Al at every mall in the metro area.
"I would bring all the necessary supplies that they had requested, and maybe that I had encouraged at some point as being a good idea, and they would share them with whoever was in their using community," Purchase said. "It happens in a very discreet, sort of underground fashion."
The group's limited supply comes from what Purchase would only describe as a "Narcan fairy."
"There are certainly people who work in my business who -- it's not to flagrantly flaunt disregarding the law -- but [who] certainly understand that there's a need to save lives for people who inject drugs and opiates," Purchase said. They "have access to a supply of Narcan and make that available to other folks working with drug users."
Purchase said the group distributes Narcan, despite the possible legal risk, because the needs of opiate addicts are often overlooked by more mainstream organizations.
"Everybody's got something that they use to navigate life, whether it's heroin or overeating or booze," Purchase said. "My thought is: Why should people have to die for that?"
But she realizes her program can reach only a limited number of people. From her vantage point as an activist who works directly on the street with addicts, she said it's obvious the state is going to need to step up to deal with the growing problem of opiate overdose.
"Truthfully, I think it's going to be a public health nightmare, that's certainly already in the making, but it's only going to get worse," Purchase said.
CONCERNS ABOUT NARCAN
There are very few groups strongly opposed to making Narcan more widely available, but some doctors and treatment professionals are concerned.
Minnesota Society of Anesthesiologists secretary and treasurer David Martin said he understands the impulse to want to get the antidote into the hands of people at risk for opiate overdoses. But Martin said one concern is that too wide a distribution of Narcan would take away doctor oversight over dosage and proper administration.
"If advocates are wanting to use it for drug addicts who may have inadvertently overdosed, that would not be the kind of environment that I would want them to measure out an appropriate dose and then inject it," said Martin, who practices at the Mayo Clinic in Rochester.
A few in the treatment industry are also torn, although many support it.
Adam Pederson is a former prescription opiate addict who now runs an anti-drug program at Minnesota Teen Challenge. The program briefs students on the dangers of drugs. He said that Narcan is helpful because it can save a life threatened by accidental overdose but that wider distribution could have unexpected consequences.
"The one thing when you're dealing with a chronic addict is a near death experience or that fear of overdose isn't necessarily there," Pederson said. "Not saying it gives a false sense of security, but it can definitely lead to that mentality of a second chance, a third chance, to continue drug use."
STATE LAGS IN ADDRESSING OPIATE USE
Neither the Minnesota Department of Health nor the Minnesota Department of Human Services have any plans to start Narcan-distribution projects in the state.
DHS drug abuse strategy officer Carol Falkowski said public health officials are still scrambling to react to the recent flood of opiates to the state.
"We have seen, in the state of Minnesota, growing and unprecedented levels of heroin and other opiate abuse and addiction," Falkowski said. "Every indicator we have shows continuing upward trends."
Falkowski said the state should take a serious look at expanding access to Narcan.
"Just as the state was on a learning curve when we first started seeing methamphetamine abuse a decade ago, we're now doing that again with opiates," Falkowski said. "Everyone is learning new ways to address it."
Commander Paul Sommer of the Anoka County Sheriff's Department said many metro area sheriffs are trying to come to grips with the overlapping epidemics of prescription drugs and heroin in communities where opiates were unheard of a decade ago.
"Heroin is still being viewed as a police problem or an enforcement problem," Sommer said. "The faster we're able to respond to it as a social problem, the better off we're going to be."
Bart of HCMC said a dialogue is just starting to emerge among public health and state agencies in Minnesota.
"When someone has overdosed, and it's a matter of life or death, it's very important to give them this medicine," Bart said. "It's a shame that Minnesota doesn't have an official program yet."