On May 23 last year, a man in an alternative sentencing program came into the City-County Building on Carroll Street for a required urine test.
Immediately after taking and passing the test, he shot up with heroin in the second-floor bathroom. As he was leaving the building, he overdosed, passing out near the elevator doors.
James Sauer, who works in the Dane County District Attorney’s deferred prosecution unit, was one of the first to find the man, who was limp and unresponsive. Sauer suspected he had overdosed, since he was showing typical signs.
“I recall his face appearing very white, and probably most noticeable was the start of opioid overdose breath[ing], which I can’t describe to you in words,” Sauer says. “You have to hear it to know what I’m talking about.”
Emergency medical technicians were called, and they administered a dose of naloxone, better known by its trade name, Narcan. The man survived.
The District Attorney’s office wants more people to have access to naloxone and recently began requiring addicts in the county’s Opiate Initiative to train on how to use it. And, in a partnership with the AIDS Resource Center of Wisconsin, the office is indirectly offering up to five doses of the drug to the recovering addicts.
Narcan is becoming much more available around the country. But its use has not come without controversy.
Pat Hrubesky, director of the Dane County Deferred Prosecution Program, says the DA’s office has moved ahead with the program.
“The whole point is to save a life and achieve recovery,” she says.
Dane County District Attorney Ismael Ozanne started the Opiate Initiative in 2013 to deal with the growing problem of heroin addiction.
The DA’s office was seeing an influx of people charged not just for possessing or selling drugs, but for crimes related to opioid and opiate addiction, like burglaries, robberies and fraud. “A lot of retail thefts are opioid related,” Hrubesky says.
In the past, if those people were convicted of possessing 3 grams or less of a drug like heroin, they could face a $10,000 fine and up to three years in prison.
The Opiate Initiative was started to keep some of those people out of prison while helping them recover.
“Our program is focused on solid case management,” Hrubesky says. Participants are required to meet weekly with Sauer, the case manager, take frequent random drug tests, be in a treatment program and make restitution. They may also be required to do community service and get involved with community groups.
And now they’re being required to attend a class on how to use naloxone. Although those who overdose won’t likely be able to give it to themselves, it’s hoped that increased training and availability of Narcan among opiate users will save lives.
Sauer describes his work with the Opiate Initiative as “intense, rigorous; probably the hardest work I’ve ever done.”
He usually oversees about 45 people, with weekly one-on-one visits where he attempts to get their lives back on track. Often, participants are homeless and jobless and have burned bridges with family and friends.
“By the time I see them, things have really unraveled, and I have to pick a place where I feel I can make some positive impact,” Sauer says. “A lot of individuals need to start out with opiate medication to remove the daily need to get drugs, the struggling with withdrawal symptoms.”
The man Sauer found passed out by the elevators was not in the Opiate Initiative program. But Sauer’s clients are at heightened risk of overdosing.
“One of the biggest risks to people with opioid addiction is when they’re [leaving] a controlled environment,” says Dr. Randall Brown, director of the Center for Addictive Disorders at UW Hospital and Clinics. “If they leave that controlled environment and use their regular dose, they’re at risk of overdose because their tolerance isn’t as high.”
Naloxone works, Brown says, by going to the opioid receptor in the brain, “kicking the opioid off of the receptor and getting the person to start breathing again.”
“It’s a very safe medication,” Brown adds. “At one point the [U.S. Food and Drug Administration] was considering making it an over-the-counter drug.”
But Brown says some worry that making the drug available increases “the potential for failure” in the form of a drug relapse.
Brown says he “can see the tension for a treatment provider wanting to encourage abstinence,” but still supports offering Narcon as an option.
The drug comes in two different forms, a nasal spray and an injection. It is already available for people in Dane County through the AIDS Resource Center of Wisconsin, which runs a needle exchange program.
Last year, the state helped make naloxone more accessible with a law that allows certified first responders, not just licensed EMTs, to carry and administer it. That gave police officers the green light to carry the drug.
The DA’s office had also asked if it could have the drug in case of emergencies, but the county’s corporation counsel does not think that would be legal.
“Although it might be a great idea for your organization to be able to administer naloxone in an emergency situation, in my opinion, Wisconsin law is not broad enough to cover your employees,” wrote assistant corporation counsel David Gault in a Feb. 23 email to Hrubesky. “The legislature has limited authorization and immunity to only EMTs and certified first responders.”
In a phone call with Isthmus, Gault says his opinion was based on a limited scope of whether county employers who aren’t first responders can administer the medication. He says he is not familiar with the Opiate Initiative program run by the DA’s office and couldn’t give an opinion on it.
Last week, the Dane County DA’s office mandated its first training program, through the AIDS Resource Center of Wisconsin, for participants in the Opiate Initiative. Three more are planned. As part of the training, the center made up to five doses available to participants. Multiple doses are offered because one may not be enough to revive someone.
“No one is required to take [the drug],” Hrubesky says. “If they want it, it’s provided.”
She says some basics are stressed in the training, which acknowledges how hard it is to kick an addiction. “Practice good self-care, don’t use alone, if you’ve been in jail for a few days don’t use the same amount when you get out of jail.”
Many users have already overdosed, Hrubesky says, noting “We’ve had some of our participants who have ‘died’ six times.”
Both Hrubesky and Sauer have heard the complaint that dispensing naloxone encourages drug use, but they don’t buy it.
Sauer believes the training drives home the reality of how dangerous opioids can be.
“If anything, it’s bringing a momentary stop action to their use and making them think,” he says. “This is our way to say, ‘we’re paying attention to this, we care about you, we want you to be alive and get that treatment and get on with your life.’”