Teaching Addicts To Stay Alive

Death Toll Drops As Baltimore Instructs Inmates How To Deal With Overdoses

By Jonathan Bor, Baltimore Sun reporter

Standing before 50 men dressed in red jumpsuits, drug educator Nathan Fields belted out the question of the hour: What are the street remedies for a heroin overdose?

"Burn their fingertips," said one inmate.

"Walk them around," cried another. "Put ice on the genitals," a voice rang out.

"Throw them in the backyard," someone said, eliciting a round of laughter.

"Guess what?" shouted Fields, addressing a rapt audience of inmates. "All those street remedies are more dangerous than the overdose itself."

Busting myths was a central point of the call-and-response that recently engaged a group of "street scholars" at the Baltimore City Detention Center. So was doing the right thing -- calling 911, performing rescue breathing and, when possible, injecting a dose of Narcan, an antidote that can reverse an addict's downward spiral by blocking the brain's opiate receptors.

For the last several weeks, the city health department has been holding a series of overdose prevention classes there, hoping to arm drug offenders with tools to save lives on the streets where most will return.

The program is part of a larger effort to further reduce a death toll that for many years rivaled that of homicide in Baltimore. Between 1999 and 2005, the last year for which figures are available, the number of city residents dying of drug overdoses dropped by about a third, to 218. That compares with about 270 homicides a year.

Nationally, the trend has been quite the opposite. Between 1999 and 2004, the number of overdose deaths rose 77 percent to almost 20,000, according to the U.S. Centers for Disease Control and Prevention. Accidental poisonings, of which overdoses were the largest part, were second to automobile accidents as a cause of death from unintentional injury. Nationally, the increase has been blamed on rising abuse of OxyContin and other narcotic painkillers, as well as cocaine and sedatives.

In Baltimore, where heroin remains the chief culprit, officials credit the decline in overdose deaths to the expansion of drug treatment slots and to the city's Staying Alive program. Launched in 2004, the program teaches addicts to avoid overdosing themselves and to recognize and treat others in the throes of doing so.

Overdose education is one of the latest wrinkles in a philosophy of harm reduction -- others are needle exchange and methadone maintenance -- which recognizes that some people will never shake drugs but seeks to minimize the damage of their addictions.

Until recently, Staying Alive focused its efforts on the city's bustling outdoor drug markets. Though officials haven't abandoned that, they decided it also made sense to bring the program into the detention center, where an estimated two-thirds of inmates are addicted to heroin when they enter. The city joined a short list of jurisdictions around the country to do so.

"It's forward thinking to do this because it deals with the reality of where people are as opposed to where we want them to be when they get outside," said Susan Sherman, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health who played a leading role in starting Staying Alive three years ago.

New Mexico was among the first states to educate inmates about overdoses, establishing its "Blue Project" two years ago in the Metropolitan Correction Center in Albuquerque. A nonprofit called Prevention Point Pittsburgh began a similar effort in the Allegheny County Jail.

New Mexico hasn't yet evaluated the impact the program is having on overdose deaths. But Bernie Lieving, the state's harm reduction coordinator, said he senses that the program "empowers people to feel like they're able to take care of themselves and each other." He said he's also encouraged that over half of the inmates have gotten prescriptions filled for Narcan.

In Maryland, the Maryland Department of Public Safety and Correctional Services invited Staying Alive into the prisons. For several years, the agency has been offering acupuncture, drug education and counseling to a limited number of offenders sentenced by the city's drug court.

In the recent class were 50 men sentenced to six-week terms in a military-style barracks tucked within the hulking stone walls of the downtown prison. Taught separately were 19 women housed elsewhere in the same low-lying building. Over the course of a year, 650 male and female inmates pass through the alternative sentencing program.

"If there's anything we can do to educate them not to die, that's something we want to do," said Gregory Warren, director of substance abuse treatment services for the Maryland Department of Public Safety and Correctional Services.

After enduring a period of forced withdrawal in prison, inmates can easily overdose if they return to drug use and assume they can tolerate the same heroin dose they took before.

"If I'm away from drugs, my body actually starts to repair itself," said Fields. So while he urged the inmates to stay drug-free, he also advised them to start slowly if they must start at all.

Later, he explained how to save others from overdose with an injection of Narcan, which can overcome the effects of heroin, OxyContin and other opiates. "But the anti-overdose medicine will do nothing to reverse the effects of a cocaine overdose," said Fields.

The inmates came equipped with the lessons of the street - only some of which were accurate. They correctly rattled off the signs and symptoms of heroin overdose: blue extremities and slow or nonexistent breathing. But just as confidently, they recited street remedies that, as Fields explained, could finish the job that heroin had started.

An unconscious addict, for instance, could drown in a cooling bath. An injection of salt water could send a victim's blood pressure soaring. Holding a match to the fingertips, meant to jar the addict into consciousness, could produce burns severe enough to require amputation.

"And if I'm unconscious and you burn me, what will I feel?" Fields asked the crowd.

"Nothing," someone cried out.

A better choice would be rescue breathing, a mouth-to-mouth technique that can keep an unconscious addict alive until paramedics arrive.

To demonstrate the technique, the teachers positioned two mannequins on a table and asked volunteers to step up. Don't start the rhythmic breathing, Fields told them, before making sure the person is truly unconscious.

The forceful pressing of knuckles upon the chest will rouse anyone who's even slightly awake without inflicting harm.

"If he jumps up, that's good," said Fields.

As the class ended, two inmates who agreed to be interviewed affirmed that the class addressed issues with which they were frighteningly familiar.

Anthony Kerr, 35, said he once overdosed on a combination of heroin, Xanax and alcohol. He passed out in a friend's apartment on a Thursday night, then awoke the following Sunday in someone else's basement.

Kerr, who is from Edmondson Village, said he learned that a friend had saved his life using a mouth-to-mouth technique that he had learned in a college lifesaving course. He said he was glad to see the technique explained to others.

"We're all clean, which is a good thing," said Kerr. "We all have a goal. We're on the same page."

Antonio Jones, 35, of Woodlawn said he hoped that the class would produce a ripple effect that would reach the streets.

"It's for me to have the information so I can help someone else save a life," he said.

Source: Baltimore Sun, April 15, 2007