Heroin overdose antidote bill awaits Gov. Nixon’s signature

Thursday, June 19, 2014 | 6:00 a.m. CDT; updated 6:46 a.m. CDT, Thursday, June 19, 2014
Gary Carmack, his son James Carmack and James' son Cian Thomason pose for a family photo. James, 25, died from a heroin overdose in September.

COLUMBIA — Last year, first-term state Rep. Steve Lynch, R-Waynesville, asked officials in his Pulaski County district about their main problems and concerns.

"I'm not sure what I thought they'd say," Lynch said. "But it wasn't heroin.”


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Missouri ranks seventh in the U.S. for deaths from drug overdoses, many of them from heroin, according to previous Missourian reporting. The number of fatal heroin overdoses in Missouri nearly tripled to 187 deaths in 2013 from 69 deaths in 2007.

Some of those deaths were in Lynch's own community, and at least one hit close to home. His friend, Pulaski County Chief Paramedic Gary Carmack, lost his child to heroin.

"I never dreamed it would be my own son," Carmack said.

James Carmack was 25 when he died from a heroin overdose in September.

"James was fighting hard. He wanted off of it," Carmack said. "I got him in rehab, but he relapsed."

The problem "went right to my heart," Lynch said. It led him to sponsor House Bill 2040. The bill would allow qualified first responders to obtain and administer a medication called naloxone, which reverses the effects of acute opioid intoxication, or overdose from drugs such as heroin and oxycontin.

Lynch said the bill, which passed 154-0 in March, was co-sponsored by representatives from "both sides of the aisle" because everyone understood how important it was.

It's now awaiting Gov. Jay Nixon's signature.

Naloxone blocks opiate receptors in the brain. If a person overdoses on a non-opioid drug — such as alcohol or cocaine — naloxone won't help save them. But, according to a Centers for Disease Control and Prevention report, giving the drug in those situations won't cause any harm to the victim.

In 2010, the Harm Reduction Coalition received reports of 10,071 overdose reversals using naloxone after training and distributing the medication to 53,032 individuals.

When the Food and Drug Administration approved the drug in 1971, it was administered intravenously. Now, naloxone is often administered nasally. A device called an atomizer is fixed on top of the syringe so the liquid medication can be sprayed into a victim's nose. Although the FDA has yet to determine the effectiveness or safety of the intranasal delivery method, the Open Society Public Health Program cited evidence of its effectiveness, noting that  "intranasal administration has been the protocol in pre-hospital settings for nearly a decade."

One major advantage of being able to deliver the medication through a nasal spray is that it's easier for nonmedical personnel, who are less likely to have experience with syringes, to administer naloxone. This includes people such as police officers who might be the first person on the scene of a drug overdose.

And time is crucial in a heroin overdose.

"Within 3-5 minutes without oxygen, brain damage starts to occur, soon followed by death," the Harm Reduction Coalition states. "With opioid overdoses, surviving or dying wholly depends on breathing and oxygen."

A post on the FDA's blog, the FDA Voice, cites naloxone's ability to reverse the slowed breathing that leads to death in overdoses: "When naloxone works, the results can be dramatic: Comatose patients can wake up in minutes."

Carmack has seen it happen. "When you see it work," he said, "it's almost like a miracle."

But naloxone is not without critics.

Jeffrey M. Goodloe, an expert in EMS medicine, has some reservations about the use of naloxone by first responders. "One size, one dose of naloxone simply doesn't fit all, and it can well violate the primary dictum of medicine: First do no harm," Goodloe writes in article for EMS World.

Goodloe is a professor and director of the EMS Division of the Department of Emergency Medicine at The University of Oklahoma School of Community Medicine in Tulsa.

Opiate abuse symptoms are not static but rather "lie on a spectrum." The most extreme symptom of opiate abuse — sudden cardiac arrest — calls for CPR intervention, not naloxone, Goodloe writes. When a victim is lethargic but breathing, "abrupt administration of naloxone can precipitate unnecessary opiate withdrawal."

But Carmack, who said he's administered the drug hundreds of times since 1976, said there's no risk. "The only real risk is somebody dying from not administering it," Carmack said.

He said that "narcan is safer than the EpiPen," a auto-injection device that allows patients with severe or life-threatening allergic reactions to treat themselves with medication.

While naloxone cannot solve the larger issue of drug addiction, proponents of the bill say saving people from a fatal overdose is a good place to start. Carmack said he believes that not only first responders but the families of people who are addicted to drugs such as heroin and oxycodone should have naloxone on hand in the event of an overdose emergency.

For now, Boone County basic EMTs, police officers and firefighters are not permitted to administer naloxone. If the governor signs the bill, it would allow — not mandate — first responders to administer the medication once they've been trained.

The proposed legislation would not change the protocol for paramedics because they're already qualified to administer naloxone to suspected overdose victims. Paramedics are trained in advanced life support, which is more extensive than basic EMT training.

Boone County Fire Protection District Battalion Chief Gale Blomenkamp said the agency has no plans in place to begin stocking naloxone kits. Before first responders can be equipped with naloxone, questions about how it will be funded and regulated must be answered. Each instranasal naloxone kit costs about $20, though the price fluctuates and varies from state to state.

Carmack said the first step is breaking down the stigma that surrounds drug addiction in order to see the addiction for what it is — an illness.

"We are all fighting this battle," Carmack said. "(Heroin) is the worst thing I’ve ever seen."

Supervising editor is Katherine Reed.

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George Cox June 19, 2014 | 8:02 a.m.

Why is this a political (legislature/governor) decision?

Every First Responder/EMT in Missouri has a physician Medical Director who must agree to the use of a protocol. Let's let the doctor who is ultimately responsible make the call.

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