Among the growing numbers of researchers and public health
officials advocating a daring new strategy to put an injectable
antidote for heroin overdoses directly into the hands of addicts,
few have the credibility of Mark Kinzly.
After 11 years as an addict, Mr. Kinzly cleaned up, began working
with needle exchange programs and became a research associate at
the Yale School of Public Health. Then came the relapse and the
overdose that nearly killed him.
"We were watching TV - I think it was the Red Sox beating the
Yankees," Mr. Kinzly, 47, recalled of the evening in 2005 when he
passed out in a colleague's apartment. "Because of our work he
knew what to do. He dialed 911 and then injected the naloxone."
Taken in high enough doses, heroin and other opioids suppress the
brain's regulation of breathing and other life-sustaining
functions. Naloxone is a chemical that blocks the brain-cell
receptors otherwise activated by heroin, acting in minutes to
restore normal breathing.
Since its approval by the Food and Drug Administration in 1971,
naloxone has become a standard treatment for overdoses, used
almost exclusively by emergency medical workers. But it has
lately become a tool for state and cities struggling to reduce
stubbornly high death rates among opiate users. By distributing
the drug and syringes to addicts and training them and their
partners in preventing, recognizing and treating overdoses, the
programs take credit for reversing more than 1,000 overdoses.
"From a public health perspective, it's a no-brainer," said Dan
O'Connell, director of the H.I.V. prevention division in the New
York State Health Department, which supports 20 naloxone
programs, all but one in New York City. "For someone who is
experiencing an overdose, naloxone can be the difference between
life and death."
But federal drug officials say distributing naloxone directly to
addicts may do more harm than good.
"It is not based on good scientific data," said Dr. Bertha
Madras, deputy director for demand reduction at the White House
Office of National Drug Control Policy. "It's based on what some
people would consider the right thing to do. But the studies
supporting it are so sparse it's painful."
She pointed to a survey in 2003 of addicts in San Francisco.
published in The Journal of Urban Health, in which 35 percent
said they might feel comfortable using more heroin if they had
naloxone on hand, and 62 percent said they might also feel less
inclined to call 911.
"These were their attitudes," Dr. Madras said. "I'm taking the
stand that in the absence of scientific evidence we don't engage
in policies that would bring more harm than benefit."
Similar concerns were expressed by Dr. H. Westley Clark, director
of the Center for Substance Abuse Treatment, a federal agency
that finances treatment programs. "Our position is that naloxone
should be administered by licensed health care professionals,"
Dr. Clark said.
Nevertheless, the direct-to-addicts model has spread rapidly
since Chicago introduced it in the late 1990s. Baltimore, New
York and San Francisco soon adopted the model, and Boston,
Philadelphia, Connecticut, Minnesota, New Mexico, Rhode Island
and Wisconsin have more recently joined the trend.
"The program here has been extremely successful," said Richard W.
Matens, assistant commissioner of health for chronic disease
prevention in Baltimore.
Overdose deaths there in 2005 were at their lowest level in more
than a decade, and Mr. Matens gives at least some credit to the
The worrisome findings of the San Francisco survey have not been
borne out by more recent studies of actual programs that include
training in prevention and treatment.
A study in 2005 of San Francisco's pilot program found that of 20
overdoses witnessed by trained addicts, 19 victims received CPR
or naloxone from the trainee, and all 20 survived. Knowledge
about managing overdoses increased, and heroin use decreased.
"Research has shown none of the concerns about naloxone
distribution to be true," said Dr. Sandro Galea, a researcher at
the University of Michigan who has written two studies of
programs in New York. "It probably is one of the few
interventions that truly can reduce the deaths from opioids
Dr. Herbert Kleber, who had Dr. Madras's position in the White
House under President George H. W. Bush and now directs the
Columbia University substance abuse division, said although he
wished the evidence supporting naloxone distribution were
stronger, "In terms of lives saved, it's probably the kind of
intervention where there's a likelihood of more good than harm."
In New York City, the 863 overdose deaths in 2005 made up the
fourth leading cause of death among people younger than 65,
according to Dr. Thomas R. Frieden, commissioner of health and
"We want people off drugs," he said. "But until they get off,
we'd like them to stay alive. That means not getting H.I.V. and
not dying of overdose."
Existing programs focus on reaching urban heroin addicts, but
naloxone is equally effective at reversing overdoses from other
opioids like OxyContin and methadone.
With overdose death rates from such drugs increasing sharply,
officials in Wilkes County, N.C., are working on a program to
dispense a naloxone nasal spray to users leaving hospital
emergency rooms, detoxification centers and jails.
The program, Project Lazarus, received approval from the state
medical board in November.
"Lazarus, biblically speaking, is one who was raised from the
dead, and that is essentially what naloxone does for these
people," said the director of the program, the Rev. Fred Brason
Dr. Sharon Stancliff, medical director of the Harm Reduction
Coalition, which operates naloxone distribution and training in
New York and San Francisco, conceded that the scientific case was
"Right now," Dr. Stancliff said, "we're at the point where we
know it's safe. We're not seeing any bad outcomes.
"And we know it's feasible. We're just beginning to get really
good evidence that it's associated with a significant reduction
in overdose deaths."
Mark Kinzly, who is back in recovery after relapsing in 2005,
says he has all the evidence he needs.
"This weekend I will go see my 9-year-old son play Pop Warner
football," he said. "I am extremely grateful that the medication
was available, and as a result I get to raise my child."