I’m relatively certain that inhaling secondhand fentanyl smoke won’t kill me, but nonetheless I pull my car into a leafy rest stop after realizing it’s been hotboxed with a synthetic opioid 50 times more potent than black tar heroin. My homeless passengers — Travis and Jason, both life-long drug addicts — sit in the back seat in varying states of opioidic nod, tooters in hand, while a $100 white rock of fentanyl smolders on a piece of tinfoil beside them. It’s the fruit of their day’s labor: shoplifting skincare products from chain pharmacies and selling them on the black market.
“My thing is creams,” explains Travis, a friendly, balding 37-year-old from East L.A., exhaling what smells like burnt marshmallows and cotton candy (due to the sugar fentanyl is mixed with). Premium creams like L’Oréal Revitalift and Olay Total Effects 7-in-1 Anti-Aging Moisturizer, to be specific, conveniently shelved close to the door for easy access, and more importantly, easy exit. Travis can lift 20 to 30 bottles in a matter of minutes, which he then sells near MacArthur Park for a quarter of the retail price.
“That’s $115 into my pocket, every day,” he says. “I feel good about bringing these products to the community where people can afford them. I have a customer who has horrible heartburn; thanks to me he can take Prilosec OTC.”
I met Travis last year at the L.A. Community Health Project (LACHP) needle exchange in Hollywood — which also distributes vials of naloxone, the lifesaving antagonist that reverses opioid overdoses — while reporting a story about how drug users are leading the naloxone revolution as they’re on the front lines of the opioid epidemic. And we’ve remained Facebook friends ever since.
You’re less likely to overdose when smoking fentanyl (which Travis and Jason call either “crack for white people” or “China,” since that’s where it’s generally manufactured) as opposed to injecting it. But it does happen, particularly with first-time opiate users or those who have been away from strong opiates for long periods of time. “We’ve had friends who’ve gotten out of jail and OD’d from one hit of China,” Travis explains. Jason, a bleach-blond 48-year-old guitarist wearing a black T-shirt emblazoned with a giant skull, nods, adding, “Lately it’s taking a lot more [naloxone] to bring them back because of the fentanyl.”
Which means addicts-turned-paramedics are having to step in with CPR while additional doses of naloxone take effect. Opioids depress the central nervous system, which is responsible for controlling breathing. Severe respiratory depression results in oxygen levels in the blood decreasing, turning lips and fingers blue. Within five minutes, brain damage starts to occur, soon followed by death.
“With black [tar heroin], if you gave someone naloxone they’d come back fairly fast and you wouldn’t have to worry about breathing for them,” Travis explains. “But it doesn’t work as fast with China so you gotta get some oxygen into that brain, or they won’t be the same person when they come back — if they come back.”
He recalls an incident recently with a woman named Jane (a pseudonym), who was distraught after learning her boyfriend had recently turned gay-for-pay. “She has four limbs and a vagina so she’d been given a bunch of free [heroin] but it was mixed with fentanyl,” Travis says, explaining that he was so busy consoling her he didn’t notice she’d shot up and fallen out. It was a scene straight out of Pulp Fiction, he says, with his dealer expressing extreme displeasure that a white woman was about to die on his couch.
Travis injected her with two vials of naloxone but she didn’t immediately respond, so he began CPR. “She was drooling and had mucus running out when I put my mouth around her nose and chin and started breathing for her,” he says. After 20 seconds, she sat up, vomited and went back to telling him about her gay(ish) boyfriend. “That kinda shit didn’t happen before,” he notes.
To counter the potency of fentanyl, I learned in December that the LACHP had begun including a third dose of naloxone in their kits, fearing two might not always bring someone back. Now, Michael Marquesen, LACHP’s executive director, tells me they’ve switched to NARCAN, the pricey brand-name nasal-inhalant version of naloxone.
But will that be enough?
Maybe not, says Roger Crystal, CEO of Opiant Pharmaceuticals, the creator of NARCAN. When I stop by Opiant’s oceanside Santa Monica offices, Crystal explains the inspiration for dedicating his medical career to managing drug overdoses came in 2005 when, as a trauma surgeon in London, he was tending to victims of the July 7th London bombing. While many in the ER had horrific injuries and lost limbs, it was the drug addicts who caught his attention the most, especially those with necrotizing fasciitis, a flesh-eating infection resulting from the use of dirty needles. He recalls how one particular patient made him realize that addiction was, in fact, a brain disease.
“He had surgery from the chest down to the pelvis and essentially had no skin. Yet security was called in because he was trying to score from his dealer. Bed bound and skinless with organs hanging out, all he could think was, “When am I gonna get my next fix?” I knew at that point that treating drug addiction would be something I’d be involved with in my medical career,” he says.
As harrowing as the scene in the London ER was, it was a visit to his brother in New York City in the early aughts that opened his eyes to the more critical opioid epidemic burgeoning in the U.S. They were out to dinner when his sister-in-law mentioned she’d woken up with a sore neck and had seen a chiropractor who’d written her a prescription for a 30-day supply of Vicodin. WTF, he recalls thinking, flabbergasted. “These are super-powerful painkillers. If I used anything like this in my practice it would’ve been only for in-patient or end-of-life care. She wasn’t in that much pain and was able to join us for dinner, yet she’d been handed dozens of strong opiates,” he says.
Crystal points to cultural differences in the way Americans have come to consider and treat pain. After all, he says, there’s nothing physiologically different between a person getting a root canal in France and in the U.S. Yet pain has become viewed as the fifth vital sign in American medicine, encouraging the overprescription of opioids so patients will report zero pain while physicians can receive additional payment from drug companies.
“U.S. doctors run their practices as a business,” he notes, using his own specialty — ear, nose and throat — as an example. “If I’m trying to grow my practice and incentivize people to come and see me, I want someone whose had their tonsils out to tell everyone, ‘I had zero pain, Dr. Crystal was the best.’ We don’t have time to sit down with each patient and explain that not all pain is bad. It’s much easier to write a prescription.”
Around the time Crystal was dumbfounded by his sister-in-law’s Vicodin prescription, he began working with the late Finnish physician, David Sinclair, on researching the potential of treating binge-eating disorder with naloxone (the basic science being that since food releases dopamine, blocking those receptors might eliminate the urge to overeat). While trials determined it would be difficult to clear a nasal naloxone spray to treat food addiction, the combined experiences in the London ER and his sister-in-law’s overprescription led Crystal to wonder if the same concept might work to treat drug overdoses.
Indeed it could, and received FDA approval in 2015 to do so.
Now, NARCAN can be obtained, without a prescription, from most pharmacies for $130 in a kit that includes two doses, while municipalities can purchase it for $75. It’s also available in hotel rooms and to first responders — saving countless lives. When I ask about exactly how many, Crystal says it’s hard to know. “On a state level, you hear police forces saying they’ve saved dozens of lives in a couple of months, but in total, we really don’t know. That said, it absolutely saves lives when first responders carry NARCAN.”
As it did recently in South Pasadena, California. “We received a call at 12:53 p.m. regarding a 24-year-old Hispanic male who was suffering from a suspected opioid overdose,” says Sergeant Tony Abdalla — director of the Tactical Medical Program at the South Pasadena Police Department — who tells me his officers arrived with doses of NARCAN in hand. They found the man face down, without a pulse, in the backyard of a house in a residential neighborhood. They began CPR and immediately followed up with one dose of NARCAN. Within four minutes, the man’s color returned, he was breathing on his own and answered questions lucidly. Six hours later, he walked out of the hospital on his own.
To be clear, he had overdosed on heroin, not fentanyl. Still, Crystal says, “The opiate epidemic is really a fentanyl crisis,” noting it was involved in 55 percent of opioid overdose deaths in 2017, per the most recent complete set of data available. It’s far more potent, acts much longer, gets into the brain quicker and hugs opioid receptors more tightly than heroin. As such, “in a fentanyl overdose, you may not be able to totally revive the person with the NARCAN dose you have,” says Scott Lukas, director of the Behavioral Psychopharmacology Research Laboratory at McLean Hospital in Belmont, Massachusetts. “Naloxone easily knocks morphine off of the receptor, but does that less so to fentanyl.”
Crystal says this is likely what resulted in the death of Prince. The half-life of fentanyl is seven to eight hours, he says. Prince was initially revived with naloxone but fell back into respiratory depression once it wore off.
It may seem like two hours (the half-life of naloxone) is sufficient, Crystal says. But levels of naloxone are dropping over that time while the levels of fentanyl remain high, often leading to re-overdose. “Your skin feels like it’s on fire when you’re hit with NARCAN, and you get highly agitated because your high has just been taken away,” Jason explains. “In my experience, everyone who’s been brought back with NARCAN is back out trying to fix within an hour because they’re miserable.”
To combat this phenomenon, Crystal and Opiant are developing a follow-up to NARCAN that’s five times more potent and designed to counteract a fentanyl overdose with just one application. He believes nasal Nalmefene — aka NARCAN 2.0 — has characteristics that are better suited to compete with fentanyl and will eliminate the risk of re-overdose.
The government is similarly optimistic. The Biomedical Advanced Research and Development Authority, a division of the Department of Health and Human Services tasked with protecting the nation from chemical, biological, radiological and nuclear threats, recently signed a $4.6 million contract with Opiant to develop nasal Nalmefene and stockpile it near hotspots where fentanyl may be weaponized, as it was in Moscow in 2002, when Chechens took over an opera house and Russians attempted to sedate them by gassing the theater with fentanyl. One hundred and nineteen people died as a result. If a similar chemical attack had occurred in the NYC subway system, Crystal predicts nasal Nalmefene will be far more effective at saving lives than naloxone.
Back in my burnt-marshmallow hotboxed Ford Focus, that $100 rock of fentanyl has been depleted and needs to be replaced. So Travis and Jason ask me to drop them off at a grocery store in West L.A. so they can “get to work.” Anti-aging cream has been a little harder to move lately, so today they’ve got their eyes on Tide Pods and Pepcidine. Afterwards, they’ll meet a guy who will shave off another rock of fentanyl before stopping by the Hollywood LACHP needle exchange to re-up on NARCAN. Travis says “a lot, lot, lot of people” are alive today because of the LACHP’s liberal NARCAN distribution, including his wife who is now 12 months sober.
So naturally, he’s thrilled when I tell him of Crystal’s plans to release NARCAN 2.0 in 2021. “Awesome,” he says with a faint grin. “Because we definitely need it.”