January 29, 2003

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The health care guerrillas

How activists illegally distribute a life-saving drug to the dispossessed.

By A.C. Thompson

BEFORE ENTERING SAN Francisco's medical underworld, this reporter must agree to a few ground rules. Don't print anybody's name. Don't divulge secret locations.

As one of the few outsiders allowed to enter the clandestine realm of the health care guerrillas, I can handle the journalistic limitations.

It's a mission that's part Che Guevara, part Mother Teresa. Eluding the gaze of the authorities, members of this shadowy movement are waging a crusade to save the lives of heroin addicts by illegally disseminating a pharmaceutical called naloxone hydrochloride.

Naloxone, also known by the brand name Narcan, is a clear, viscous liquid that revives people who've stopped breathing after ingesting an excess of heroin or any other opiate-based substance. It's the stuff John Travolta's character jammed into Uma Thurman's chest in Pulp Fiction. Call it Lazarus in a hypodermic.

For the guerrillas, there's plenty of work to be done. Heroin overdoses are now San Francisco's number-one cause of accidental death, killing 333 people between 1997 and 2000, a number that far outranks car crashes, falls, and workplace accidents. In this town, heroin generally claims many more lives than guns in any given year.

The plan is simple: Give free naloxone to the needle-using masses, a demographic that totals 14,000 according to official estimates. Teach them to administer it in the event of an O.D. Save lives. "We could prevent so many deaths if people just had naloxone around," one operative tells me.

There's just one hitch: the guerrillas aren't doctors. Nonphysicians, obviously, are barred by law from handing out prescription drugs – it's a felony that can carry up to 10 years in federal prison. And some people in law enforcement and medical circles are not amused with the guerrillas.

The movement, which has been around in one form or another for the past five years, is minuscule – maybe half a dozen people. A sympathetic physician supplies the naloxone. A handful of vials gets passed out each week. Generally, the guerrillas give an hourlong seminar on preventing O.D.s before handing out the drug.

On a recent afternoon I sat in on a class taught by two guerrillas. "The first time I ever used heroin, I overdosed, and this wonderful drug Narcan brought me back to life," announces Guerrilla A, who is now clean.

For the five young users in attendance, brushes with death are a way of life. A pink-haired lady with a scabbed face and track-marked arms says she has O.D.'d five or six times. "I grew up around heroin addicts," says a twentysomething woman who saw her parents overdose. "I've overdosed lots of times, but only from coke," says a baby-faced guy with a mohawk, laughing.

In the course of the hour, the guerrillas sketch the physiomechanics of an overdose and offer a crash course in CPR (choice quote: "If you let the person choke on their vomit, they're toast"), before explaining how to inject naloxone. "It takes three or four minutes to take effect," Guerrilla A says. "And it only works on opiates."

As the class concludes, the guerrillas dole out five bottles of naloxone and a dozen thick-gauge syringes. "I don't know where this stuff came from," Guerrilla A says conspiratorially. "You never saw us."

"And we," Guerrilla B adds, pointing to the students, "never saw you."

Not everybody thinks the guerrillas are doing the world a service. The Drug Enforcement Administration, for one, isn't enthused. "Those folks distributing it illegally are in harm's way," DEA spokesperson Richard Meyer says. "If they're violating federal law, then we have an obligation to get involved."

Some frontline medical personnel are adamantly opposed. "It's a dangerous mistake to offer access to this drug as an alternative to professional medical care," Santa Cruz paramedic Robert Swarner writes in a 1999 essay in Harm Reduction Communication, a public health journal. Swarner notes that in rare cases naloxone "has been found to cause sharp increases in blood pressure, allergic reactions, cardiac arrhythmia and other peculiar side effects, including death."

In an e-mail, Gary Dunlap, executive director of the California Association of Alcoholism and Drug Abuse Counselors, says his organization doesn't "support illegal use or distribution of any drug."

But increasingly, the medical community is coming to favor widespread naloxone distribution. Physician Karen Seal, a researcher at UC San Francisco, recently conducted a pilot study on the subject, training 24 heroin users to use naloxone. "Our participants actually used their skills to bring people back and save lives," Seal tells me. In a six-month span, she says, "20 lives were saved."

The most efficacious response to an overdose, medical researchers agree, is calling for an ambulance – partially because paramedics are taught to pump naloxone into overdose victims. But hard-drug users are often reluctant to dial for help, even when a friend is lying on the floor turning blue. Many users are afraid police officers will show up with the paramedics.

Handing out the drug to the cop-wary could cut down the city's death toll, says sociologist Peter Davidson, also at UCSF. In a published study of 703 heroin overdoses, Davidson and fellow researchers found that onlookers – i.e., fellow heroin addicts – contacted 911 in only 53 percent of the incidents.

"So far there's been no large-scale studies on naloxone distribution," Davidson says. "What we've got are small studies and lots of anecdotal stuff that says it doesn't increase heroin use and it looks like a very good thing." Like San Francisco, Chicago has a subterranean network, while New Mexico's state health department has launched a small above-ground program.

Davidson would like to see California follow New Mexico's lead. "The frustrating thing is that nearly all advances in this field have to start out illegally. Needle exchange started illegally. Now it's naloxone."

I meet my East Bay contact in a bar around the corner from a needle exchange site in gritty West Berkeley. After passing out 70 vials of naloxone in the past year, this guerrilla readily points out drawbacks of the drug. "It goes bad," the guerrilla says. "It doesn't have a superlong shelf life. And every now and then somebody thinks they can get high off it, simply 'cause it's a drug."

Still, the guerrilla says the mission has had some very concrete success: "So far we've saved probably five people."

E-mail A.C. Thompson at ac_thompson@sfbg.com.