A memorable moment in the gangster film Pulp Fiction finds Uma Thurman's character near death from a heroin overdose, then speedily revived when an adrenalin-filled syringe is plunged through her breastbone and into her heart.
That's not at all how Toronto Public Health's new opiate-reversal kits work – their antidote can be shot into any muscle. Nonetheless, distributed under the auspices of the city's needle-exchange program, the kits' results have been almost as dramatic in cities such as Chicago where they have been put to use.
The kits contain naloxone, an injectable antidote for overdoses of heroin, morphine, oxycontin and other opium-based narcotics that is highly effective and has long been deployed in hospital emergency rooms. Now it has a wider, buddy-system use. Toronto physician Philip Berger, who has spent decades administering to drug addicts and other street people, applauds the city's new initiative, launched Aug. 31. So far about 75 of the kits have been handed out, worth about $25 apiece, comprising two new syringes and two 1-cc doses of naloxone.
Years ago, a patient of Dr. Berger was charged with manslaughter (later acquitted) when his girlfriend died of an accidental heroin overdose. Had naloxone been available, Dr. Berger suggests, the woman's life might have been saved.
"It's part of a general approach for reducing the harm, illness and death associated with drug use, rather than trying to eliminate drug use, which is totally hopeless."
Shaun Hopkins oversees Toronto's needle-exchange program, which dates back to 1989, and reaches perhaps a few thousand (recipients do not have to supply names) of Toronto's estimated 10,000 to 25,000 intravenous drug-users.
Since naloxone distribution began, she's aware of at least four instances where an addict in serious trouble was revived with a shot of the drug, also known by its brand name Narcan; two went to hospital for observation, two did not. Roughly 100 people die in Toronto from drug overdoses each year, chiefly heroin-related, and the hope is to dent those numbers.
So why now?
"I was hearing more and more about these programs and how important they've been in other cities," Ms. Hopkins said.
These include Chicago, New York, San Francisco and Boston, and naloxone is also used at Vancouver's InSite drug clinic, which last month got a green light from the Supreme Court (Toronto is currently studying the feasibility of a similar project, which Mayor Rob Ford strongly opposes. Mr. Ford's office said he was unaware of the naloxone program).
The only other Canadian needle-exchange program that distributes naloxone is the Edmonton agency Streetworks.
"It has been very successful, we are seeing lives saved," said Ashley Cherniwchan, the registered nurse attached to Streetworks who oversees naloxone distribution. Since the full program began in 2007, she's aware of eight instances of successful intervention, but is sure many more have been unreported.
Junkies usually overdose for two reasons – they underestimate the strength of the drug, or they've resumed injecting after a break – and administering the antidote is not complicated.
Drug users are coached in spotting the warning signs: slow, shallow breathing, bluish lips, general unresponsiveness. The naloxone is injected into the muscle, even through clothing, rather than into a vein, and revival starts within one to four minutes.
The partner is also instructed to do chest compressions, roll the person on to their side to facilitate breathing, and call 911 – whether they stick around for the ambulance or not.
Naloxone has no side effects, but its main function – rapidly purging the system of opioids by blocking receptors in the brain – can be cathartic.
"The only problem is that it puts the person receiving it in a state of acute withdrawal, so they're going to wake up and feel like using," Dr. Berger said. "But it gives them an opportunity to use judiciously and carefully."
Naloxone's success in Chicago
The first street agency in North America to distribute naloxone was the Chicago Recovery Alliance, and as in Toronto and Edmonton, several years of groundwork came first.
In a city whose population is slightly larger than Toronto's, more than 22,000 overdose prevention kits have been distributed by the CRA since 2001, and executive director Dan Bigg knows of a remarkable 2,720 instances in which a heroin or morphine overdose was reversed.
"It's such a model of hope, even UN Global Fund has caught on to it," he says of naloxone, which he has personally administered many times.
"It strengthens everything you do in outreach: Safer injections, safer sex, all of a sudden you have a consistent, life-affirming approach."
In a program built around one drug user saving another with a quick, easy shot, one particular do-it-yourself client stands out: A bricklayer from Cicero, Ill., who would shoot up heroin while in the other hand holding a syringe of naloxone as he drifted off, in case he needed it.
"He just plunges it in, and he says he's done that two or three times and revived himself," Mr. Bigg said. "But that's very unusual."
As for that overdose scene in Pulp Fiction – fiction it truly is, Mr. Bigg says.
The adrenalin ostensibly used to revive Uma Thurman's character is principally used for heart-attack victims.
"And when you overdose on opiates your heart is fine initially, the people I revived, their hearts were beating rapidly. The problem is, you don't breathe enough, although finally with a lack of oxygen your heart will begin to stop and then you die. So keep the person breathing, that's the primary thing we teach."