The needle poked through the skin on Denise Johnson’s arm, and it was the last thing she remembered before she overdosed on heroin.
Her memory was wiped clean. When she woke up after being injected with naloxone, the life-saving opioid antidote, she didn’t know where she was or what she was doing.
She urinated on herself. Her skin prickled like needles attacking every inch of her body. It felt like a bad dream.
She remembered first responders screaming in her face, trying to determine if she was actually waking up and what drug she was on.
“I’m clean! I’m clean!” she pleaded.
She forgot she had just relapsed from rehab.
Naloxone would bring both back from the brink of death.
Bostick overdosed six times in three years. Throughout her addiction, Johnson overdosed three times, but it once took six doses of naloxone to get her breathing.
In Manatee County this year, EMS and the county’s fire districts together have administered more than 3,200 doses of naloxone.
Heroin and fentanyl have taken a costly toll on the county for the past few years. Overdoses and deaths are on the rise, putting a strain on resources, the medical examiner’s office, funeral homes and even newborns. Sen. Marco Rubio, R-Fla., met with county leaders at Manatee Memorial Hospital in October and was visibly surprised to hear the hospital treats 15 to 20 overdose patients per day.
Gov. Rick Scott in 2011 signed House Bill 7095, known as the “pill mill bill” that shut down businesses that were irresponsibly giving out prescription pills. It was lauded as a success, as it did decrease the number of prescription pill overdoses. But the law didn’t come with funding to help get those addicted to pills into treatment. Instead, it inadvertently increased the number of illegal opioid overdoses as addicts found something cheaper — heroin — to feed their problem.
Earlier this month, President Barack Obama signed the 21st Century Cures Act, which includes $1 billion funding to the U.S. Department of Health and Human Services for anti-drug program grants. Although it hasn’t been finalized, the president’s initial budget lists Florida as eligible for up to $47 million to expand treatment opportunities. In the meantime, naloxone usage is likely to increase.
The biggest naloxone administrator each year is Manatee County EMS because it covers the entire county and tends to arrive first on an overdose scene. In 2015, the agency spent $59,204 on naloxone. In 2016, it cost $107,504 for supplies.
In a simplified sense, the relationship between addicts and first responders is altruistic. When an addict overdoses, the two are intimately acquainted for moments before one is rushed off to the hospital for more help and the other goes to save another addict.
Each time Johnson overdosed, her memory came back in chunks.
The last time she overdosed, her friend was shooting her up and Johnson remembered that it was a lot of heroin. Before she passed out, she saw people around her trying to wake up a man who was sitting across the room. In went the needle. Then she was at the hospital.
Johnson used to be a bail bondsman and started doing hardcore drugs with some of her clients. They liked to keep her around in case something bad happened, and they would give her whatever she wanted. When she woke up at the hospital, a sworn officer she knew from her bail bondsman days recognized her.
“When are you going to grow up?” he asked her. “When are you going to stop this? You could have died like him.”
The man everyone had tried to wake up had died of an overdose.
At 23, Bostick started using heroin in attempts to keep her family together. The father of her child was addicted to anything he could get his hands on: heroin, pills, crack cocaine. But for the first two years of their relationship, she didn’t know he was an addict. She didn’t want her own daughter to grow up without a dad like she did, and using was easier than arguing about his habit.
“When I first started, I could manage it,” Bostick said. “I could only use on weekends, and then weekends turned into every day and then it was every couple of hours and then it was every minute.”
The first time she overdosed, her then- 4-year-old daughter Hannah was in the backseat. Bostick snorted before she left to pick up a friend, then they shot up together and drove to meet their drug dealer. Her friend who was driving later told Bostick that she had been using her phone when she turned blue and stopped breathing. She was revived in the parking lot of a McDonald’s, and her mother gained custody of Hannah.
Her wake-up call should have been losing her daughter, she said. Johnson also lost custody of her children, 11-year-old Devin, who lives with his aunt in Texas, and 5-year-old Angel, who lives with her adoptive mother. It was the hardest thing to go through. But Bostick never knew how to deal with emotions except to mask them with drugs.
When naloxone revived her from an overdose, she was alive but she was angry.
Her high was gone. She felt every movement, every emotion.
The palms of a paramedic’s hands pounded on her chest to keep her heartbeat. Vomit, caused by the naloxone injection, dribbled down her chin. The anguish of her child being taken away came back to her. All she could think about was how she could escape so she could snort heroin again to make it all go away — again.
“It’s a blessing not to wake up and be sick. It’s a blessing not to wake up to know where you’re going to get high again; who you’re going to hurt today; if I’m going to end up going to jail,” Bostick said. “And I never had a fear of that.”
For the past two years in Manatee County, the amount of naloxone first responders used always spiked in July. No one knows why.
“If we could figure that out, we could probably figure out a lot of things,” said Manatee County Sheriff’s Office spokesman Dave Bristow.
The trend matches across the board. In 2015, July naloxone usage accounted for about 20 percent of the year’s administered doses. This year, July usage accounted for about 25 percent of the annual count.
The last times Bostick and Johnson each overdosed, it happened to be July.
Some speculate that July is when the potent stuff gets mixed on the market, as end-of-life painkiller fentanyl and animal-tranquilizer carfentanil became more likely suspects passing for heroin. Last year, fentanyl was found in 77 people who died in Manatee County and heroin was found in 45 people.
Fire districts began carrying naloxone on their engines in 2015.
Southern Manatee Fire & Rescue Fire Chief Brian Gorski applied for a grant with state Rep. Jim Boyd, R-Bradenton, to get naloxone supplied on their fire engines. They received 200 kits of Evzio, an auto-injector with 0.4 milligrams of naloxone. It’s a talking device that tells you exactly how to use it and is injected into the thigh muscle of a patient. At the time, it cost about $850 per kit, which includes two doses. Now, it costs more than $3,700.
Southern Manatee, which includes the areas around U.S. 301, is the district with the most naloxone usage, ahead of the city of Bradenton and Cedar Hammock Fire District. In 2015, Southern Manatee used 257 doses, with 55 in July. This year through November, Southern Manatee used 390 doses, with 103 of them used in July.
When Gorski reapplied for the grant for 2016, they received 100 kits. They started purchasing the nasal spray version of naloxone called Narcan with their own funds, generated by the ad valorem tax.
First responders have occasionally treated the same addicts within a few hours of releasing them from their care. Naloxone is a temporary fix, only lasting about 90 minutes, and typically after the user is treated for an overdose, addicts want to get that high back and will have to use more drugs, Gorski said. When naloxone wears off, the drug they had used will suddenly hit them and they tend to overdose again.
“We treat people and turn people back out on the street,” said Myakka Fire Chief Daniel Cacchiotti.
At first, firefighters would use as many naloxone doses as it took to wake someone up from an overdose. Gorski said if the patient is 18 or older, they can just walk away without any record of an overdose. That’s all they are allowed to do. Now firefighters use just enough naloxone to get an overdose patient breathing so they can be sent to the hospital for a formal record.
A dead zone exists in the place between addicted and clean. Bostick said she had to fight for three days to get help at the rehabilitation facility Centerstone of Florida, where she said an addict’s system has to be fully detoxed to get in.
Cacchiotti wondered if there is a way to put patients who are still using directly into a rehab program instead of releasing them to have them die or go to jail.
“If you can’t control the supply, you control the demand,” he said.
In the past three months, Gorski said firefighters have seen people wielding their own naloxone, trying to help out a friend in case first responders were too late.
“They got smart enough to know what they were taking was dangerous, so they must have purchased one,” Gorski said.
No prescription required
Opioids attach to proteins called opioid receptors, decreasing the sensation of the user’s pain. When naloxone is introduced into the user’s system, the drug removes the opioid from the proteins and prevents more from binding.
Florida’s 878 CVS Pharmacy stores began selling naloxone in July. Corporate representatives won’t say how much naloxone they’ve sold.
To get naloxone from CVS, patients don’t need a prescription, but there needs to be a standing order. That means the doctor issues a written order that certain people can teach patients how to use naloxone and distribute it to them if they meet certain guidelines.
Patients can purchase naloxone in a nasal spray form for $95 and in an injectable form for $45, and it can potentially be covered by insurance.
“I know the reason behind it to them seems legitimate, but they’re not addicts,” Bostick said of those who want naloxone made publicly available.
Johnson chimed in, “Addicts will run with it. They’ll think it’s an excuse.”
They feel as though this direct access to naloxone will drive the idea that there’s no consequences to drug use.
“At least if you go to the hospital, they have a record that this person’s a heroin addict,” Bostick said.
Each woman is recovering one day at a time, and they have their goals driven by faith and family.
“When you’re in it, you don’t feel anything,” Bostick said. “I didn’t feel like I had a problem. I didn’t feel like I was hurting anyone.”
They’re trying to rebuild burned bridges.
When Johnson was in jail, she wrote down all the wrongs she had done. She cried for days and called her dad to apologize.
Now, every night, Johnson catalogs everything she did that day because she realized that it’s minute decisions that can lead to a relapse.
“It’s a daily thing that I have to recognize so I don’t make those wrong decisions, so I keep those doors shut that don’t need to be opened anymore, because I know where they get me,” she said.
Through recovery, she’s working toward starting her own cleaning business and hopes to see her son for Christmas.
Bostick became a certified nursing assistant. She was afraid of what her teachers would think when they found out that she was a recovering heroin addict, but their trust and support persisted, and she knows to keep herself away from prescription opioids at work.
She’s also working on her case plan to have her daughter back permanently.
“My daughter loves me unconditionally. Her love for me never changed,” she said. “They’re giving me the opportunity to be her parent again.”
With their success still exists the small chance that they may falter, and they’re constantly in check with themselves. They know their recovery takes patience, constant consideration and hard work. They have gained so much, and there’s that much more to lose.
The drugs of Manatee County are constantly in flux, getting stronger or weaker with every day, every dealer. Not that long ago, Johnson said, street drugs were “safer.” An addict for the most part knew what they were getting.
“Today, it’s like playing Russian roulette,” Johnson said.
Naloxone is just the empty chamber.