Editor's note: The illicit drug trade is undergoing a seismic shift, with Utah in the middle of the deadly impact of opioids. This is the latest in an ongoing series about this modern-day plague and the search for solutions.
On a bone-chilling Thursday afternoon in December, Patrick Rezac and Ally Lelandais are on a mission to save lives.
In Lelandais’ silver Toyota RAV4, they zip past a row of boarded-up State Street storefronts in downtown Salt Lake City until they spot a familiar neon-lettered sign announcing a motel where sex workers service their customers and drug addicts nourish their habits.
A cesspool of drugs, disease and crime — that’s how most passersby would size up this spot.
But to Rezac and Lelandais — both recovering addicts themselves — it represents a golden opportunity.
They pull into the debris-strewn parking lot. Rezac rummages around in the trunk of his car and comes up with a clear plastic bag that on the outside is unremarkable. But on the inside, there is a syringe, a 1-inch needle and a tiny vial of naloxone, a clear liquid containing the power to restore life.
When injected into muscle or vein, under the skin or sprayed up the nose, naloxone will reverse the effects of an opioid overdose and return the user to the land of the living.
Fifty-seven Utah law enforcement agencies carry naloxone, and more than 500 pharmacies in the state are equipped with the drug. Earlier this month, the Odyssey House, a Salt Lake City-based treatment center, paired each of its almost 200 outpatient and transitional housing clients with naloxone injection kits over Christmas.
As the opioid epidemic rages across the country, naloxone has established a reputation as a silver bullet — one of the most simple and effective ways to save those who overdose on narcotics. But the drug is not without its critics, who say it keeps addicts alive but does little to address the underlying problems that fuel addiction in the first place.
Even advocates of naloxone distribution, like Rezac, say it's not a long-term solution to the opioid crisis, and that the real problem is that there aren't enough treatment beds available for people who need and want them. But until that changes, Rezac and Lelandais do the one thing they can: Through One Voice Recovery, Rezac's nonprofit organization, they come to spots like this one along State Street every week to deliver naloxone kits to drug users and try to help those seeking treatment to get it.
Rezac knocks on the door of one of the rooms. A man in gray sweatpants and a tattered blue rain slicker opens the door a crack. The motel’s tenants are wary of visitors — most of whom are police officers or angry managers demanding payment.
The man is gaunt, his cheeks drained of color, but his face lights up when he sees Rezac.
“What’s up dude?” says Rezac, smiling as he hands him a naloxone kit. The man thanks him.
Rezac, a lean 44-year-old with close-cropped black hair and sharp, angular features, has an intense, almost intimidating energy. He is an unsentimental man, but kind.
He lays his hand gently on the man’s shoulder.
“You stay safe 'til I see you next time,” he says softly.
Rezac repeats a similar ritual at five other motel units. Then he checks his watch.
“We gotta keep moving,” he says to Lelandais.
He wishes he could stay longer, but he has a full day of deliveries ahead.
They jump back in the car, pull out of the parking lot, and disappear into the passing traffic.
Keeping users alive
On average, six Utahns die every week from an opioid overdose.
From 2013 to 2015, Utah ranked seventh-highest in the nation for drug overdose deaths, and nearly 2,500 people died from opioid overdose from 2014 to 2015.
Naloxone, originally approved by the Food and Drug Administration in 1971, came to prominence only in the past decade as the opioid crisis began sweeping the nation, killing more than 64,000 Americans last year alone.
Naloxone is easy to inject — no doctor is required to administer it — and its rapid, powerful impact has led to its nationwide reputation as a life-saving miracle drug.
Overdose occurs when the body receives a dose of opioids so high that the incoming drug completely saturates the narcotic receptors in the part of the brain that controls breathing. When that happens, the narcotic turns off the brain’s respiratory center, and the user stops breathing.
Naloxone works by binding to the brain’s narcotic receptors so powerfully that it knocks off the opioid that’s already there. The user wakes up and suddenly starts to breathe again.
Timing is key. In order to work, naloxone must be given soon after a person overdoses. In some cases, the window of opportunity to administer naloxone lasts less than five minutes before the person succumbs — not long enough for an ambulance to arrive.
In order to ensure that naloxone is on hand during that critical time period when a reversal is possible, Utah and other states have passed legislation to make naloxone more widely available to the general population.
In 2014, the Utah Legislature passed a bill allowing doctors to prescribe naloxone for a patient or for any family members, significant others or friends who their patient is concerned about.
In 2016, Utah made naloxone available over the counter at pharmacies without a prescription. In that same year, a bill passed that made it possible for nonmedical laypeople to furnish naloxone, so that anyone could become a naloxone outreach provider, not just physicians and pharmacists.
In 2017, the Utah Department of Health launched a pilot program giving roughly $230,000 to organizations — fire departments, health departments, law enforcement agencies, and nonprofits — to purchase naloxone. In the first six months of this year, naloxone kits funded by the pilot program reversed 46 overdoses.
Dr. Jennifer Plumb, assistant professor of pediatrics at the University of Utah, has been one of the strongest voices urging Utah to make naloxone widely available. In July 2015, she and her brother Sam Plumb started Utah Naloxone, a nonprofit organization founded in honor of their brother Andy, who died from an overdose at the age of 22.
In the past two and half years, Utah's naloxone distribution efforts have resulted in the reversal of 1,902 narcotic overdoses.
Plumb says that although the state’s evolving naloxone policies are encouraging, they haven’t been as effective as she had hoped.
“In the beginning, I conceptualized that naloxone distribution would be just like getting a flu shot,” she explains. “I thought that once it was available, everyone would line up and get it. Unfortunately, that’s not what has happened.”
She says that’s because unlike the flu shot, there is a high level of cultural stigma attached to drug use.
“In a small rural area in Utah, if your pharmacist is also your next-door neighbor, are you going to be comfortable asking for naloxone because your son is addicted to heroin? Maybe not,” she says.
In addition, many substance abusers have troubled relationships with government and law enforcement agencies and are likely to shy away from asking a police officer for naloxone or picking up a kit from a local health department or fire stations.
That’s why she says its critical to bring naloxone directly to the people who need it most, wherever they may be: the kitchen of a mom whose teenage son is addicted to heroin; a sex worker living in an apartment in South Salt Lake; a homeless man in a tent on a grassy freeway median; the living room of an elderly woman taking narcotics for pain relief after a surgery.
“With limited resources, we have to think about where the biggest bang for our naloxone buck is,” she says.
And that’s where One Voice Recovery comes in. Its mobile outreach delivery model allows the organization’s representatives to go out into the community, identify and establish relationships with people at risk for opioid overdose, and put naloxone directly into their hands.
In February 2017, Utah Naloxone established a partnership with One Voice Recovery, giving them free kits in exchange for their mobile outreach services.
One Voice Recovery distributes more than 125 kits every week, which have reversed at least 55 overdoses since March 2017.
Meeting addicts where they are
Back in Lelandais’ RAV4 on State Street, Rezac gets a phone call.
“Hey, this is Patrick ... What’s that? ... They’re gonna throw you out?”
The call is from a heroin addict. He tells Rezac that he’s been evicted from his motel and has nowhere to stay.
“I can’t live this way anymore, man,” says the man. “I gotta get into treatment.”
Rezac tells him to meet him at a nearby inn, where he promises to put him up for a night while they find a treatment bed for him. Rezac says he always keeps enough cash on hand to place one or two people in a motel overnight, if they express a desire to get treatment.
Rezac pulls into the parking lot and gets out of the car.
“Hey, man, what’s up?” says Rezac, reaching out to shake his hand.
Rezac pays for the man's room. Then he walks with him to the door of his motel room, and gives him a naloxone kit — just in case.
“You used to use, man?” the man asks Rezac.
“Yeah, man, heavily,” Rezac replies.
“Well, if you made it out of this hell, maybe I can too.”
Rezac founded One Voice Recovery in 2016, after emerging from his 18th stint in rehab.
His addiction started 13 years before that, when he was 30 years old and living in downtown San Francisco working as a case manager for homeless youth. One weekend after hitting a few bars, his friend offered him cocaine. He wasn’t that interested — Rezac had tried the drug once when he was a teenager and “hated it” — but he said to appease his friend, he took some.
He was immediately hooked.
“Two hours later, I was at an ATM pulling out $500, two weeks later I was smoking crack, and two months later, I was injecting meth,” he remembers. “I had no idea how powerfully the drug would affect me.”
He says that after so many unsuccessful tries at rehab, what ultimately worked was for his treatment providers to “meet me where I was at.”
Rezac was angry at the world for abuse he had suffered as a child. He had a hair-trigger temper and was repeatedly kicked out of treatment programs for lashing out at counselors or other program participants.
The staff of the final treatment program he entered, Maple Mountain Recovery Center in Mapleton, Utah, understood that the source of his anger was trauma and that he needed to be helped to process his trauma in order to move forward.
The idea of “meeting addicts where they are at” — both physically and emotionally — is at the heart of One Voice Recovery.
Almost every day, Rezac goes out in his car and visits sites across the state, from white collar households to homeless campsites to motels, bringing naloxone, clean needles and syringes to people addicted to opioids.
Preventing the spread of disease is also a critical part of One Voice Recovery’s work. The organization provides HIV and Hepatitis C testing, and two days a week, Rezac is accompanied by workers from the Salt Lake County Health Department, who administer Hepatitis A vaccinations.
Rezac says his communication style is the key to building trust with the population he serves. He is open about his own history of drug use and his path to recovery.
“I don’t talk to them in a clinical way,” he says. “I talk to them like I’m one of them.”
Naloxone is part of an approach to drug addiction called “harm reduction” — the idea that users need to be kept alive and healthy until they feel ready to seek treatment.
But critics of naloxone say the drug perpetuates a never-ending cycle of addiction, keeping addicts alive but not addressing the underlying problem causing their addiction in the first place.
Chris Delamare, spokesman for Utah Gold Cross Ambulance, who has worked in the emergency medical service industry for 27 years, says medics use naloxone to reverse overdoses on the same people over and over.
“Naloxone is the ambulance at the bottom of the cliff,” argues Utah Rep. Steve Eliason, who has been at the forefront of several pieces of naloxone-related legislation. “We have to keep the ambulance there to save people who fall, but what we really need are better fences at the top of the cliff to stop people from falling in the first place.”
By establishing long-term trusting relationships with the population he serves, Rezac’s ultimate goal is to build bridges to recovery. His program provides not only naloxone kits, clean syringes and vaccinations, but also a concrete pathway for people to escape the cycle of addiction.
“That’s the motivation behind all of this,” says Rezac. “Having conversations with people about recovery and linking people to treatment.”
Rezac encourages substance abusers to take ownership of their own paths to recovery and empowers them to be leaders in the drug-using community.
He said he helps a 50-year-old sex worker and heroin addict who, in turn, has been able to help others for more than a year.
Every time Rezac stops by her hotel room, he gives her extra naloxone kits so she can have one on hand in case someone around her suffers an overdose. He says so far she has used naloxone to save five lives.
In a homeless encampment in North Salt Lake, less than a block away from the Utah Health Department headquarters, a 55-year-old man named Tennessee sits outside his tent, shivering.
A recent snowfall has left patches of ice and snow on the top of his tent, where his pregnant girlfriend is sleeping.
He wears a black hat and a scarf wrapped tightly around his neck and over his mouth. He pulls it down so he can say hello as Rezac and Lelandais stomp across the frozen ground toward his tent.
“Hey, man!” Lelandais calls out to him. “It’s so good to see you again. You staying warm?”
Tennessee has been living in the encampment for four months. He came to Utah six years ago from, as his name implies, Tennessee.
He moved to Utah full of hope after landing a job at the Tesoro Oil Refinery during Utah’s 2012 oil boom.
But then he got hooked on heroin and his life fell apart.
Rezac and Lelandais met him five weeks ago, while doing outreach at homeless encampments across the city.
“They’ve been real friendly to me,” he says. “It’s real nice to be treated like a human being.”
Lelandais hands him two naloxone kits — one for him and one for his girlfriend.
Then Tennessee pulls out a business card from the Volunteers of America.
“They gave me this card and told me I had to go to detox before I could start treatment,” he tells Lelandais. “Today’s the day. I’m ready to go.”
Rezac picks up his cellphone and calls the detox program.
“I just called Michele from the VOA,” says Rezac. “When she calls back, I’ll tell her to come here and set up an appointment for you. And we’ll follow up with you again tomorrow to make sure you’ve heard from her.”
Before they leave, Lelandais gives him a long hug.
“Thank y'all so much,” he says.
When addicts tell Rezac they are ready to seek treatment, he immediately gets to work. He calls one of the treatment centers he works with and asks if they have a bed.
The length of the wait usually depends on whether the person has insurance, and whether they have income to spare.
According to Rezac, publicly funded detoxes typically have a one- to three-day wait, and publicly funded treatment centers often have a 30-day wait.
Private detoxes and treatment centers can usually accept patients the same day but most come with a hefty price tag, making this option impossible for Tennessee and other homeless or low-income individuals.
“I think its absolutely devastating, ridiculous and absurd that people have to wait for a treatment bed,” says Rezac. “We have all these amazing private treatment centers in Utah, but only a small handful of options for people who are poor or uninsured.”
Michele with the Volunteers of America returned Rezac’s call, and he was able to get Tennessee a detox appointment for 2:30 p.m. the next day.
But when Lelandais showed up at the campsite to pick him up, he was gone.
“If we could have taken Tennessee right there, things might have been different,” he says. “But the fact that we had to wait until the next day — a lot can happen in 24 hours to get in the way of someone wanting to access treatment.”
Rezac says in the last year, One Voice Recovery has placed nine people into treatment, and eight of them are still in recovery.
But Rezac says as hard as he works to build bridges toward recovery, “the biggest problem is that there aren’t enough beds to take care of the people who need and want treatment.”
He says that naloxone is a life-saving tool, and applauds the state for prioritizing naloxone distribution in recent years.
But he says while naloxone might lower the state’s overdose death toll, it’s not a long-term solution to Utah’s opioid epidemic.
“I hate that I have to tell people that we’ll come back tomorrow and try to get you on a waiting list. Because in the next 24 hours people can die,” he says. “Unless we increase our capacity to actually treat people, the cycle of addiction and death will never end.”