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Opioid Epidemic

In the Heart of Appalachia, One Group Works Overtime to Reduce Overdoses

Lawson Koeppel, executive director and co-founder of Virginia Harm Reduction Coalition, center, assembles naloxone kits, which contain the opioid overdose reversing drug. Volunteers Christopher Wagner and Charles Fisher  help load the kits before taking them out into the community. The group is committed to preventing overdose deaths in Roanoke. (Photo by Stephanie Klein-Davis for Direct Relief)
Lawson Koeppel, executive director and co-founder of Virginia Harm Reduction Coalition, center, assembles naloxone kits, which contain the opioid overdose reversing drug. Volunteers Christopher Wagner and Charles Fisher help load the kits before taking them out into the community. The group is committed to preventing overdose deaths in Roanoke. (Photo by Stephanie Klein-Davis for Direct Relief)

ROANOKE, Va. – In a drab, converted motel room on a Friday night last month, Lawson Koeppel and two other volunteers were packing kits of medicine and syringes, each with the ability to reverse a drug overdose and save a life.

Since December 2018, Koeppel’s nonprofit, the Virginia Harm Reduction Coalition, has given out over 3,000 doses of naloxone during a period when it has been needed most.

Sitting at the edge of the Appalachian Mountains, the city is in the thick of the nation’s opioid epidemic.

Though drug overdoses fell about 5% nationally last year in the United States from a 2017 all-time high of 70,237 deaths, opioid-related overdoses have stayed about the same, with approximately 47,600 deaths in 2017 and 2018. Roanoke saw all-time highs in opioid drug overdoses in 2017, which then rose another 14%, to 56 deaths, in 2018, according to the Virginia Department of Health.

While in a master’s program at Radford University, Koeppel witnessed the carnage of opioid abuse in western Virginia. He and some classmates, all of whom had once been drug users, started working together to advance harm reduction programs. Koeppel would eventually partner with Tanya Segura, who was invited to speak to his class, to create their nonprofit last December.

“Our first priority was to purchase naloxone. To help somebody, they have to be alive,” Koeppel said during a phone interview with Direct Relief.  Most of their vials have been given out to drug users, people who are in regular contact with drug users, and harm reduction groups in other parts of the state.

Vials of naloxone are put into the kits, along with other supplies needed to administer the drug to prevent an overdose. (Photo by Stephanie Klein-Davis for Direct Relief)

A Life-Saving Drug, If You Can Get It

Decreases in overdose deaths nationwide — which remain a leading cause of death in the U.S. — are correlated with a 106% increase in naloxone prescriptions from 2017-2018, according to a CDC report. The drug works by temporarily restoring breathing and consciousness after an opioid drug overdose.

Koeppel said that his group has received 300 reversal reports, which are instances when the drug has been used to reverse an overdose, though he cautioned that such data is hard to parse, since reversals are underreported and it is difficult to identify duplicate reports.

Because of its effectiveness, the U.S. Surgeon General’s advisory on naloxone and opioid overdose states, “Naloxone is a safe antidote to a suspected overdose and, when given in time, can save a life.” U.S. Surgeon General Vice Admiral Jerome Adams has urged more Americans to carry naloxone.

All but three U.S. states either have a standing order or remit the matter to local jurisdictions, enabling them to issue standing orders to distribute naloxone without a prescription. Many states have also passed Good Samaritan legislation to incentivize bystanders to act and attempt to save a life.

But access to naloxone is not always easy, due to a combination of “cost and stigma barriers,” according to a report the University of Pennsylvania’s Leonard Davis Institute of Economics and the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, known as CHERISH.

As the sun sets over Roanoke, Koeppel's group sets out into the city to distribute naloxone wherever its needed. (Photo by Stephanie Klein-Davis for Direct Relief)
As the sun sets over Roanoke, Koeppel’s group sets out into the city to distribute naloxone wherever its needed. (Photo by Stephanie Klein-Davis for Direct Relief)

“We get naloxone from Direct Relief and other health departments in Virginia and go meet folks where they are: hotel rooms, trap houses, at offices behind a hotel, literally wherever people are,” said Koeppel, who stressed that the most of the naloxone is given to people with the expectation that the initial recipient will, in turn, give to others who need it. Since 2017, more than 350,000 doses of naloxone have been distributed by Direct Relief across the United States, free of charge, to health centers, free and charitable clinics, and addiction recovery groups like Koeppel’s.

Though Koeppel and Segura try to respond to calls and messages for help as they come in at all hours of the day and night, they feel their model allows for an optimized distribution method that reaches the most people.

Koeppel’s initiative is one of several in Virginia — including the Chris Atwood Foundation, which Koeppel said served as a model for him and other similar groups — that have stepped in to implement state-level legislation that allows for naloxone to be given without a prescription.

Lived Experience

Like many harm reduction programs, the effort extends beyond just distributing naloxone. They educate drug users and others in the community about safer drug use and available healthcare resources. Koeppel’s group also hands out basic medical supplies like antibiotic ointment, bandages, tourniquets, and condoms. The Virginia Harm Reduction Coalition is a registered nonprofit, has an advisory board comprised of doctors and other medical professionals, and is run and operated by volunteers.

“Harm reduction programs are an entry point to broader health care,” said Elaine Martin, director of HIV and hepatitis prevention services for the Virginia Department of Health.

Martin also stressed the crucial value of groups like Koeppel’s in addressing the opioid epidemic.

“It takes a special skill set to reach out and gain trust in that (drug user) community,” Martin said.

“I know what it’s like to wake up in the morning, not want to get high and still end up getting high. I know what it’s like to be stigmatized for drug use. I know what it’s like to be ostracized,” Koeppel said.

He said he brings this perspective to interactions with drug users, which he sees as more than just handing out naloxone or lecturing folks on safety. Koeppel said the most effective way for him to have an impact is to engage in conversations. Beyond this, he coordinates with programs that remove conditions — such as requiring abstinence from drugs — before providing care.

“If you offer somebody a way to improve their health… It turns out, they take it, especially if it’s a low barrier,” Koeppel said.

Beyond The Drug

In addition to naloxone-based programs, Virginia passed legislation to allow for syringe exchange programs that combat the spread of HIV, hepatitis, and other infectious diseases.

A comprehensive review of medical studies in the Penn/CHERISH report concluded that overdose education and naloxone distribution programs, such as Koeppel’s, are “effective and cost-effective in reducing opioid overdose deaths in people who use heroin and other opioids.”

Dr. Nico Conti, an internal medicine resident based in northeast Ohio, which has been hit hard by the opioid epidemic, said he is amazed every time he sees Narcan, a nasal spray form of naloxone, reverse an overdose.

“It can be lifesaving in overdose situations,” Conti said. “I deal with the aftermath of opioid abuse on a daily basis and feel very strongly that naloxone should be made as accessible as possible.”

In March of 2018, two economics professors shared a non-peer reviewed study that pointed to an increase in opioid use without a reduction in death rate after laws allowing easier access to naloxone. As reported by The Atlantic, the report led to a “firestorm” of criticism and exposed the differing methodology used within the economics and public health communities.

“In most endeavors, if you lower risk barriers, more people participate. Total use does go up, but total harm decreases,” said Koeppel. “So, yes, we’re enabling people. We’re enabling people to stay alive, we’re enabling people to protect their health, and we’re enabling people to protect the health of their community.”

“We know we’ve had an impact, and I think it’s a good impact,” Koeppel said.

Lawson Koeppel, 42, Executive Director/Co-founder. Virginia Harm Reduction Coalition, loads kits with Naloxone in his Roanoke office located in an old motel, to pass out to the community to help save lives. Lawson describes a way to check someone who has overdosed by rubbing them hard on the sternum before using the Naloxone. (Photo by Stephanie Klein-Davis for Direct Relief))
Lawson Koeppel describes a way to check someone who has overdosed by rubbing them hard on the sternum before using naloxone. (Photo by Stephanie Klein-Davis for Direct Relief)

Reflecting on what drives him to run out to rough areas in the middle of the night, even and especially on weekends, Koeppel said it all comes back to what he’s been through, and his hope to help others find a way to recovery, or at least to not die because of an overdose.

“There’s a survivors’ instinct, you want to run back into the burning building and save other people and that’s kind of the impetus here. We know people we love are dying. And there is a pretty easy cure for opioids. We have a magic bullet for the thing that’s causing most deaths,” Koeppel said.

Even as naloxone remains the key element necessary to save lives, Koeppel said the medicine is not the whole ballgame when it comes to helping drug users stay alive.

“As much as we talk about tools, it is about that, but it’s about the relationships and the impact you have on an individual when they see they’re worthy of care, especially when they’ve been told they’re not,” Koeppel said.

“It’s not just lifesaving, it was life changing for me, knowing somebody believed in me, and considered me worthy of their attention,” Koeppel said.

Stephanie Klein-Davis contributed additional reporting to this story from Roanoke.

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