I. Near Death

Looking in her rearview mirror to change lanes in gridlock traffic on I-76, Brittany Salerno saw her then-boyfriend, Joshua, with his head slumped back and his skin turning gray.

Panicking, she called 911 and took the nearest exit to Girard Avenue. She got out of her car and stood on the 34th Street median in the pouring rain. She looked south and saw the ambulance coming up the road.

“I was terrified,” she said. “I’m slamming on people’s windows, begging them for water, begging them for help because I had no idea what to do.”

Joshua’s mother, who was also in the car, performed rescue breathing to keep him alive.

“I just prayed to God,” said Salerno, who added that she doesn’t pray often. “I just remember saying, ‘Please, don’t make this the worst day of my life. I’m not ready for it.’”

Brittany Salerno, 28, stands on the median at 34th Street in West Philadelphia where her ex-boyfriend overdosed last year. PHOTO BY SYDNEY SCHAEFER

It took eight doses of naloxone to bring Joshua back. Naloxone is an opioid overdose reversal medication commonly known by its brand name Narcan.

After going to the hospital that day, Joshua was discharged with Narcan. Salerno has been carrying it ever since.

Like Salerno, an increasing number of Philadelphians are carrying Narcan with them wherever they go. Their motivations differ — some have suffered personal loss, and others carry it because they feel a duty as citizens.

Whatever the reason, everyday Philadelphians are on the front lines of the opioid epidemic, reversing overdoses and saving lives using naloxone.

A woman stands in the doorway of a row home in South Philadelphia’s Point Breeze neighborhood. PHOTO BY SYDNEY SCHAEFER

II. The Epidemic

Philadelphians are carrying Narcan for good reason the city has some of the highest overdose rates in the country.

In 2017, Philadelphia saw a 34 percent spike in fatal drug overdoses after more than 1,200 people died. Opioids accounted for 88 percent of those overdose deaths, which is up from 80 percent the year before.

The most common culprit in overdose deaths is fentanyl, a synthetic opioid more powerful than heroin that can be fatal even in small doses. In 2017, fentanyl became the leading cause of opioid-related deaths in Philadelphia — it was present in 84 percent of fatal overdoses.

In the midst of increasing overdose deaths, naloxone is helping save some lives.

As 2017 came to a close, overdose deaths began to decline. Although the direct cause of the drop is unknown, a report from the Philadelphia Department of Public Health listed the distribution of Narcan by the City of Philadelphia and other community agencies as a potential contributing factor.

Narcan sits in a police bag. PHOTO BY SYDNEY SCHAEFER

III. The Standing Order

In late 2015, Pennsylvania Physician General Rachel Levine signed a standing order that allows all Pennsylvania residents to obtain naloxone from a pharmacy without a prescription from their doctor.

There are various forms of naloxone, including an injectable form and two nasal sprays: Narcan and another generic version of naloxone that does not come assembled.

“We have an epidemic the likes of which we’ve never seen before,” said Gov. Tom Wolf at an October 2015 press conference announcing the standing order, according to a report from the Pittsburgh Post-Gazette. “This is a disease like cancer, heart disease and diabetes. We have to address it is [sic] just like we’ve addressed other diseases.”

Without insurance, a Narcan kit that includes two 4 mg doses can cost between $130 and $140. Even for those with insurance, the cost varies. Some people have no copay, while others have to pay close to $100.

For those without insurance or whose copays are too expensive, the Philadelphia harm reduction nonprofit Prevention Point gives away free Narcan kits.

But barriers still exist to getting naloxone, even for those who are willing and able to pay. Same-day pickup isn’t always available, according to the City of Philadelphia’s Narcan fact sheet. Sometimes, pharmacists aren’t even aware of how the standing order works.

Independence Blue Cross, a health insurance company in Southeastern Pennsylvania, announced that starting on March 1, members who have IBX’s pharmacy benefits can get naloxone for free. The policy doesn’t apply to those who only have IBX’s medical coverage.

“Now you don’t even need a prescription, you don’t even need to pay for it,” said Ruth Stoolman, IBX’s public relations manager. “We’re making it so much more accessible, removing every barrier that you could think of to try to make sure people get it.”

IBX members who are eligible to get free naloxone with their plans have to meet their deductibles before they can pick it up at a pharmacy.

In addition to increasing access to naloxone, the state’s standing order also gives those who administer the overdose-reversal medication immunity from any liability.

“It’s just like CPR,” said Elvis Rosado, Prevention Point’s education and community outreach coordinator. “Nobody can sue you because you assisted in bringing them back to life.”

The standing order will stay in effect until Levine no longer holds the position of physician general. Last month, the United States Surgeon General Dr. Jerome Adams released a national advisory urging everyone to carry the life-saving medication.

“Expanding the awareness and availability of this medication is a key part of the public health response to the opioid epidemic,” the advisory reads. “Increasing the availability and targeted distribution of naloxone is a critical component of our efforts to reduce opioid-related overdose deaths and, when combined with the availability of effective treatment, to ending the opioid epidemic.”

This increase in awareness and access has not only affected everyday citizens, but also first responders. David’s Law, which was passed in 2014, provides immunity from prosecution for individuals who call 911 to report an overdose and gives first responders access to naloxone.

“When I first heard about it, I was like, ‘I’m not a medic,’” said Eric Miller of the Marple Township Police Department in Delaware County. “A lot of police were skeptical.”

Miller and his coworkers assumed they would have to use an IV to administer the medication, not realizing it would come as a nasal spray, which is much faster and easier to use.

Once their fears were alleviated, the officers got on board. The Delaware County police officers have been carrying Narcan for almost three years now.

Due to similar efforts in Philadelphia, the Philadelphia Fire and Police departments, alongside SEPTA Police, have reversed more than 7,000 overdoses.

An advertisement urging people to carry naloxone on display in the Snyder station on the Broad Street Line subway stop. PHOTO BY SYDNEY SCHAEFER

IV. Philadelphia's Initiative

Now billboard, bus and subway advertisements are popping up throughout the city, all bearing the same message: Carry naloxone.

With this recent Philadelphia Department of Public Health campaign, the goal is to get Narcan into the hands of everyday Philadelphians.

The $100,000 ad campaign stemmed from a report produced by The Mayor’s Task Force to Combat the Opioid Epidemic, formed by Mayor Jim Kenney in January 2017.

The members produced a public report after two months of meetings. The report addressed various issues related to the opioid epidemic, but specifically urged the city to launch a public education campaign about Narcan that would increase “knowledge, use and access” to the overdose antidote.

“We need to distribute [naloxone] more, so that everybody has that, should they come across someone, their loved one or a stranger, who has had an overdose to try to keep them alive,” said Dr. Thomas Farley, the commissioner for the Department of Public Health and co-chair of the Mayor’s Task Force to Combat the Opioid Epidemic.

Dr. Thomas Farley, the commissioner for the Department of Public Health and co-chair of the Mayor’s Task Force to Combat the Opioid Epidemic, speaks at a community forum hosted by the Mayor’s Task Force at South Philadelphia High School on April 30. PHOTO BY SYDNEY SCHAEFER
A woman stands up out of her seat to address Dr. Thomas Farley and others at the South Philadelphia High School community forum. PHOTO BY SYDNEY SCHAEFER

The city began hosting free public Narcan trainings in 2016 for anyone interested in learning how to use it. Since then, the Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) has trained nearly 1,000 people.

In 2016, the city hosted four sessions from September through December to train 236 people. In 2017, the city held four more sessions, this time training nearly double that number — 560 Philadelphians.

So far this year, the city has held two trainings for 127 people. Additional sessions are scheduled each month for the remainder of the year.

“It’s been impressive, just the coordination, the mobilization efforts, how quickly things have come together, the availability of the [naloxone] trainings and the resource,” said Andrea October, a clinical project manager in the health promotion unit of DBHIDS and volunteer instructor at the city’s training sessions.

“I feel like now with us coming together, it’s not just the problem of people who are struggling with addiction, but it’s everyone’s problem, and everyone has to try to help in the solution,” she added.

Leonia Johnson speaks to Narcan trainings attendees in the DBHIDS office on April 18. PHOTO BY SYDNEY SCHAEFER
Andrea October (right) addresses a room of Narcan training attendees in the DBHIDS office on April 18. PHOTO BY SYDNEY SCHAEFER

Philadelphians are also learning to use Narcan at other trainings around the city. As a part of Rosado’s work at Prevention Point, he conducts frequent off-site trainings. Just last month, he trained hundreds of people during two sessions at Temple University.

Rosado has been carrying Narcan for about three years. He keeps it in an old point-and-shoot camera pouch attached to his belt loop.

“No one should be without Narcan,” Rosado said.

Elvis Rosado, Prevention Point’s education and community outreach coordinator, holds Narcan at a training session on April 18 in Temple University’s Ritter Hall. PHOTO BY SYDNEY SCHAEFER
Temple University students get trained on how to use Narcan by Elvis Rosado on April 18 in Temple University’s Ritter Hall. PHOTO BY SYDNEY SCHAEFER

Prevention Point started hosting its own naloxone trainings about nine years ago, Rosado said. At first, they were training people with the injectable form of naloxone, Later, they switched to Narcan, which is easier to administer.  

“Overall, it’s just to bring awareness and make sure that people realize they have access to it and it’s readily available,” Rosado said.

Brendan Letts poses for a portrait in his Delaware County apartment. PHOTO BY SYDNEY SCHAEFER

V. A Second Chance

Brendan Letts overdosed for the first and only time at his mother’s kitchen table in 2014.

She found him lying on the ground and called 911. When he opened his eyes minutes later, Letts realized the paramedics were carrying him out of the house on a stretcher. A police officer had hit him twice with Narcan.

Letts said he felt embarrassed that he overdosed, and he was angry at the officer for throwing him into instant withdrawal.

“He was the devil to me,” Letts added. “I hated him.”

Letts spent the rest of 2014 and early 2015 in and out of treatment centers in Delaware County until his mother gave him an ultimatum.

“She said, ‘I’m either giving you a one-way ticket across the country, or you have to find a recovery house,’” Letts said.

For Letts, that moment was a wake-up call.

Letts got into treatment for the fourth and final time. He then spent the following 18 months at MVP Recovery Now, a recovery house in Delaware County.

The executive director of the recovery house asked Letts to speak about his experience with Narcan in a video that would later be shown at a police officers’ luncheon in October 2017.

Letts also attended the luncheon, where he learned Officer Kevin Smith from Nether Providence Township — the man who revived him with Narcan when he overdosed — was sitting right behind him.

“I was just at a loss for words,” Letts said. “I was stuttering, and him and I were both in tears.”

“He was just so humble about it,” he added. “He didn’t want to take any credit at all.”

Brendan Letts holds a copy of Delaware County’s daily newspaper, the Daily Times. PHOTO BY SYDNEY SCHAEFER

That weekend, a photo of Letts and Smith at the luncheon was published on the front page of the Daily Times, a daily newspaper in Delaware County.

Letts said his original perception of Smith changed completely from when he overdosed.

When he met Smith, Letts told him, “You’re an angel now. I can’t thank you enough.”

“I just told him how much better my life is,” Letts said. “And it literally is beyond my wildest dreams.”