ADDICTS LEARN TO SAVE OTHERS FROM DEATH

In San Francisco, Fatal Overdoses Have Fallen Since The City Started
'Harm Reduction' Programs

SAN FRANCISCO - Denise Williams, a frail and homeless heroin addict,
fills her sandwich bag with a dozen clean needles and wanders to the
back of the crowded Tenderloin health clinic for a five-minute lesson.

It's a crash course on how to save a life.

Leaning over a dummy on the floor, Williams, 50, practices breathing
into the mouth of someone out cold. She then collects two free
needles preloaded with naloxone, a medication that can revive an
overdosing opiate addict within minutes, and is on her way.

"I'm glad they're showing us this stuff," said Williams, who was
revived with a dose of naloxone herself last summer. "I don't want to
just sit there if someone ends up in a bad situation."

Mostly because of drug abuse among baby boomers, Californians are
dying of overdoses in such large numbers that they may soon surpass
auto accidents as the state's leading cause of accidental death.

But here in San Francisco, the death rate from overdose is at its
lowest level in nearly a decade.

In 2003, the latest year for which the state has figures, a record
3,691 drug users died, up 42% since 1998 and up nearly 75% since
1990. The total surpasses deaths from firearms, homicides and AIDS.

Meanwhile, overdose deaths in San Francisco, which has one of the
highest rates of drug use in the state, have fallen from 178 in 1998
to 144 two years ago. Since then, officials believe, the number may
have dropped to fewer than 100 deaths.

The training of addicts to save their brethren is one reason, public
health officials say. Officials here have embraced a number of "harm
reduction" practices in recent years. And the city has focused
primarily on middle-aged users, whose rate of overdose statewide has
doubled in the last dozen years.

The approach is controversial because it bypasses the "Say No" and
"Get Treatment Now" messages. It assumes overdoses will occur and
strives mostly to keep addicts from dying.

Critics, including some physicians, worry that public funding of such
a program endorses addiction.

"Addiction is a disease, and overdoses are simply a symptom of the
disease," said Dr. David Smith, medical director of the Haight
Ashbury Free Clinics, one of San Francisco's largest drug treatment
providers, which does not distribute naloxone. "We believe we should
be focusing more on getting people into treatment."

Naloxone works by blocking opiates from attaching to the brain's
pleasure-seeking receptors. It sends users into immediate - and often
agonizing - withdrawal. Still, many doctors say the medication does
not have proven long-term harmful effects.

In 2003, San Francisco became the first city in the state to publicly
fund naloxone distribution, which now costs about $50,000 a year.
Since then, officials say, addicts have reported saving 116 people
with the medication, although this could not be independently verified.

Naloxone distribution is part of a larger campaign aimed at keeping
addicts from getting high by themselves. Four years ago, the public
health department began posting "Fix It With a Friend" billboards
around the city, highlighting the risks of solo use.

Two of San Francisco's biggest overdose targets are single-room
occupancy hotels and the Tenderloin district, because they typically
attract older addicts.

Older addicts often use drugs alone, while younger people, research
shows, tend to use them in groups. One of the major risk factors for
a fatal overdose is not having anyone to call paramedics when the
first signs of an overdose appear.

The city also has joined forces with a nonprofit group that sends
volunteers to local jails and treatment centers to warn about the
risks of starting up drug use again even after a short hiatus. They
often pass out "Got Naloxone?" stickers, reminiscent of milk commercials.

Experts estimate that a quarter of overdoses occur soon after addicts
leave treatment or jail.

Peter Morse, a pierced and tattooed overdose prevention counselor
with the city-supported D.O.P.E. Project (Drug Overdose Prevention
and Education), said one of the hardest tasks is convincing people
that it's worthwhile to save addicts who are essentially killing themselves.

"This makes their situation not so hopeless," Morse said as he walked
down a trash-strewn block in the Tenderloin, which he called one of
the city's drug-abuse epicenters. "This doesn't have to be a death
sentence for them."

Williams, who has been using heroin since she was 21, said a friend
administered naloxone to her early this summer. Minutes later, she
woke up on the street as the ambulance was arriving, in pain and nauseated.

"It made me feel cold, and it left a real bad taste in my mouth," she
said. "I'm glad they did it, but I didn't like the feeling."

Among junkies, word is spreading about naloxone.

Jack Rocchetti, 40, recently came to a needle exchange seeking
naloxone training. He learned about the medication a week before,
when one friend used it on another.

Rocchetti, a beefy former fork lift operator with a rosary around his
neck, has been using heroin on and off for 18 years. He stopped for
almost a year until last April, he said, when he started using again
because of a depression over a midlife crisis.

"I'm 40 years old, and I don't have much to show for it," he said.
"I'm starting to get too old for this."

The city's overdose prevention campaign has been driven in part by
research. A UC San Francisco study examining overdose deaths in San
Francisco in the late 1990s, one of the few such analyses on the
topic, showed that close to half the city's overdoses were among
older users who lived in single-room occupancy hotels. And more than
a third of the deaths were within 500 meters of one intersection -
Turk and Jones streets - in the Tenderloin.

"One of the things people will tell you is that we should focus on
trying to get addicts in treatment," said Dr. Josh Bamberger, medical
director of the San Francisco Department of Health's division of
Housing and Urban Health. "You can't get a dead addict into treatment."

In interviews, state and local health officials in Los Angeles
acknowledge that, other than in San Francisco, there is virtually no
strategy to address the statewide rise in drug deaths.

"We have been focused on expanding our needle exchanges and have a
limited amount of money to use," said Dr. Jonathan Fielding, Los
Angeles County's health officer. He said he had not been aware of San
Francisco's success in reducing overdose deaths in recent years and
may recommend that Los Angeles begin a naloxone distribution program.

Around the nation, a handful of cities and states, including
Baltimore, Chicago and Santa Fe, N.M., have instituted overdose
prevention plans and have begun distribution of naloxone. Their
overdose deaths are down as much as 30% since their naloxone programs began.

More recently, health officials in California's Humboldt County began
distributing a small number of naloxone needles last year, and New
York state legalized distribution this summer.

Dan Bigg, director of the Chicago Recovery Alliance, a nonprofit harm
reduction coalition, said he had no doubt naloxone and harm reduction
were effective. "What we have here is an antidote to the problem," he
said. "Now we just have to convince people it's worth it."