America's first president, George Washington, once said that death is "an abyss from where no traveller is permitted to return". But he didn't bargain on heroin injectors. Many live their lives teetering on the edge of death, and some begin free-falling into an overdose state: their breathing stops, their face turns blue and their jaw stiffens into the early form of riga mortis. They are gliding down that stream of no return. But then, like something out of a movie, someone will jab them with a magical drug that brinks them back from the brink, and they breath again, living to fight, or get high, another day.
Naloxone is re-animating hundreds of people in Britain each year. At least five heroin overdose victims are brought back from the brink using naloxone every day in Scotland. Figures for England are patchy as there is shamefully no national naloxone programme, but the London Ambulance Service told me that in the last ten months 1,440 people have been given naloxone. That's five lives a day in the capital, without adding on the extra lives saved by drug workers and heroin users who administer it too. In Wales last year, kits handed out to people who work and live with heroin users saved two lives a day.
But what's it like to be brought back from the grave, and what about those people who, in the heat of the moment, have pulled back heroin users away from crossing the River Styx?
"I can remember sinking into that warm envelope – the comfort zone – and everything just falling off my shoulders, the feeling of being 'free'," says former long-term heroin user Kevin Jaffray about a time he OD'd hours after coming out of prison. "I guess that feeling somehow translates as how it would feel to die, and it's actually quite a relieving and comforting feeling that somehow overrides the reality and fear of death."
As his body began to shut down – as his lungs stopped working and his brain began to be starved of oxygen – he was jabbed with a shot of naloxone and the Grim Reaper faded into the distance.
"Coming round is horrible. I guess it feels like being a rabbit caught in the spotlights. You have no idea what's going on; you're usually surrounded by a crowd of strangers; people in uniform or your mates are in your face telling you that you were dead," says Kevin, now a drugs educator, peer worker and consultant based in Bedford. "You are disorientated, confused, weak and very scared. You just want to sink back into the protective wraparound the heroin brings; you want everything and everyone to just go away. Every piece of you wants to get up and run, and just keep going, but there's no energy, nothing – total disassociation from reality, with everything around you playing out like a shit reality show in which you're the unwilling star with nowhere to hide."
"I've been revived with naloxone five times, and those are the ones that I remember," he continues. "My life was a cycle made up of prison, hospitals, homelessness and the constant search for oblivion to take my mind off the pain of living. I guess my fear of living was stronger than my fear of dying. The problem with coming round after naloxone is that the brain won't accept the fact you've been dead. It's almost like a defence mechanism that softens the harsh reality of what's just happened. And this denial from the truth kicks in and all you want is that medicine to give you oblivion again."
Within the heroin injecting community, overdoses are a part of life. Barbara, a former long-term heroin and crack user now receiving heroin substitute treatment, estimates she's saved the lives of around 15 fellow heroin users using a mix of CPR, mouth-to-mouth and, three times this year, naloxone. She's been saved herself seven times, three by naloxone.
Barbara describes overdosing and being brought back with naloxone as a "bit like banging your head" while cycling to work. She was first saved with naloxone aged 19, after ignoring warnings the heroin she had just bought was highly potent. "I took a hit in the car with my boyfriend, and the next thing I knew I woke up at 2AM in a hospital," she says. "The first thing I noticed was that the doctor was annoyed at me – he was really cranky. He said, 'Do you realise what you are doing? You nearly died.' I noticed my boyfriend had been crying."
Didn't it stop you from wanting to inject heroin? "No. I thought I better be a bit more careful, but nothing more than that. It is very odd that an OD does not create a massive schism in your thought process, saying, 'Hey, you are on the wrong track, you nearly killed yourself – stop!' Instead I just thought I fucked up. One minute you are injecting and feeling high, and the next you're waking up with no idea what happened in the last ten minutes."
The act of slipping towards death is such a pain-free experience, which is maybe why heroin users fail to learn from overdoses and some end up being hauled back from death by naloxone numerous times. "You are disconnected from the whole experience because of the drug's cushioning effect. All of a sudden it's over and your parents are coming to your funeral. The reason it's hard to appreciate the fact you have virtually died and returned is that overdosing is not a slow descent into death," says Barbara. "When I saved my ex-boyfriend with naloxone, one of the things he said afterwards was: 'Oh my god, that was so easy to die.'"
WATCH: 'Swansea Love Story', our documentary about young heroin users in Wales
But as people drift towards become another statistic in the rising number of heroin-related drug deaths in the UK, sometimes there will be someone trying to pull them back. And for these people who aren't trained medics but are forced to use naloxone on others, it's often a terrifying scene. Saving her ex-boyfriend's life, as he slowly turned blue in her London flat two months ago, was one of the most traumatic events in Barbara's life.
"I was on the phone to a friend, making a cup of tea in the kitchen. He was talking to me and then, when I looked into the living room, I noticed his face going a bit grey. By the time I was taking the tea bags out he had stopped talking and the colour had totally drained from his face, from grey, to blue, to dark blue. He wasn't breathing."
Barbara gave him mouth-to-mouth, pressing on the inside of his mouth to release his already stiffened jaw. She says the hardest thing about MTM is the force you need to push air into the lungs of an OD victim, "because it's like their body is actively resisting staying alive". All the time, in between breaths, Barbara was trying to recall where she had put her naloxone kit. But she knew every second she spent trying to find it was vital, like a life or death hunt for some misplaced car keys. The first cupboard she checked was fruitless, so she went back to mouth-to-mouth. But still there was no response. Then out of the blue she knew: top knicker drawer. She made a dash for it, grabbed the syringe and plunged the needle straight through his jeans into his thigh. "After another minute, the colour of his face turned browny yellow instead of blue," says Barbara. "He opened his eyes and he didn't know what happened. I told him he'd just OD'd and all he said was, 'Have I?'
"You think death is so serious – such a big thing. When all of a sudden it's pain-free, simple: sit back in your chair, here's the headphones and you'll be on the other side in 50 seconds, let's go. But for those trying to help them it's one of worst things in your life. The horror of it."
To fellow heroin users, some of whom will still be high from their own hit, rescuing your injecting mate is often a harrowing experience. Andrew McAuley, senior epidemiologist at Health Protection Scotland, has interviewed drug users who have saved their friends with naloxone. As with anyone suddenly called on to save the life of someone dying in front of their eyes, they told him their overriding emotions were panic and fear.
As soon as someone overdoses, the clock starts ticking, and the most common cause of a fatal overdose is respiratory failure. Heroin users know this because most of them have seen friends die in front of them. The longer an OD victim is left alone, the more chance they will suffer permanent brain damage or die. Generally there is a two-hour window before a death of no return, although many OD victims will not be discovered until late on during that timeframe.
Before the first naloxone kits were distributed outside paramedics and hospitals to the drug community in 2005, all drug users could do if someone was slipping away was to try to revive them physically, or weigh up the risks of calling an ambulance (some people see any 999 call as a potentially damaging brush with the law). Despite being scared witless, most drug users McAuley spoke to said they felt relief and pride after saving lives with naloxone, and that some had gone on to form close bonds with those they assisted.
But not all those saved are happy about it. In fact, some are very pissed off. A study into naloxone kits carried out by the South London & Maudsley NHS Foundation Trust in 2009 revealed that one woman who had been brought round demanded £20 compensation from her rescuer for the wasted hit.
In the past two months, Marcus Ellis, a drug worker at Bristol Drug Project, has saved two lives, both heroin users who OD'd in the local graveyard. The first was of a man in his thirties lying on the floor with white froth surrounding his mouth. He had stopped breathing. After four doses of naloxone (each syringe contains five doses) he started shallow breathing and Marcus could see the whites of his eyes. He came round and later thanked Marcus, saying how grateful he was. Every time they see each other, Marcus says, "He gives me one of those smiles. We don't talk about it, but he knows I saved his life."
Not long after, Marcus was in the graveyard again, injecting naloxone into a man in his forties who had turned blue. When he came round his first words were: "Who the fuck are you? You've ruined my buzz." Although he couldn't move, he warned the paramedic who had just arrived that any attempt to take him to hospital would result in a fight. "His friend went into the next bush to get a hit and they then both walked off into the sunset. Sad thing is I just saved his life for a couple of days. Two days later he died after overdosing in his bedroom on his own, where there was no one to save him."
Some people who are saved are annoyed with their rescuers not because of a wasted hit, but because they intended on killing themselves. Jim Thompson of Glasgow's homeless team says a rough sleeping woman he saved from OD two months ago later apologised for having a go at him. "She had wanted to die because her life was not good; she had been separated from her children. She was very sad, but she apologised for being 'cheeky' after I'd saved her life. I've not seen her since, although I heard she's in and out of jail."
As the heroin-related death toll rises to record levels in the UK, the need for a rapid, Scottish-style expansion of naloxone into the hands of people who work and live around heroin users is obvious.
Kirsten Horsburgh, national naloxone coordinator for the Scottish Drugs Forum told me: "The majority of overdoses involve opioids and are witnessed. This provides a perfect opportunity for people to intervene and buy precious time until an ambulance arrives. There is no question that naloxone saves lives and, in the right hands, could prevent hundreds of accidental and avoidable deaths."
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