The newly installed NaloxBox at Adams Public Library contains doses of naloxone, an antidote for opioid overdoses. Susan Zalkind

Designers hope the overdose treatment will soon be as ubiquitous as fire extinguishers or defibrillators.

Wedged between shelves of hardback thrillers and DVDs, a whitesquare box adorned with a red cross blends into the scene at the Adams Public Library, belying the potency of its contents.

Inside are four doses of a nasal spray that reverses the effects of opioid overdoses. It is one of the first boxes to be installed—a new tool to attack the growing opioid epidemic. But its creators hope the boxed supply of naloxone, called NaloxBox, will soon be as ubiquitous as defibrillators or even fire extinguishers, so that people overdosing on opioids in public spaces will be treated as if they were suffering from any other public health emergency.

Geoff Capraro, a Brown medical school professor and emergency room doctor, said he came up with the idea to make more naloxone publicly available, along with Rhode Island School of Design professor Claudia Rébola, after treating an influx of patients for opioid overdoses in recent years.

“[Naloxone] can resuscitate a person like few other drugs,” Capraro said. Rhode Island, like many other states, has already instituted a number of measures to make overdose drugs more available to people who need it, when they need it.

The state passed a Good Samaritan Law, which protects people who call for help in cases of suspected overdose from the risk of prosecution, in an attempt to get addicts to call for help. State officials and have also made the drug available over the counter, and naloxone advocates have worked to train and equip community members who might face an overdosing peer.

But despite the interventions, fatal overdose numbers are climbing in Rhode Island, as they are in much of America. “The opioid epidemic is frustratingly expanding and growing,” said Capraro.

A study conducted by the Rhode Island Department of Health determined that one critical gap in distributions was in public places, especially those with public bathrooms, such as laundromats, fast food restaurants, and libraries. Rhode Island is the first state to implement NaloxBox, through a series of grants dispensed by the Health Department.

The purpose of NaloxBox is to is to allow bystanders to help someone suffering from an overdose, in some of the most common places overdoses occur. Each box contains four doses of naloxone, in an easy-to-administer nasal spray form, a mask for assisting with rescue breathing, and a pair of medical gloves. Anyone can open the box, follow the instructions, and potentially save a life.

Rébola said her intention in designing the box with the clear case, and rounded edges, was "to design a product that really feels approachable, familiar, usable."

"We don't want people to be scared of the device," she said.

The fact that Rhode Island is the smallest state in the union “sometimes allows us to be a laboratory for other states,” said Joseph Wendelken, the spokesperson for the health department.

The group has installed 44 boxes so far, in homeless shelters, addiction clinics, and three public libraries. Soon, advocates hope to also place them in fast food restaurants.

‘It’s not about encouraging addiction’

At Adams Public Library on a Friday morning, Annajane Yolken is training a group of librarians on how to administer naloxone.

“I really equate it to CPR,” she said, describing the sounds of gurgled snoring, which is one indicator of a potential opioid overdose. Yolken encourages the librarians to practice knocking on the door if anyone stays in the bathroom for more than five minutes, and always to have a bathroom key on hand. Yolken, the Executive Director of Protect Families First, received a mini-grant from the state to supply and train people in public spaces to use naloxone.

Rhode Island, like much of the U.S., has seen its rate of overdoses from opioids spike. According to DPH in 2011 there were 173 fatal drug overdoses in the state, by 2016 that number had nearly doubled.

Wendelken attributes the jump to new supplies of heroin, and its more potent cousin, fentanyl—a synthetic opioid between 50 and 100 times more powerful than heroin—often substituted for heroin unbeknownst to users.

“When you buy drugs it’s not like there is an ingredients list,” said Yolken during her training, adding that those who have recently been incarcerated or in recovery are also at a higher risk of overdose.

Eileen Hayes, the director of Amos House, a shelter and soup kitchen for those struggling with addiction, in Upper South Providence, said that many users now carry the anti-overdose medication with them. Amos House was one of the first places to install a NaloxBox earlier this summer.

“It’s really a scary time,” said Hayes of the opioid epidemic. When she first began her work at Amos House 17 years ago, she was mainly treating crack and cocaine users. The problem with opioids, specifically fentanyl, is that people die much faster.

She said Amos House has found success after training and supplying employees with naloxone last year. The first woman the agency administered the drug to, after she overdosed in the bathroom, is now staff at the agency; another man is clean after he was revived from an overdose by six doses of naloxone, said Hayes, rattling off a list of people she knows whose lives have been saved by the drug.

Hayes has heard criticism from people who believe widely distributing the medication could incite people to use drugs, but she said that argument is akin to the belief that “if you let teenagers have birth control you are encouraging them to have sex.”

“It really is about life and death. It is not about encouraging addiction,” said Hayes. “We really have to help people through the crisis for them to begin to get help.”

Hayes said supplying addiction counselors and distributing the antidote to users, doesn’t go far enough.

“It could be the dining room manager who finds someone who overdosed,” she said, adding that unlike in homeless shelters, it is less likely that librarians or restaurant workers have the medication on hand, which is when NaloxBox is most likely to save lives.

Yolken said she has hit roadblocks when trying to install the boxes in restaurants, despite support from local managers. “Things got stalled when they needed to have approval from a national legal team or the franchise owner,” she said.

Capraro and Rébola intend to get the boxes installed in a wider variety of places. Out of the 44 boxes installed, two have already needed to be refilled, and Capraro can confirm at least one instance where a bystander used the supplies to save someone’s life—though he declined to state which location due to privacy concerns.

Cindy Muhlback, the director at the Adams Public Library, said she has not had any overdoses in the library yet, though she knows colleagues who have. At the very least, said Muhlback, NaloxBox “shows that the library cares about people, which we do.”

This article is part of our project, “The Diagnosis,” which is supported by a grant from the Robert Wood Johnson Foundation.

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