A couple weeks ago, Morgan Farrington heard loud, wheezing gasps coming from the other side of her bedroom wall.

They weren’t the typical noises a person might make when they sleep. For Farrington, who works on the front lines of the opioid epidemic, the sounds were chillingly familiar.

“I thought, that is not snoring,” Farrington said. “That is a death rattle.”

She grabbed some naloxone – also known as Narcan – and rushed into the room to administer the drug that blocks opioids and reverses overdoses. The person who had been staying with Farrington’s roommate survived. It was Farrington’s fourth rescue of the week, she said.

Farrington founded the organization Goodworks in Huntsville in 2019 to help people who use drugs by providing services under the broad umbrella of harm reduction. In places like San Francisco and Philadelphia, organizations and clinics doing that kind of work can provide an array of services including clean syringes, naloxone, testing for HIV and hepatitis and even a supervised space for using drugs.

Providing clean syringes to drug users in Alabama is illegal. So Farrington hoped to do something more modest. She wanted to train people how to use naloxone and distribute the treatment to people who use drugs and their loved ones.

She planned a party and made posters. Then someone told her she might want to investigate state law. That’s when Farrington found out only doctors, dentists, pharmacists and public health nurses could legally distribute naloxone in Alabama.

“Anybody can administer it,” Farrington said. “You just have to be somebody to pass it out.”

Deaths from overdoses have skyrocketed in Alabama during the pandemic, driven in large part by increasing amounts of fentanyl in the supply of illegal drugs. Naloxone is a critical tool in the fight against overdose deaths, a lifesaving antidote that can be administered as an injection or a nasal spray.

The number of drug overdose deaths in Alabama more than doubled between August 2016 and August 2022, according to the U.S. Centers for Disease Control and Prevention. The number of overdose deaths involving fentanyl increased from 453 in 2020 to 1,069 in 2021, according to the 2023 Drug Threat Assessment report from the Gulf Coast High Intensity Drug Trafficking Area Operations Center.

Today Farrington occasionally ventures into Huntsville’s homeless encampments to check on residents. She will examine wounds to look for infections, offer fentanyl test strips and rides to medical clinics and other services. Alabama law won’t allow her to hand out naloxone, even though homeless addicts are among the most vulnerable to fatal overdose.

But many of those she helps aren’t homeless and don’t live on the street. Addiction exists in all corners of Huntsville, she said, although it may look different in Jones Valley than it does down at the homeless camp.

“This is a city that’s got a lot of people with new money,” Farrington said. “So, it’s got a lot of closet opioid use and it’s a lot of prescription opioid use. There’s a big fissure between the people with prescription opioid use and people who have dealers.”

Making naloxone more accessible

Public health departments in Alabama have been at the forefront of efforts to increase access to naloxone. Both the Alabama Department of Public Health and the Jefferson County Department of Health offer free naloxone and training in how to use it.

Those systems work well for some drug users and family members with stable addresses and the ability to get the treatment in the mail. However, not everyone can order online or attend training sessions.

Dr. Darlene Traffanstedt, medical director for the Jefferson County Department of Health, said the agency can send free naloxone to anyone in the state who visits its online portal. The department also offers naloxone at in-person events and to people who request it at the health department building.

Other states in the South, including Tennessee and North Carolina, had revised their laws to allow community groups to distribute the medication.

“In North Carolina, a physician or pharmacist can dispense to a community-based organization and the community-based organization can distribute to the public,” Traffanstedt said. “So there are states that have gotten very creative with how their law is written and how their programs are implemented to allow community-based organizations to distribute naloxone.”

Although experts in addiction treatment have pushed to loosen Alabama law in the past, this year changes to the way certain types of naloxone are sold could make legislation unnecessary, Traffanstedt said. The company that makes Narcan has asked the U.S. Food and Drug Administration to allow the drug to be sold over the counter. Alabama’s restrictions on prescription naloxone wouldn’t apply to over-the-counter products, which could be purchased and distributed by community organizations.

Leaders of the Medical Association of the State of Alabama have come out in favor of the change, which could happen by the end of the month.

“At a time when Alabama and all states are seeing a surge in fentanyl overdose deaths, increasing access to naloxone will save lives,” said Dr. Julia Boothe, president of the Medical Association of the State of Alabama, in a statement. “Doctors in Alabama applaud the independent advisors’ unanimous decision and are hopeful the FDA will follow through and make Narcan available over the counter.”

That change could make it easier to get the antidote into the right hands, but it won’t reduce all barriers, she said.

“Typically, when things first go over the counter, the costs remain fairly high and then as additional generics or other competitors come to the market, the price goes down,” Traffanstedt said. “Our department does not plan to stop providing free naloxone.”

Harm reduction

Farrington first learned about naloxone when she was living in New Orleans. At the time, she worked as a bartender and spent a lot of time around people who drank and used drugs, and also used substances herself.

Someone introduced her to the idea of harm reduction – where people work to improve the safety of drug use without encouraging it or discouraging it. Harm reduction efforts, such as providing clean syringes, can help prevent outbreaks of infectious diseases to keep users and the community healthy. Farrington learned about naloxone, which was widely available and distributed by volunteers in the Big Easy

Soon after she learned how to use naloxone, a friend overdosed. Farrington used the medication to revive her.

“It was terrifying,” Farrington said. “I didn’t sleep for about another 36 hours after that. It was like a friend of mine and she was purple on the floor. It was horrible. I’ve never seen anything like it before.”

Farrington trained as an EMT, learning emergency care and CPR. She hoped to bring those skills to Huntsville.

She soon found a deep hostility to the philosophy of harm reduction. Instead, Alabama political leaders tend to treat the opioid epidemic as a criminal issue. So Farrington stopped talking about harm reduction and focused instead on improving naloxone distribution.

“I’m not hoping to change the worldview of the state, I just want to make it less illegal for me to keep people alive,” she said.

Fighting overdose by fighting stigma

Patrick Bezotte, a friend of Farrington’s, has struggled with substance use disorder for years. Naloxone has saved his life several times, and he credits Farrington for educating him and other users about the importance of the medication.

“These new drugs are way more dangerous than any of the other ones and I wasn’t prepared for it at all,” Bezotte said. “My life’s been saved four times. I usually keep Narcan on me as long as I can get a hold of it.”

Critics of harm reduction and easier access to naloxone say easy access to the medication encourages users to engage in risks and avoid consequences. One controversial study found that access to the treatment might be linked to increasing numbers of emergency room visits for opioid overdoses.

Bezotte said he feels like the people who hold those opinions don’t believe his life is worth saving. When naloxone is available, the biggest risks happen when people use alone.

“I’ve lost some people really close,” Bezotte said. “I’ve figured out that if there’s someone who really cares about them around, people usually survive.”

Farrington said people who are ashamed of their drug use are more likely to use by themselves. Supporting people who are actively using may help them feel their life have value, which is a critical first step on the road to recovery.

“Narcan enables breathing,” Farrington said. “That’s the truth. I for one am a proponent of inhalation. It’s a lot harder to get to the other side of that binary of sober or need to be sober if you’re dead. You can’t get sober if you’re dead.”