They bought $10 bags of the city's purest heroin and returned to their spot to shoot up. Suddenly, Thomas, a South Philly native, saw the man's skin turn gray and his lips turn blue. The man dropped to one knee, then the other. He had a pulse, but his breathing was faint, almost gone.
Thomas leaned over and breathed into the man's mouth, then yanked Narcan from his own pocket and stuck the syringe into the man's buttocks.
In about 30 seconds, the man's eyes popped open. He rolled over and started vomiting violently, because the drug had thrust him into painful withdrawal.
"He was real mad at me. I mean, really pissed," Thomas recalled. "But I didn't want to let him die."
The Daily News is withholding Thomas' last name because he is at an inpatient drug-treatment facility.
With the nation's opioid death rate skyrocketing, police officers, paramedics, and family members of addicts have been carrying Narcan to bring people back from heroin and prescription pill overdoses for several years.
But as more people outside the medical field, particularly addicts themselves, have gained access to naloxone, the prices for this antidote to death have soared in Pennsylvania and across the country.
In 2014 alone, one naloxone manufacturer raised its price by 50 percent, and another boosted its price by 60 percent, according to the U.S. Food and Drug Administration.
Pharmaceutical companies and pharmacists are now putting a price tag on heroin users' lives, and the Daily News found it can be as high as $187 in Philadelphia.
"The prices of naloxone are going up all the time," said Roland Lamb, director of the city's Office of Addiction Services for the Department of Behavioral Health and Intellectual disAbility Services.
"This is America. Whenever you have demand, you see price increases."
Order and chaos
Most people struggling with addiction who carry Narcan obtained it from social service agencies that typically get it from a wholesaler. But others who try to get it themselves at pharmacies are running into roadblocks.
In October, the state's physician general, Rachel Levine, signed a statewide standing order for naloxone, essentially giving everyone in Pennsylvania a prescription for the lifesaving drug.
"I did this because of the severity of the crisis," Levine said. "If you know your loved one is addicted, by the time 911 comes, it may be too late."
In theory, anyone should now be able to go to a pharmacist and obtain naloxone with Levine's standing order, but the Daily News found that was not the case.
Of three Rite Aid pharmacies and one CVS pharmacy visited recently in Frankford, only one Rite Aid, at 8445 Frankford Ave., was aware of Levine's standing order.
The other two Rite Aids and the CVS said a prescription from a physician would be required, despite the fact that a Rite Aid corporate spokeswoman wrote in an email: "Naloxone can be dispensed at any of our PA pharmacies without a prescription based on protocol."
A CVS spokesperson did not return a request for comment.
None of the pharmacies had naloxone in stock, but all said it could be ordered.
Pat Epple, executive director of the Pennsylvania Pharmacists Association, said some pharmacists may not have paid attention to news of the standing order, and others may be aware of it and wary.
"Standing orders are rare, and because of that there might be a bit of distrust," Epple said. "I think they get very nervous about that because the penalties are so severe."
When told that three out of four pharmacies visited weren't aware of her standing order, Levine said: "I think we'll redouble our efforts to get the word out."
At all costs
Pricing for naloxone, which is available in a syringe or as a nasal spray, varied wildly at the pharmacies visited.
A pharmacy employee at the Rite Aid at 9200 Frankford Ave. said a package of the naloxone nasal spray cost $187.
"I've never heard it be that high," Levine said of the quoted price. "That's disappointing."
Just down the street, another Rite Aid at 6363 Frankford Ave. quoted $54.99 for a package of two nasal sprays.
The Rite Aid spokeswoman said the chain's cost is usually about $120 for two doses and two aspirators.
The CVS at 8700 Frankford said the package of two nasal sprays costs $158.99.
Cost of the injectable syringes ranged also, with most around $25 for one dose or $55 for two.
Epple, of the pharmacists association, said that if pharmacists are conducting a cash sale for naloxone, they can set their own price.
Supplier and demand
Citizens aren't the only ones facing rising prices for naloxone.
Prevention Point, a Kensington-based multiservice public health organization, gets naloxone from a wholesaler. Last year, the agency paid about $80,000 for its supply.
Workers trained 1,100 people last year to administer Narcan and provided them with the doses, according to Silvana Mazzella, director of programs. That's up from about 600 or so the year before.
The majority were heroin users at risk of overdose, Mazzella said.
"We've chosen to give out naloxone despite the price increase because the need is there," Mazzella said. "We've been able to do so by not buying as many less-lifesaving medical supplies."
When Delaware County became the first in the state to equip all of its cops with naloxone in November 2014, the price from the pharmaceutical company Amphastar to the county for each 2mg dose was $22, said Delaware County District Attorney Jack Whelan.
Now, it's closer to $50, he said.
"We were the first to implement the program, so when I ordered it, there was not the supply-and-demand issue there is now," Whelan said. "The price has been driven up."
Two weeks ago, Delaware County announced it was switching its naloxone provider to Adapt Pharma, an Ireland-based company with offices in Radnor that just began producing nasal Narcan. Delaware County will pay $37 for a 4mg dose from Adapt.
In a separate announcement with Gov. Wolf last week, Adapt said it would give every public high school in Pennsylvania and the country a free dose of nasal Narcan. In September, Wolf and the state's secretary of education suggested that every school district in the state keep naloxone in stock.
A Philadelphia School District spokeswoman said the district does not stock naloxone and nobody was aware of any opioid-related overdoses or incidents at a district school within the last five years.
With demand for the drug increasing rapidly, public officials are concerned that prices are soaring.
Last March, presidential hopeful Sen. Bernie Sanders and Rep. Elijah Cummings wrote a scathing letter to Amphastar.
"The rapid increase in the cost of this lifesaving medication in such a short time frame is a significant public health concern," they wrote.
Amphastar did not return requests for comment, but in a letter from the company's lawyer to Sanders and Cummings, Amphastar attributed rising prices to increasing costs for "raw materials, energy, and labor."
But Daniel Raymond, policy director for the Harm Reduction Coalition, a national organization that focuses on health issues related to drug use, said there's another theory, too.
"There's a lot of suspicion that they increased their price as naloxone became more mainstream," he said.
Raymond said that as recently as 10 years ago, an injectable dose of Narcan - which was approved by the FDA in 1971 - was as cheap as $1 a shot. But in the last few years, as states have passed laws for greater access to naloxone, demand has exploded. Raymond hopes increasing competition in the market from companies like Adapt will affect pricing.
"Ideally, we'll start to see more competition," he said. "As we see more companies step in as producers, then we'll see prices stabilize."
OD deaths rising
The demand for naloxone has increased as the rate of opioid-related deaths has increased. Opioid overdoses are now the leading cause of accidental deaths in the state and the nation, killing more people each year than car accidents.
In 2014, 652 people died from drug overdoses in Philadelphia compared with 493 deaths in 2013. Toxicology tests detected heroin in a majority of those deaths, according to Lamb, of the Department of Behavioral Health and Intellectual disAbility Services.
In February 2015, the Philadelphia Police Department started equipping some of its officers with Narcan. Since that time, city cops have saved 121 people from overdosing, police said. Despite those saves, in the first half of 2015 - statistics for the full year are not yet available - 241 people who died of overdoses in Philadelphia had opioids in their system, according to city stats.
Even in Delaware County, where cops have saved 171 people with naloxone since November 2014, the number of opioid-related deaths has skyrocketed from 52 in 2014 to 101 in 2015.
"We're out there making all these strides, but we're still seeing an increase in deaths, not a decrease," Whelan said. "So we've seen the epidemic has taken off on us."
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