CADDO MILLS, Texas -- Callie Crow stood in a small room in the Caddo Mills Police Department in front of eight officers - the city's entire police force at the time - and demonstrated how to save a life with a simple nasal spray.
The video above is from a previous report.
She held the bottle close to her nose and compared it to run-of-the-mill allergy spray: Once you put the nozzle into a person's nose, you simply press the plunger in to release the dose of naloxone, a drug also known as Narcan that reverses and blocks the effects of opioids.
"Narcan cannot hurt someone," Crow, a paramedic of 27 years, stressed. "If you give this in a situation when it's not an opioid overdose, it does nothing."
And, she added, people who deploy Narcan to try to save someone from an overdose face no liability in Texas. The eyes of the officers widened. They scratched down notes on their pads.
"You can't get in trouble. You can't hurt anyone," Crow said. "It's pretty simple, it's like a no-brainer."
During the training event in late March in northeast Texas, Crow gave the police department 12 Narcan kits.
"Your device is the most simple one, and it's like gold," she told the group.
Then, her voice saddened. "You guys are my second-to-last training, and now there's no more in the entire state."
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For years, Crow and her charity, Drew's 27 Chains, have depended on a federally funded state program run out of the UT Health San Antonio School of Nursing for free Narcan. But in January, the program ran out of money for the fiscal year, which began in September.
Since then, Crow and her charity have been unable to access more. That means the free training Crow and other groups like hers regularly put on for law enforcement across the state and other first responders has been halted for months.
While large police departments in metro areas like Houston and Dallas can pay for the high cost of the drug from their budgets, smaller nonprofits and law enforcement agencies do not have big enough budgets to pay for naloxone out of pocket.
"Everybody that's been providing this training over the last few years, we're all out," said Joy Alonzo, co-chair of the Opioid Task Force at Texas A&M University in College Station. "We're kind of on our own."
For the advocates, the state program could not have run out of the drug at a worse time. Opioid overdoses continue to rise nationally. The Centers for Disease Control and Prevention announced in May that a record-breaking 107,000 people had died from overdoses in 2021. That's a 15% increase from 2020, which itself saw a 30% increase from the year before.
"Not a day goes by that I don't receive a desperate request for low or no-cost nasal naloxone from health departments, first responders, health systems, community pharmacies, you name it," Alonzo said. "All say the same thing, there aren't any low or no-cost options, and their patients can't pay $135 for a naloxone rescue kit."
That has led to calls for Texas to do more to make the treatment easily available to law enforcement and regular Texans, including by putting some of the state's own money into the program instead of relying on federal grants
State leaders like Gov. Greg Abbott have focused intensely on opioids in recent months, but mainly by highlighting efforts to fight the smuggling of fentanyl, a powerful synthetic opioid, through Texas' southern border. Abbott's Operation Lone Star has devoted billions of dollars to stopping the drug's flow into Texas.
In a July news conference, Abbott blamed the Biden administration for what he called a growing fentanyl crisis and touted the work of the Department of Public Safety's Houston crime lab, which tests counterfeit drugs.
"Because of President Biden's open border policies, deadly fentanyl is flooding America, with enough seized lethal doses to kill almost every man, woman, and child in the nation," Abbott said.
But state leaders have paid considerably less attention to providing first responders the training to prevent overdoses once they happen.
"We've got less Narcan going out and there's more overdoses taking place. That's a bad formula," said Charles Thibodeaux, a licensed chemical dependency counselor who co-founded the Texas Overdose Naloxone Initiative in Austin. "The state of Texas needs to step in, the Department of Health and Human Services needs to step in, and see to it that their constituents have access to lifesaving medication."
"It's made a huge impact"
For Crow, training people on the life-saving possibilities of naloxone is personal.
Her organization is named after her son, Drew, who died of an opioid overdose in June 2020. It's called Drew's 27 Chains because its first event was a disc golf charity event in which the baskets are made of chains. The 27 commemorates Drew's age when he died.
As part of the event, Crow gave out free Narcan kits and trained people on how to use them. She thought the effort would end there, but in the weeks after, she received multiple requests by police departments to do training for them.
With the help of the UT Health San Antonio program, Crow put on up to four trainings a week for first responders and civic groups, in which she gave participants Narcan free of charge. Crow tracks every new report of a life saved by a Narcan kit she gave away - 30 so far.
"It's made a huge impact because it doesn't just impact that one person but their entire family," she said. "That's the purpose, to make sure that another family doesn't have to go through what we've been through."
One of the most satisfying parts was teaching police departments how to use naloxone. The police officer who had responded to Drew's death had Narcan on his belt, but did not use it, she said. Instead, he waited until paramedics arrived to treat him. In the seven minutes that took, Drew went into cardiac arrest. He ultimately died.
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"I don't blame that officer at all," Crow said. "I believe in Drew's purpose. Drew is touching a lot of people and giving his story is also very therapeutic."
The demand for training sessions was so high that Crow quit her ambulance job in late 2020 and, with funding from her mother, devoted herself full time to the charity. Since then, she's trained more than 60 different police departments on how to use Narcan - mostly smaller agencies that don't have the resources to pay for the drug on their own - along with volunteer fire departments and church groups. She estimates she's given away nearly half a million dollars worth of Narcan.
But after the state's free Narcan program ran out of funds this year, Crow had no place to get it. As a small charity, Crow didn't have the funds to pay for naloxone at its market price and could not supply it to the groups she trained.
As her funds have dried up, she's halted the trainings and has had to return to her job as a paramedic. With no Narcan to give out and little time outside her day job to devote to the charity, she's all but dissolved Drew's 27 Chains.
High demand, not enough money
The state's free supply has dried up for a confluence of reasons. In 2017, Texas Health and Human Services started the Texas Targeted Opioid Response program, a public health initiative to combat the opioid crisis in the state. The program, which works to expand access to prevention, early intervention, treatment, and long-term recovery support, was federally funded by the Substance Abuse and Mental Health Services Administration.
Part of the overdose prevention effort is a grant-funded naloxone distribution program, which was contracted out to UT Health San Antonio School of Nursing and dubbed the "More Narcan Please" program. The program gave out free Narcan, a godsend to harm reduction groups and small town first responder agencies which did not have the budget to pay for the drug on their own. One two-dose kit could cost upwards of $125.
During its first four years, Narcan flowed freely to the harm reduction groups. Adan Dominguez, the program director at El Paso's opioid crisis center Punto de Partida, estimates he's received more than 4,000 doses since its start. Alonzo, the A&M task force co-chair, said she's given out an estimated $4.5 million worth of the drug. Ty Bishop, a Health and Human Services spokesperson, said the Texas Targeted Opioid Response had distributed more than 263,357 units of naloxone, each of which has two doses, between March 2019 and May 2022.
At first, law enforcement agencies were hesitant to use Narcan. They feared their officers would be liable if something went wrong and many were duped by a viral internet video that said just touching fentanyl could cause officers to overdose. That video was widely debunked, but continues to hold sway in many law enforcement circles.
But a push by harm reduction groups to educate first responders on how to reverse opioid overdoses led to many police departments learning that fentanyl could not be absorbed through the skin and that touching the substance would not cause them to overdose. They also learned that in 2015, the Legislature had passed a law to protect first responders from liability if they used naloxone to try to bring back a person from an opioid overdose.
That led more law enforcement officers, first responders, and harm reduction groups to start asking for Narcan from the nursing school's program. As the opioid crisis continued to rage, the program, in a sense, became a victim of its own success.
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"Over time, the demand has grown and the overdose crisis has gotten dramatically worse so I think that police departments and volunteer fire departments that never thought they wanted it or needed it before, now they want it," Alonzo said. "Everybody now wants to be part of the solution and there's a finite amount of money there."
But it wasn't just the high demand. The state had also planned to purchase a much cheaper intramuscular version of naloxone, which is taken by injection, to stretch its grant funding further. A shortage of the intramuscular version in 2021 forced the state to buy the much more expensive intranasal naloxone, which caused it to drain its funds within months of that year's grant funding, Bishop said.
A dose of intramuscular naloxone costs between $1 and $25 a unit, while a kit of two doses of Narcan can cost more than $125. Even at the state's negotiated rate of $75 a kit for Narcan, the cost for intranasal naloxone was far higher.
The state's federal grant for the program was also smaller than the previous year.
The money granted to the Texas Targeted Opioid Response every year varies depending on how much the Substance Abuse and Mental Health Services Administration gives to the state's Health and Human Services Commission. A chunk of that money is then given to the naloxone distribution program.
For the 2022 fiscal year, which began last September, the naloxone distribution program received $4.65 million. It had received just shy of $6 million the year before.
The $4.65 million was supposed to last for the entire year. But by January, the program had spent all its money and the More Narcan Please program posted a notice on its website that it was not accepting any new naloxone requests.
"Now they want it"
The lack of Narcan hit the harm reduction programs hard. They'd spent years teaching law enforcement agencies, first responders and the drug users they interacted with about the drug's life-saving effects. Now, when those groups came to them wanting more, they had no supply.
"At first it was a lot of Narcan with very few takers," Dominguez said. "Now they want it and now we ran out."
Harm reduction groups and smaller police agencies can apply for other private or government grants to pay for naloxone or can purchase the drug themselves from vendors. But harm reduction experts say the grants are not easy to come by in the state.
"I've been applying for more money ever since I can remember," Alonzo said. "I never planned to be dependent on (the More Narcan Please program), but it turns out in Texas it's not so easy to get grant money for substance use or opioid use disorder in general."
Lt. Jason Burns, who is the grant writer for the Caddo Mills Police Department, said looking for naloxone grants on top of his daily workload was untenable and his agency did not have the funds to pay for the drug out of pocket.
"We're not going to be able to pay $180 a box. So what do we do once we're done? There's lots of other things that we have to buy in the budget and Narcan's not going to be on that list," he said. "I would love to have it there, obviously. But ammunition is going to come before Narcan, you know, vests, any other tools or uniforms."
Dominguez said his group is working with El Paso's mental health authority to keep Punto de Partida's Narcan supply flowing, but it won't make up for the numbers the crisis center used to get from the state.
"We're not going to get 4,000 doses from them," Dominguez said.
Where Punto de Partida used to get their supply free from UT Health San Antonio, the nonprofit is now buying it from its local mental health authority at $75 a kit.
Bishop said the state's contract will be up for renewal in September.
"In the meantime, HHSC is working with other TTOR contractors to purchase and distribute naloxone through their programs," she said in an email. "We have also identified funds that will be added to the current budget by the end of this summer."
The More Narcan Please program is also asking organizations that haven't used the naloxone they've received to return it to the state. By April, Bishop said, those requests had yielded 700 naloxone kits.
In the meantime, some harm reduction groups have resorted to giving out expired naloxone to drug users who could benefit from them. Naloxone has an expiration date of two years, but has been known to work for up to 20 to 30 years. Law enforcement agencies and first responders, however, can't take the expired medicine for public use.
Alonzo, the opioid task force expert, said the program has worked as intended in getting naloxone out to people who can use it in life-threatening situations and praised its leadership.
But she said the situation shows the folly in tackling a public health problem through grants rather than a sustainable source of funding from the state's government.
"That's a very poor sustainability strategy," she said.
She said the state should allocate a steady stream of funding for the naloxone distribution program in its budget.
In 2019, the state created the "Opioid Antagonist Grant Program" and allocated $500,000 toward it. But only four police departments received funds from the program - mostly from the Houston area which the program's creator, Sen. Joan Huffman, R-Houston, represents. About $11,000 of the grant's programs were not used.
The Legislature did not fund the program in 2021 and it ceased to exist.
Other harm reduction specialists are frustrated that Texas leaders have not prioritized spending more state dollars to provide free naloxone.
"It's bullshit being the largest state in the nation and not having Narcan available. More people died of opioid overdose than cars, guns and violence," Thibodeaux said. "There's a cure for it and we're putting millions and millions of dollars at the border and there's no Narcan."
Last year, Abbott made $100 million available in grants for his border security efforts called Operation Lone Star. About $58 million of those have already been fulfilled, but $42 million remain available. Last month, Abbott made another $30 million in grants available for border security programs.
At the Caddo Mills Police Department training in March, officers walked up to Crow after the event and lamented that she'd have no more access to free Narcan to help agencies like theirs.
That morning, the police department had been asked to respond to a person who authorities believed had mixed fentanyl with other drugs, Police Chief Kimbre Collier said. Because of the training, Collier said, her department would know how to respond to such calls in the future.
That kind of training was invaluable, she said.
"I would like to see her funding return," Collier said. "That everyone's funding return - to save lives."
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