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When Devyn Debarge overdosed on fentanyl two months ago, he woke up in an ambulance with his shirt cut open and electrodes stuck to his chest.

It took him a few minutes to realize what had happened and understand that if paramedics had not administered the opioid overdose reversal drug naloxone, he would have died.

“I thought I was waking up from a nap,” the 35-year-old said.

It’s during these often disorienting moments post-overdose that outreach workers with the Hawaii Health & Harm Reduction Center want to be present.

The nonprofit is pursuing a formal partnership with the Honolulu Emergency Services Department that would allow it to be notified whenever first responders attend to overdoses in public places, like sidewalks or parks. Through this collaboration, the agencies hope they can reach more people immediately after an overdose, connect them to resources, and, hopefully, get them into treatment.

“It’s trying to take something that could be one of the worst days, which is an overdose, and leverage it for more access to resources, support and for folks to, if they’re ready, willing or able, to get into treatment,” said Heather Lusk, executive director of the Health & Harm Reduction Center.

The partnership comes as fatal overdoses, particularly those caused by the synthetic opioid fentanyl, reached their highest point on record last year.

Critical Outreach

Fatal drug overdoses in the state have nearly doubled since 2014, according to the Hawaii Department of Health. There were 160 deadly overdoses in 2014 and 309 last year.

While most of these fatalities were caused by meth, fentanyl has been a rising culprit. The synthetic opioid caused just nine fatal overdoses in 2014 and 103 in 2023, according to the department.

Fentanyl has become increasingly prevalent because of its high potency, making it cheaper and easier to smuggle because so little is needed for users to get high, and it has been appearing in nearly every type of illicit drug, Lusk said.

Ian Santee, deputy director of the Emergency Services Department, said continued collaboration between paramedics; CORE, a program overseen by EMS that responses to non-violent, homelessness-related 911 calls, and the Health & Harm Reduction Center is essential as they try to tackle a growing crisis.

City lawyers are in the process of reviewing a business associate agreement between EMS and the Health & Harm Reduction Center that would allow the agencies to share data, including protected health information about patients.

While the Health & Harm Reduction Center already does some post-overdose outreach, its workers rely mainly on coconut wireless to find out when there’s been an overdose in the community. Lusk said a formal partnership with EMS would allow her outreach team to intercept more people in the critical moments after an overdose.

Some people who’ve overdosed don’t even want to interact with EMS after they’ve been revived because they may associate the agency with law enforcement, Lusk said.

According to the Department of Health, people who overdose and receive naloxone from friends or bystanders before EMS arrives are 88% more likely to refuse transport to a hospital once the ambulance gets there.

But they may be willing to interact with an outreach worker who could be someone they know personally or recognize from the community, said Mim Shukrun, who works in the Health & Harm Reduction Center’s syringe exchange van.

“These are our people, our community members,” she said.

Debarge, who was standing outside the syringe exchange van on a recent Tuesday in Chinatown, said community members know and trust the organization. Caseworkers last year helped him order his birth certificate from California and get an ID.

“They’re out there in the community and they’re reaching out for us,” he said. “They really do care.”

Having a trusted person on scene immediately after an overdose is vital, Lusk said, especially because those moments can be life-altering for some people.

Debarge’s overdose experience taught him that fentanyl was not a drug to mess with. He said he’s lost four friends recently to fentanyl overdoses.

“I was supposed to be one of those guys,” he said. “I’m like a miracle.”

But for others, an overdose doesn’t necessarily motivate them to want to stop using.

Mersadies Perez, 28, said she’s used naloxone to revive her boyfriend from overdoses 25 times. She’s also overdosed herself but never on fentanyl, she said.

People need to get to the root of their problems in order to make the decision to stop using drugs, she said.

Lusk said for those who aren’t ready to seek treatment, it’s important they continue to use safely until they’re ready to make that change. Outreach workers can help them by providing supplies, like naloxone, fentanyl test strips and clean needles. Some may see this kind of assistance as enabling, but Lusk, who is in recovery herself, says it’s life-saving.

“If you die of an overdose, you don’t have a chance of recovery,” she said. “And so I would hope that everybody believes that every life is worth saving so that people have the opportunity to recover and make different choices.”

Reducing Fatalities

One of the most important steps that can be taken to reduce fatalities is increasing access to naloxone, said Dan Galanis, epidemiologist with the Department of Health’s EMS and Injury Prevention Branch.

“Hopefully, eventually, they’ll be able to stop using these kinds of substances and recover from their addictions, but at the same time we’re also endorsing this harm reduction approach,” he said.

A that went into effect this year requiring establishments that serve alcohol to have naloxone on the premises was a step in the right direction, Santee said.

Lusk said her organization is also hoping to get more naloxone vending machines installed around the islands. There are already 30 , including at correctional centers and hospitals.

The machines, which cost around $8,000 each, dispense the medication at no cost to the consumer, Lusk said. The first 30 machines were purchased using a federal grant from the Centers for Disease Control and Prevention. The Department of Health was originally paying to stock the machines with naloxone, which costs about $25-30 per two-dose box, Lusk said. Now the doses are being paid for out of the state’s Opioid Settlement Fund.

About $1.8 million has been spent from the fund on naloxone purchases, according to the Department of Health. The fund has about $36 million currently, and $4.5 million has been spent or encumbered so far.

Honolulu has received around $1.3 million, which is managed by EMS, and Hawaii County is set to receive $478,400 in the coming weeks, according to the Department of Health. Maui and Kauai counties have also made requests for funds but have not received checks yet.

Advocates have complained the state has been slow to dole out the checks. The department said the process of reviewing a request and approving a check can take three to four months.

Lusk said she wishes the funds would be given out faster because the community is in crisis mode and overdoses occur nearly every day.

“There is kind of the collective grief, which I’m seeing in my staff, anybody that does this work,” she said. “We’re almost a decade in now. We’re just losing so many people.”

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