Books, internet, naloxone? How Utah libraries created a ‘culture shift’ around opioid addiction

Anyone can walk into a branch of the Salt Lake County Library and get free naloxone.

(Francisco Kjolseth | The Salt Lake Tribune) Dr. Jennifer Plumb, medical director of the nonprofit organization Utah Naloxone, opens up a kit to reveal its contents on Tuesday, Oct. 12, 2021.

Editor’s note: This story discusses opioid misuse and addiction. If you or someone you know is at risk of an opioid overdose, visit UtahNaloxone.org or your local public library to obtain free naloxone. If you or someone you know are in need of medical services, visit the Utah Naloxone Wellness Center, aka Andy’s.

Walking into a public library and requesting naloxone feels a bit like being in on a secret. But the experience is as normal as picking up a book on hold — except you leave with the ability to reverse an opioid overdose.

An overdose happens when the level of opioids in a person’s system gets too high, which slows or stops their breathing. Opioids include prescription painkillers, fentanyl and heroin. Administering naloxone, an opioid reversal drug, can restore normal breathing within minutes as it blocks opioid receptors in the brain.

More than 10 Utahns die from an opioid-related overdose each week. Utah’s 2014 naloxone access law, along with an amendment passed in 2016, made it legal for any individual to provide naloxone to another person or administer it if they believed that person was overdosing.

But the law alone wasn’t enough to get naloxone into the hands of people who needed it, according to Dr. Jennifer Plumb, medical director of the nonprofit organization Utah Naloxone. That’s where libraries came in.

(Francisco Kjolseth | The Salt Lake Tribune) Dr. Jennifer Plumb, medical director of Utah Naloxone, pictured on Tuesday, Oct. 12, 2021, founded the organization with her brother Sam as a “rescue mission” to get the life-saving medication into the hands of as many people as possible.

Naloxone has been distributed for free at all 18 Salt Lake County Library branches since 2018. The drug is distributed in two-dose “rescue kits.” Today, it’s also available at all eight branches of the Salt Lake City Public Library system, as well as four libraries in Utah County — in Eagle Mountain, Saratoga Springs, Spanish Fork and Salem. It’s also available in Utah State Library bookmobiles, which serve eight rural Utah counties, as well as Utah County.

To date, Utah Naloxone has distributed more than 5,000 kits to libraries. The Salt Lake County Library gives out about 500 to 600 kits to residents annually, which would’ve been unheard of a few years ago. Opioid abuse and treatment — and by extension, naloxone — is often surrounded by stigma, “because there’s a lot of shame associated with it,” Plumb said.

But putting naloxone in a safe, neutral space as “normal and mainstream as a library,” she said, created an “enormous culture shift.”

No questions asked

To get naloxone through the library system, all you have to do is ask. When a Tribune reporter requested a rescue kit at the Day-Riverside branch in Rose Park, the librarian only asked if anyone was in danger, then provided the kit and said all instructions were inside.

When libraries were shut down because of COVID-19 restrictions, patrons could still request a naloxone kit with their curbside pickup orders.

Plumb noted that Utah Naloxone has recently had to halve the number of kits it can supply to facilities amid a nationwide shortage of affordable naloxone. But “we have not cut library supply at this time,” she said in an email.

Each rescue kit, packaged in a zip-close bag, contains a dark inner bag with two single-use syringes and two small vials of naloxone inside. A person who is overdosing should be given an entire 1 millimeter vial, injected straight into the muscle of the outer thigh or shoulder, the pamphlet states. Two doses are included in case the person does not respond to the first shot.

Signs of opioid overdose:

  • Not responsive, even if you rub their chest with your knuckles, shake them or call their name.

  • Breathing slows or stops. You may hear snoring sounds or a “death rattle.”

  • Lips and fingernails have a blue or gray tone.

  • Skin is pale and clammy.

  • Very small “pinpoint” pupils.

— “Opioid safety and how to use naloxone” pamphlet by Utah Naloxone.

The process of obtaining naloxone from a public library is discreet by design, Plumb said, because she knows firsthand that the stigma of opioid addiction and overdose can discourage people from intervening in case of an emergency.

When Plumb’s brother Andy overdosed on heroin in 1996, his friends had been too terrified to call for help and left him alone in a basement to die, Plumb said.

His death inspired her and her brother Sam to launch Utah Naloxone, a “rescue mission” to get the medication that could have saved Andy’s life into the hands of as many people as possible.

What to do if someone is overdosing on opioids:

  • If a person is showing overdose symptoms, call 911. If you have naloxone, administer it to the person.

  • If they don’t respond in three minutes, give them a second dose, which is provided in the kit available at area libraries.

  • Perform rescue breathing and/or give chest compressions.

  • Stay with the person until help arrives, in case they stop breathing again.

— “Opioid safety and how to use naloxone” pamphlet by Utah Naloxone.

When Utah Naloxone was founded in 2015, Utah’s naloxone access law had already been in place for about a year. But Plumb said she and Sam still weren’t seeing the medication being supplied and weren’t seeing people accessing it.

The problem, she discovered, was that it didn’t matter how many doctors were prescribing the medication and how many pharmacies were dispensing it. “The majority of people who really needed access to it were not going to ask their doctor for it, were not going to ask their pharmacist for it, were not going to have money to pay for it,” she said. They “were not even going to have that conversation.”

While distributing naloxone and providing syringe exchange services in Salt Lake City with her brother, she noticed people would open up to him, she said, but they could tell she was a doctor.

Many with opioid addictions “want to talk to someone that they’re comfortable with, that they feel, you know, not threatened by. That they don’t feel judged by,” she said.

And librarians are “totally nonthreatening,” she said.

‘They trust the librarians’

Former Salt Lake County Library marketing and communications manager Liz Sollis pushed for the branches to be equipped to distribute naloxone “because so many people access the library there in the community,” she said. And at the time, although naloxone was legal for people to administer and to receive prescriptions for, “a lot of people didn’t know how to go about it.”

From the beginning, the strategy to not collect any personal information from people was deliberate. “All I want is that they feel comfortable with naloxone,” Plumb said, instead of worrying about “ending up on a list.”

The program’s unofficial “no questions asked” policy can make it difficult to quantify its impact. But the Salt Lake County Library was one of eight public library systems nationwide whose responses to the opioid crisis were recently studied as part of a research project by the Public Library Association and the OCLC, a global library cooperative.

(Francisco Kjolseth | The Salt Lake Tribune) Dr. Jennifer Plumb, medical director of Utah Naloxone, who founded the organization with her brother Sam as a “rescue mission” to get the life-saving medication into the hands of as many people as possible, keeps a sticker on her truck as she continues her advocacy work.

In a 2019 report on the project’s findings, Salt Lake County stood out for a few reasons. At 817 deaths, it had the highest number of fatal drug overdoses per 100,000 people from 2015 to 2017, compared to other areas examined. The county library system also was the only one in the study to distribute naloxone to the public, through a partnership with Utah Naloxone.

In addition to giving out over 1,300 kits in that period, the Salt Lake County Library also trained its staff on topics including how to recognize an overdose, statistics on who is impacted by the opioid crisis, and how to administer naloxone.

In Salt Lake County specifically, the distribution of naloxone was so successful that the library system also now also gives out gun locks to help prevent suicide, through a partnership with the Utah Department of Public Safety. Other library systems have contacted the Salt Lake County Library, wanting to learn how they, too, can provide naloxone to people.

“We at the library think that this partnership and this program is a great success, because there’s obviously a need in our community to have this information and these life-saving resources,” Sara Neal, marketing and communications manager at the Salt Lake County Library, said in a statement. “It’s just so wonderful that we’re able to fulfill that community connection, to have [rescue kits] available to people.”

In the 2019 report, a county library manager cited trust as a major reason why people feel comfortable asking a librarian for help.

“Most people who are going to the library are looking for something to improve their life,” the unnamed person said in the report. “Maybe they want to teach their kid to read. Maybe they want to study to take a test. Maybe they need to escape from a domestic violence situation.

“The library can present resources to them in a way that is not abrasive,” the report continues. “It’s accessible, and they trust the librarians to ask for it. Because of this I think the opioid work is such a perfect fit.”

A community member who received a naloxone kit at a branch of the Salt Lake County Library is quoted in the research project report. “I live in a community shelter where there are a lot of opioids being abused, and I’ll get woken up at 3 o’clock in the morning with someone yelling, ‘Does anyone have Narcan?’” Narcan is a brand-name nasal spray form of naloxone.

“So it’s like it finally hit me,” the quote continues. “I need to start carrying it.”

(Francisco Kjolseth | The Salt Lake Tribune) Dr. Jennifer Plumb, medical director of the nonprofit organization Utah Naloxone, opens up a kit to reveal its contents on Tuesday, Oct. 12, 2021.

Before Salt Lake County libraries started giving out naloxone, Plumb described the secretive process she’d sometimes have to go through to get the medication to people in need. Using a prepaid “burner phone,” she’d arrange to meet individuals at a gas station or post office.

Now, she just points people to their local library. Having naloxone there has contributed to the “normalization” and “regularization” of it, she said.

The kind of person who might potentially save someone who is overdosing “isn’t just doctors,” she said. “It isn’t just people who arrive with sirens and badges.”

Oftentimes, it’s a friend who finds a drug user in crisis, or a parent, spouse or sibling, Plumb said.

“All of these folks have been lost,” she said. “We will have learned from losing them. And we will all step into that space where we can save lives.”

Correction • Oct. 20, 11 a.m.: This story has been updated to correct the title of Liz Sollis, who formerly worked as the marketing and communications manager for Salt Lake County Library.

Five facts about opioids and naloxone:

• Misusing prescription painkillers is not safer than heroin. “Just because something comes from a pharmacy doesn’t mean it’s safe,” said Jennifer Plumb, medical director of Utah Naloxone.

• Naloxone can’t harm a person who is overdosing on drugs other than opioids, according to the Centers for Disease Control and Prevention. It is better to administer it, even if you’re unsure.

• Naloxone cannot be used to get high. It’s a “one-job drug,” Plumb said, used only to reverse opioid overdoses.

• If you administer naloxone to another person, Utah law says you cannot be held legally responsible if you acted because you believed they were overdosing. However, you’re legally required to call 911 if you administer naloxone to someone.

• The risk of developing a dependency on opioids rises sharply after only five days of use, according to the Mayo Clinic.