The man lay on a bedroom floor between an Xbox and a puddle of spilled water.
His eyes were closed, feet splayed. The only movement came from the police officer next to him who was repeatedly pushing so hard on the man’s bare chest it seemed to sink down to the floor boards.
Hannah Rost took in the scene as she stepped through the door.
Rost, 32, was now the third La Mesa officer inside the suburban home, and she thought the man lying at her feet looked several years younger.
“Not breathing at all?” Rost asked, according to body camera footage.
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The man’s olive skin had a bluish tinge and whoever had called 911 thought fentanyl, a powerful pain reliever, was the cause. Rost snapped on gloves. She already had a small plastic container marked “Narcan Nasal Spray” in hand.
The substance inside, known as naloxone, has become perhaps the most prominent tool for reversing opioid overdoses. The federal government allows the spray to be used without prescription and San Diego County has made it available, for free, in vending machines around the region. Local jails carry it. So do schools.
It’s in near constant use. Medics in Escondido deployed Narcan more than 180 times last year, officials said. East County’s Heartland Fire and Rescue needed 200-plus doses during the same period. Chula Vista carried naloxone to 426 potential overdoses while San Diego’s fire department administered it nearly 4,500 times.
None of those numbers include police, nor do they capture overdoses treated without first responders. In 2023, San Diego County helped publicly distribute more than 84,800 spray containers.
When Rost was first equipped with Narcan a few years ago, she wasn’t sure it could really bring somebody on the brink of death back to life. Because there was no way to immediately know why this man had stopped breathing on a Tuesday afternoon last July, Rost couldn’t be sure it would work now.
The officer placed two fingers on top of the container and a thumb below. She slipped the nozzle into the man’s nose and pushed a long red button.
Liquid burst from the tip. The fluid’s speed exceeded 30 feet per second, about as fast as a boxer’s fist.
Millions of molecules shot forward. They were followed by a billion. Then a trillion. One over-the-counter container of Narcan contains molecules in the quintillions, a number requiring eighteen zeros, and each sailed into the nasal cavity like stones hurled at the night sky.
The naloxone barreled past hair and mucus before sliding between the man’s skin cells. They were now inside his body.
Less than one second had passed. Rost still had the spray container in the man’s nose.
The world naloxone entered was dark, wet and loud. The decibel level inside a human body can exceed that of a vacuum cleaner, and much of the roar comes from the blood. Adults have about 60,000 miles of vessels, enough to twice wrap around the Earth, and that blood flow was naloxone’s best way forward.
The molecules squeezed into the man’s capillaries and were swept deeper in. Some sped toward the heart and were pumped out to his chest and arms and toes, but the only place they needed to go was one cluster of nerve cells a few inches behind the nose.
Look at your hand. Now imagine the fingers are fraying at the tips, like old rope, and that your arm is disconcertingly thin. That’s roughly the shape of a nerve cell, or neuron.
There are billions in the brain, a dense labyrinth passing information left and right, and the group atop the spinal cord is especially important. This area, known as the medulla oblongata, serves as your control tower for breathing.
Holding your breath underwater? Those nerve cells help shout: Swim to the surface. Getting lightheaded? Time to exhale.
The man’s medulla was not doing this job. Something had found a way to turn off those cells.
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A neuron’s “fingers” feature tiny openings, called receptors. Opioids are designed to land on receptors, float back out and then dip in again, a process that only takes around a thousandth of a second. Yet that’s enough time to cause a debilitating chain reaction.
Proteins are released inside the nerve cell, potassium can be forced out and calcium is blocked from entering altogether, all of which slows a neuron’s ability to pass along signals.
Said another way, it’s like the opioid’s whispering: Slow down.
The fact that opioids can “talk” to neurons isn’t always bad. Slowing pain signals decreases pain. But when someone takes too much OxyContin or heroin or fentanyl, the drugs bash into so many neurons and attach to so many receptors that all sorts of signals can end up blocked, including breathing.
You can last only a few minutes with limited oxygen before brain cells start to die.
Rost pulled the nozzle out of the man’s nose.
The naloxone rushed through his capillaries, passed again through vessel walls and spilled into the medulla. A claustrophobic solar system was waiting.
To a naloxone molecule, each neuron would have loomed like a planet. And if Rost was correct, and the man had overdosed on fentanyl, those planets were surrounded by opioids.
The naloxone couldn’t destroy the drug. It was unable to force calcium back into neurons or order lungs to suck in air. It wasn’t really capable of doing anything.
Except playing defense.
Naloxone fits receptors even better than opioids. If, through sheer force of numbers, the molecules could plug enough holes and thereby keep out the drugs, even temporarily, maybe the neurons could wake up enough so the man would know to breathe.
A cloud of naloxone grew inside his brain. The molecules ricocheted off each other and knocked into opioids and crashed onto neuronal surfaces until one happened to land on an exposed receptor. Another filled a different receptor. The cloud grew.
Outside the man’s body, medics from Heartland Fire and Rescue walked through the bedroom door and weaved around a keyboard and a skateboard and a basket of toiletries. Twenty-five seconds had passed since naloxone entered the body. “You guys wanna move him that way?” one asked. Rost grabbed a wrist. The man’s eyes were slits and his head floppy as officers adjusted his body.
Without warning he opened his mouth. “Eeeeguuuuuuuuuugh.” Air rushed into his lungs. He took a second breath. Then, silence.
Sixty seconds now. Seven people squeezed into the room. Wires appeared. A machine beeped. A young woman in pajama pants watched from the doorway, silently moving aside whenever someone needed to pass by.
Rost held the man’s head steady. The man was breathing again, but barely. Sometimes it sounded like air had to fight its way in while other breaths stopped halfway, as if his throat had been squeezed by an invisible hand.
Beep.
Naloxone dipped in and out of nerve cells. Some receptors were unguarded. Others were not.
Beep.
Four minutes. An oxygen machine turned on with a hiss. Voices drifted over the man’s body.
“I’m having trouble with his pulse ox.”
“His skin was super pale.”
Medics prepared to inject even more naloxone into an arm. Rost held the oxygen mask over the man’s face. Suddenly his body jerked. “Hold on, hold on, hold on bud,” Rost said, her voice getting softer. “Relax, relax, relax.”
She pulled back the mask. The man’s eyes scrunched.
“Sir.”
“Hey, wake up.”
“Let’s stay calm, OK?”
It looked like the naloxone was winning. This introduced a new problem.
When someone frequently uses opioids, their nerve cells notice that pain signals aren’t getting through. The neurons compensate by sending even stronger signals, which in turn require higher doses of drugs to ease the same level of pain.
Overdoses can happen when a person’s opioid tolerance has grown so much that only large amounts can dull neurons trying to fire on all cylinders. Using naloxone to restore signaling is like shifting a truck from “park” to “drive” while the gas pedal’s already on the floor.
You’re not just feeling pain and nausea and everything else that’s been suppressed. You’re feeling it all turned up to a level you might not have known existed.
Rost put a hand on the man’s head and stroked his hair with her thumb, gently at first, then more firmly as the man’s body again went still.
“We’re gonna pick you up, OK?” a voice said. “Just stay put.”
By this time the man was on a MegaMover, essentially a tarp with handles. Rost took the head. Three others gripped the sides and bottom and the man’s knees knocked together as he was lifted off the ground.
The young woman leaned over the tarp as it passed. “You’re OK, baby.”
The group was almost outside when the man writhed. They set him back down.
“Turn him.”
The man sat up.
“You guys got a puke bag or anything?”
“You’re OK, baby, you’re OK.”
The man stayed silent. It wasn’t clear how aware he was of the people around him.
“He’s trying to hold it.”
“Let it out.”
The man retched. Soon after, a hand appeared with a plastic bag. He spit into it.
“You’re OK, baby.”
Pain, however, was not the man’s biggest problem.
The body doesn’t know what naloxone is. New molecules swimming around the brain can be a threat, so substances called enzymes had long ago deployed inside the man to attack the intruders. The naloxone didn’t stand a chance.
Any molecules that escaped into his blood weren’t safe either. That naloxone eventually flowed into the liver, the body’s garbage disposal, and within a half-hour enough naloxone could be broken down for the opioids to resume their work.
The man’s body wanted to remove that drug, too. Yet opioids take longer to clear out, meaning that without medical aid the man could re-overdose purely from what was still floating in the back of his head.
Rost and the medics picked the man back up, walked into the sunlight and set him on a stretcher. It had taken 8 minutes and 19 seconds for the man to breathe on his own.
Once he was secure, the officer returned to the home.
“You think it’s fentanyl?” Rost asked the young woman. She responded, “No, I know it’s fentanyl.”
Rost asked where he kept his drugs. The woman lifted an arm, gestured toward the bedroom and then let her hand fall against a hip. “There’s stuff everywhere.”
Outside, the man was lifted into an ambulance.
Rost watched without speaking. She felt there was now a chance he’d live at least one more day.
A range of experts were interviewed about how naloxone works.
In alphabetical order: Lauren Alexander, a medical doctor on staff at the Point Loma Nazarene University wellness center; Liana Asatryan, assistant professor of clinical pharmacy at the University of Southern California; Aileen Chu, a pharmacist at Sharp and an adjunct professor at PLNU; Richard Clark, director of the medical toxicology division at UC San Diego Health; Gregory Collins, associate professor of pharmacology at The University of Texas Health Science Center at San Antonio; Daryl Davies, professor of clinical pharmacy at USC; Tori Espensen, a neuroscientist on staff at SciLine; Christopher Evans, director of the Shirley and Stefan Hatos Center for Neuropharmacology at UCLA; Kevin Maxwell, clinical associate professor at the University of San Diego.