The epidemic of overdoses from pills and heroin has hit Staten Island harder than anyplace else in New York City. Illustration by Chad Hagen

Joseph D’Agosto, a paramedic with the Fire Department’s 23rd E.M.S. Battalion, on Staten Island, is the best person in New York City. During his twenty-four years on the job, he has saved many lives—“hundreds, probably,” he says. D’Agosto is known throughout the department as an instructor in emergency medical techniques. When I went looking for him the other day at battalion headquarters, near the southern end of the island, one of his colleagues said he was out, called him on the phone, and told me an address where I could find him. Somehow I had the impression that D’Agosto would be conducting an instructional session, but he turned out to be getting a tattoo of an owl (“for wisdom”) on his left forearm at Contemporary Tattoo and Gallery, occasional workplace of his friend and E.M.S. colleague Josh Fitch, who was washing down D’Agosto’s arm for stencilling when I came in.

Staten Island has a lot of tattoo parlors, Italian delicatessens, two-story office buildings with empty spaces to rent, massage therapists, car services, Italian restaurants, places that give rock-music lessons and host children’s birthday parties, laundromats, liquor stores, tire shops, nail parlors, foot spas, pet-grooming salons, hair salons, barbershops (“buzz cuts, fades, tape-ups”). A small-business miscellany, sprung from the borough’s abundant middle-class life, lines the bigger roads like Hylan Boulevard from one end of the island to the other.

Most Staten Island enterprises are as their signs describe them. Occasionally, one or two storefronts that look no different from the rest also do a steady, word-of-mouth business in the illegal sale of OxyContin, oxycodone, Percocet, and other prescription painkillers. A neighborhood ice-cream truck playing its jingle might also be selling pills, according to police, who keep an eye on ice-cream trucks. A window-blinds and drapery store sold oxycodone pills until the N.Y.P.D. arrested one of the owners and the store closed. At a barbershop called Beyond Styles, on Giffords Lane, in the Great Kills neighborhood, police arrested the owner and two accomplices in October of 2013 for selling oxycodone and other drugs—two thousand pills a week, according to the Drug Enforcement Administration.

The silent sniper fire of overdoses from pills and heroin that has been picking people off one at a time in increasing numbers all over the country for almost twenty years has hit Staten Island harder than anyplace else in the city. For a number of reasons, this borough of four hundred and seventy thousand-plus people offers unusually good entry routes for the opioid epidemic. In 2012, thirty-six people on Staten Island overdosed on heroin and thirty-seven on prescription opioid pills, for an average of almost exactly one overdose death every five days. Many of the dead have been young people in their late teens to early thirties. In this self-contained place, everybody seems to know everybody, and the grief as the deaths accumulate has been frantic and terrified.

I wanted to talk to Joseph D’Agosto because he had recently appeared in the Staten Island Advance for saving an overdose victim. That alone would not have got him in the news, because he saves overdose victims with some frequency. What made this rescue different was that he used a nasal-spray syringe of a drug known as Narcan, whose name comes from the first syllables of “narcotic antagonist,” a term for opioids that reverse the action of other opioids. In Narcan, the antagonist drug is an opioid called naloxone. Like heroin, naloxone is highly soluble in the blood, and it acts almost instantly, reversing the effects of heroin or pain-relief opioid pills often in one or two minutes. Formerly, D’Agosto and other paramedics administered an intravenous dosage of naloxone to revive overdose victims; general use of the nasal-spray injector is something new.

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Josh Fitch traced the outline of the owl tattoo on D’Agosto’s arm, which D’Agosto extended as if getting an I.V. himself. “We received a call for an unresponsive person in the courtyard of an apartment building, early morning, around three or four o’clock, on a night shift last February,” D’Agosto told me. “The unresponsive person, a lady in her sixties, was slumped over on a bench, in like a robe or a housecoat. Near her we found a pill bottle for painkillers, almost empty, and I saw on the label that it had been filled only a week before. She was not breathing, lips blue, pupils miotic—pinpoint-size—all symptoms of opioid O.D. We put her head back, secured a breathing passage. I took the Narcan injector and sprayed a milligram of the naloxone solution in each nostril, and about a minute later she coughed and started breathing again. My partner that night, Henry Cordero, and I were, like, ‘O.K.! We figured it out!’ We put her on the stretcher and brought her to the hospital, and they took over from there.

“In the past, when we used the naloxone with the I.V., that worked, too, of course. But finding a vein for the I.V. can be difficult. Maybe the person was an I.V. drug user and he’s got collapsed veins in his arms. Maybe you’re in a dim hallway, family members around you crying and screaming—there it’s not as easy finding a vein as in a well-lit hospital room. Also, you have the problem of when they come to, sometimes they get agitated and want to fight you, and with the I.V. there can be a danger of a needle stick from someone who may have a disease. With the Narcan atomizer, none of that is a problem, and anybody can use it. You don’t need a special skill—you just spray it in the nose. And everybody’s got a nose.”

The Narcan nasal-spray program began in Staten Island’s 120th Precinct in January. All first responders—police and firefighters, along with the E.M.T.s—received Narcan syringes and instruction on how to use them. Including the police was important, because they usually get to the scene first, and speed counts; when an overdose victim stops breathing, brain damage begins in four to six minutes and death soon follows. By March, responders with Narcan had saved three overdose victims in the precinct. City higher-ups decided to extend the program to the rest of the borough and, soon afterward, to the rest of the city. More Narcan-produced rescues followed. In June, Governor Andrew Cuomo announced that the Narcan kits would be given to every first-responder unit in the state.

It used to be that the medical profession undertreated pain. Doctors didn’t want to create opioid addicts, and the consensus was that patients should suffer rather than risk addiction. That started to change in the seventies, with the rise of the pain-management movement, when pain came to be seen not only as a symptom but as an illness in itself. Now the worry was of “opiophobia.” A widely used pharmaceuticals textbook advised, “Although many physicians are concerned about ‘creating addicts,’ very few individuals begin their drug addiction problems by misuse of prescription drugs. . . . Fear of producing such medical addicts results in needless suffering among patients with pain.”

Strong opioids like morphine or oxycodone already existed for patients with intense, short-term pain from healing trauma or end-of-life illnesses. Long-term, chronic pain was another matter—no existing drug was ideal for that. Seeing the need, Purdue Frederick, a pharmaceutical company in Norwalk, Connecticut, developed a long-term pain reliever called MS Contin, which was a morphine pill with a time-release formula. When the patent ran out on MS Contin, Purdue introduced a time-release oxycodone pill, OxyContin.