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As Hurricane Irma was heading toward Florida, Dr. Hensel Tookes and his team were handing out clean needles and Narcan, a drug that can reverse the effects of opioids, to residents of Miami.

The impending storm meant that people in recovery could lose access to their medications and with the added stress, they could turn to heroin or fentanyl and possibly overdose. By handing out Narcan and clean needles, Tookes was hoping to prevent overdoses.

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Hurricane Irma on September 10, right before landfall on Florida

“Hurricanes are stressful, but I think my major concern was people who were reliant on medication-assisted treatment, especially Suboxone and methadone, would not have access to those services in the event of a major storm,” he said, “and therefore would be likely to use heroin and have a risk for overdose because the heroin and the fentanyl on the streets is an extremely powerful combination.”

The Miami needle exchange program, as well as other efforts in Florida, seemed to work, he said. While he did not hear of any reports of the Narcan being used at shelters, others who used the needle exchange program reported that they had used Narcan to revive people in their communities.

“Our participants were truly the first responders to their communities, which was great,” Tookes said.

Giving out Narcan was a suggestion of the National Harm Reduction Coalition, Tookes said, but it was also based on others’ previous experiences with hurricanes. Houston had just been hit by Harvey, and Sandy in 2012 left behind lessons for addressing the opioid problem.

“We were very prepared for Hurricane Irma as a state as a whole,” Tookes said.

Shelters in Palm Beach County, Florida, had overdoses, according to local news coverage, but neither shelters in Miami nor Tampa did. Although one shelter in Tampa had a woman go into labor, Tampa Police Department spokesman Stephen Hegarty said in an email.

Florida’s Department of Children and Families worked to make sure hurricane shelters had Narcan in case of overdoses, spokesman David Frady said in an email. The shelters also had first responders who could administer the drug, he said.

The state also worked with methadone clinics to provide a week’s supply of a methadone, a medication used to help people with substance abuse disorder, said Corine Stancil, the state opioid treatment authority.

Making sure people had a week’s supply of medication was important because many facilities were shut down for days during Hurricane Irma, Tookes said. His needle exchange program was closed for six days, and they were one of the earlier programs to open back up, he said.

Hurricanes also affects the flow of heroin and fentanyl. With infrastructure down, it makes it more difficult for people to get access to the illicit substance. And despite the common misconception, people don’t stockpile their heroin, said Dr. Babak Tofighi, an associate professor of medicine at New York University who interviewed more than 80 people using medication-assisted opioid treatment during Hurricane Sandy.

With infrastructure down, access to medication was one of the issues during Sandy. In New York, flooding inundated the hospital where his patients received treatment, Tofighi said.

“The biggest public health need post disaster isn’t cuts and bruises from falling debris, it’s actually people that run out of medicine,” he said.

The lack of access to medication is why states need to give clinics permission for take home doses of medication used to treat substance abuse disorder, he said.

“They need to give take home doses of methadone. They give take home doses of Suboxone in advance just in case roads, a lot of other infrastructure is destroyed and act as a barrier for patients coming back to treatment,” Tofighi said.

Tookes said that Miami’s opioid response has returned to normal. Now he’s looking to Puerto Rico, which was hit by Hurricane Maria shortly after Irma. Tofighi predicted that people will relapse with the lack of access to medication-assisted treatment, although it might not be immediate since it could take time for the heroin and fentanyl supply to return as well.

With the damage to the infrastructure and that fact that many of the territory’s clinics are not open, Tookes said he has a hard time picturing the opioid scene in Puerto Rico.

“You know you can’t even compare the situation we had in Miami to what’s going on in Puerto Rico,” Tookes said.