The prescription drug naloxone reverses opiate overdoses and saves lives. But getting the emergency intervention into the hands of folks on the front line is controversial. For their clients' sake, treatment providers need to step up.
Addiction treatment is changing, and not just because states are slashing already-tight substance abuse intervention budgets. Prescription painkillers ride the latest deadly wave of drug dependence. Nationwide, overdose deaths have surpassed even auto fatalities as the leading cause of accidental death; according to the Centers for Disease Control and Prevention (CDC), distribution through pharmacies of opiate-based painkillers such as Vicodin and Oxycontin is equal to 700 mg of morphine per person, enough for every American to take an average dose of Vicodin every four hours for three weeks.
Several solutions have been adopted to reverse the trend. These include efforts to limit “doctor shopping”; restrictions on the number of pain pills that can be prescribed to one patient; 911 "Good Samaritan" laws that grant limited immunity from criminal prosecution to overdose witnesses who call for help; and increased access to the opiate antidote, naloxone.
Naloxone access is of particular significance to treatment providers, as one proposed intervention involves supplying the antidote to opiate-addicted clients through rehabilitation centers. Also known by the brand name Narcan, naloxone is an opiate inverse agonist that binds to the same brain receptors as an opiate, blocking the overdose effects, specifically depression of the central nervous system and respiratory system. It is effective, safe, has no potential for abuse, and can be administered through intramuscular injection or intranasal spray. For decades, naloxone has been used by paramedics to reverse respiratory failure in overdose victims, but as the number of deaths continues to rise, so does the clamor for easier and broader access to the anti-OD drug for law enforcement, community outreach programs, treatment providers, and even drugs users and their loved ones.
Like all harm reduction measures, naloxone distribution is controversial due largely to opposition from advocates of an abstinence-only approach to drug use. They claim that naloxone will increase use of opiate painkillers, heroin and other narcotics by serving as a “Plan B,” encouraging addicts to use—and more frequently and in riskier amounts. Because they know that naloxone can save their lives, they will lose their fear of overdose (and death). These advocates also voice concern that by directly addressing the possibility of relapse after treatment, naloxone distribution goes against the dominant abstinence-only rehabilitation model.
Proponents of access to Narcan make a moral and a scientific argument: The antidote saves lives and gives users a second chance at treatment; numerous empirical studies report that increased access to naloxone does not result in increased drug use. One reason is that overdosing is far from free of risk since most addicts experiencing an OD are unconscious and unable to self-administer the antidote; they require someone else to save them. Additionally, if you ask a drug user about his or her experience with naloxone, the person will likely shudder at the memory.
Naloxone, especially when taken in large amounts, can plunge users into acute withdrawal in a matter of minutes, a misery that no addict takes lightly.
The use of prescription antidotes to reverse the potential harm of a medication is not new. For example, physicians prescribe glucagon to patients with severe diabetes who experience sudden episodes of low blood sugar. People who suffer from severe allergic reactions carry an EpiPen (a self-injector of epinephrine). In reality, having naloxone on hand to reverse an opiate overdose is an old concept applied to a new drug.
Because most overdoses occur in the presence of the user’s significant others, many community programs, and some treatment centers, are training them on how to recognize the signs of an overdose, initiate rescue breathing, and administer naloxone. A 2008 study found that with proper training, opiate users and their loved ones were able to respond to an overdose as effectively as medical personnel. In 2012, the CDC reported over 10,000 lives saved through the lay administration of naloxone accessed through community programs and treatment providers. Last year the American Medical Association endorsed the practice.
In some states, treatment providers and other non-medical personnel are able to distribute the prescription antidote under a doctor’s “standing orders.” This practice translates into significant cost savings for individuals and taxpayers, as using a $20 vial of naloxone at home is far cheaper than involving an ambulance and paramedics). The Food and Drug Administration is considering making naloxone available over the counter, but for now, standing orders are the best means to wide distribution.
Whether treatment providers will adopt the routine practice of distributing naloxone to outgoing clients remains to be seen, but early attempts show promise. Ten years ago, tiny Wilkes County, North Carolina, had the third-highest overdose rate in the nation. This was mostly due to a large blue-collar and elderly population, high rates of mixing alcohol with painkillers, and the difficulty of getting ambulances through rural, mountainous terrain. A small nonprofit named Project Lazarus began encouraging physicians to co-prescribe naloxone to opiate-using patients, prisoners leaving incarceration facilities, and treatment and detoxification centers. Overdoses in Wilkes County plunged by 69%; the model is now being adopted statewide, including at Womack Army Medical Center, Ft. Bragg, in a program called Operation Opioid SAFE. Project Lazarus and the North Carolina Harm Reduction Coalition, a nonprofit that advocates for saner drug policy (where I am program coordinator), are pushing for overdose prevention legislation in the state that includes 911 Good Samaritan laws, the “standing order” model, and greater naloxone access for law enforcement, community programs and treatment facilities.
As the prescription epidemic continues to sweep through communities, treatment providers are likely to become increasingly involved in the debate over naloxone access and other solutions to drug overdose. Naloxone won’t cure addiction and it won’t save everyone, but it’s a start. And to approach any big problem, even one as complex and longstanding as addiction and overdose, a big solution has to start somewhere.
Providers can locate the nearest overdose prevention program at the Overdose Prevention Alliance. Go to Prescribe to Prevent if you are interested in prescribing naloxone rescue kits.
By Tessie Castillo, 20th February 2013. (Tessie Castillo is the program coordinator at the North Carolina Harm Reduction Coalition. She works, writes and does public speaking on overdose prevention, drug policy, HIV/AIDS, law enforcement and public health.)
[Picture source: http://youthrise.org/overdose/naloxone A group for reducing drug related harm]
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We Can End Opiate OD Deaths