3 Ways Communities are Using Naloxone to Fight the Opioid Epidemic and Save Lives
Imagine you’re on your way home from work. As you approach your street you notice your neighbor collapsed against the wall of his building, pale and unconscious. You know this person well. You know about his chronic back pain from years of heavy lifting as a construction worker. You remember the day a few years ago when he came to you relieved, having seen a doctor who prescribed him oxycodone, a medication that finally made his pain go away. You know this year he has searched unsuccessfully for an alternative, that the prescription drugs were no longer strong enough, and he could barely afford them. And you thought about him when a local organization invited you to learn about opioid overdoses and receive training on administering a drug called naloxone. As you approach him today, you note his clammy face and ashen skin tone, purple fingernails, and shallow breathing. You find the device you were given at your training and push the plunger, puffing naloxone into his nostril. Moments later as you call 911 you can already see his chest begin to rise and fall regularly. You reversed the overdose, you saved his life.
This scenario is playing out with increasing frequency across the country. In the last year, opioids have surged into headlines nationwide as opioid misuse and overdose became a crisis, epidemic, and now, as of last week, officially a public health emergency. Opioid overdose has become so common that ordinary citizens are armed and ready with naloxone, a medication designed to reverse it.
First, Some Background
Opioids are a class of drugs that include licit prescription pain relievers (oxycodone, hydrocodone, codeine, morphine, fentanyl), and the illicit drug heroin. Between 1991 and 2013 the number of opioid prescriptions written surged from 76 million to 207 million per year. In years prior, opioids were generally only prescribed to treat short-term pain (e.g. from surgery or serious injury) or cancer-related pain. In the 1990s pharmaceutical companies began pushing Opioid Analgesics as the answer to chronic pain, assuring doctors that patients would not become addicted. By 2013, the United States, with about 5% of the world’s population, was consuming 99% of the world’s hydrocodone (Vicodin), and 88% of the oxycodone (Percocet and OxyContin).
Simultaneously during this time, the country has seen a dramatic increase in heroin use across all regions and among a broad range of demographic groups, including significant increases in groups with historically low rates - doubling the rate among young adults ages 18–25. The majority of heroin users (9 out of 10) are also using multiple substances, putting them at a greater risk for overdose: 45% of people who used heroin in 2013 were also addicted to prescription opioid painkillers. Individuals who are dependent on prescription opioids sometimes turn to heroin because the two drugs are analogous in their effect but heroin is cheaper (one-tenth the price) and, following an influx in the drug market starting around 1999, fairly easy to obtain.
As opioid consumption increased, so have opioid overdose deaths. According to the the Center for Disease Control and Prevention (CDC), each day 91 Americans die from opioid overdose, and preliminary data shows that opioid overdoses accounted for 64,000 lives in 2016, a 21 percent increase from 2015. The epidemic’s latest and deadliest forces are synthetic drugs, fentanyl and carfentanyl (often laced with heroin). These opioids are particularly powerful: fentanyl is similar to morphine but 50 to 100 times more potent; carfentanyl is 10,000 times more powerful than morphine – so potent it has been used by foreign militaries as a chemical weapon, and is only legally approved in the United States for tranquilizing large animals. These synthetic opioids are accountable for tripling opioid overdose deaths from 3,000 in 2013 to 10,000 in 2015, and in one study, were accountable for more than half of opioid overdose deaths in 2016.
The relentless pace of these tragedies has taken a toll on communities and left friends, families and neighbors of individuals struggling with opioid dependency feeling powerless.
In April 2014, the FDA approved naloxone, a medication which can be administered by minimally trained laypeople to treat individuals suspected to be experiencing an opioid overdose. Commonly referred to by the brand name Narcan, naloxone is an opioid antagonist that works by blocking opioids from attaching to the brain’s opioid receptors. During an overdose, opioids overwhelm these receptors and cause breathing to slow down or stop, depriving the brain of oxygen and leading to death. When it is administered – either as an intramuscular injection (like an epi pen) or nasal spray, depending on the product – naloxone can restore breathing within 2-5 minutes. Though fast-acting, naloxone is only effective for 20-90 minutes and can wear off depending on the opioid concentration in the individual’s bloodstream, which can linger in the system for hours. Emergency medical attention is still critical, and additional doses of naloxone may be necessary. As of June 2015, the CDC estimate that Narcan kits saved nearly 27,000 lives.
Here are some instructional videos on how to recognize an overdose and how to administer naloxone:
As the country struggles to keep up with the pace of opioid overdose deaths, local communities have galvanized to develop and promote innovative strategies to get naloxone into the hands of any potential life savers, looking at a greater range of first responders and beyond to play a role.
First on the Scene
In recent years, naloxone administration has rapidly expanded beyond medical care settings, such as hospital emergency departments or emergency medical services, to all first responders. Firefighters and police, who are often the first on the scene of a reported overdose, have increasingly joined the frontlines of the opioid overdose epidemic by carrying and administering naloxone. In many communities, particularly in rural counties, the number of overdoses has outstripped or put severe strains on the local emergency medical response capacity; there simply aren’t enough paramedics to go around. According to the North Carolina Harm Reduction Coalition, over 1200 police departments across the nation now carry naloxone, and in April of this year, New Mexico became the first state to pass a law requiring all state and local law enforcement officers to be equipped with the drug.
Taking a Stand
The Food and Drug Administration (FDA) has not yet approved an over the counter (OTC) naloxone product. This means that by federal regulation, naloxone can only be obtained with a prescription and dispensed by a pharmacist. And until manufacturers complete the necessary process to develop and test an OTC product – a process that the FDA has been trying to facilitate in the face of the opioid epidemic – states and local communities have had to take measures to circumvent these restrictions to ensure naloxone is accessible.
As of July 2017, at least 16 states have passed legislation issuing a statewide standing order for naloxone, which facilitates naloxone distribution without a prescription, making it available to the general public and resolving concerns about the legality of organizations and advocacy groups distributing it to the community. In these cases a state health officer, such as the Physician General, or commissioner of the state public health agency, signs a state-wide, non-patient specific prescription authorizing pharmacists to dispense naloxone to any individuals requesting its use for reversing an overdose. In other localities, individual physicians are issuing their own standing orders, setting criteria that allow designated people – such as outreach workers, first responders, or bystanders – to receive naloxone without a direct prescription. Some other states have made these individualized standing orders available upon request from the state health commission.
In a national report by the CDC, individuals who use drugs performed nearly 83% of naloxone overdose reversals, underscoring both the relevance and the capacity of bystander intervention, and the importance of ensuring lay access to naloxone.
Thinking Inside and Outside the Box
The scope of the opioid epidemic and the need for naloxone has increasingly inspired innovators to develop new and creative methods to empower individuals to act in the event of an overdose.
In 2016 the FDA partnered with the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) to launch a contest challenging participants to create a mobile app that could connect individuals experiencing an overdose with nearby naloxone carriers to maximize the effectiveness of distributing the drug to laypeople. The winning submission, OD Help, featured considerations for geographic and population density variations, synchronization with external breathing monitors, and alerts to an individual’s support network.
Earlier this year, officials in Cambridge, Massachusetts, began initial testing of a proposal to install lockboxes containing naloxone on street corners in neighborhoods with high rates of drug use. Following in the footsteps of the sharing economy (e.g. Airbnb, Uber, bike-share schemes), the proposed program would allow emergency dispatchers responding to 911 calls reporting an overdose to direct the caller to access naloxone from a nearby lockbox and then administer it to the victim. The program would allow the lifesaving intervention to be initiated almost immediately – before the emergency responders arrive – cutting down on response time and increasing the chances of a successful rescue. Although still in an experimental phase, the lockbox developers hope to see their model implemented in communities in need throughout the country.
Lifesaving, with Limitations
While naloxone is an incredibly effective tool for decreasing the most dangerous consequence of substance use – death – it is neither a cure for an individual’s opioid abuse or dependence nor for the opioid crisis at large. In many communities, rising costs associated with naloxone programs as well as longstanding attitudes towards substance use and substance users have been a barrier to increasing access.
Many critics, particularly in government or law enforcement, have suggested that the increasing availability of naloxone provides individuals with a safety net for risky drug use, and propose deterrent measures, such as imposing limits to the frequency of emergency response naloxone administration per individual and compulsory treatment or incarceration. However, it is often individuals in treatment for or recovery from opioid use who are at an elevated risk for overdose death if they relapse due to diminished drug tolerance. For example, studies of prison populations in several states demonstrate that 75% of inmates who detox while incarcerated relapse within three months, and 15% of all deaths among former inmates are related to opioid overdose, illustrating the sometimes cyclical path between overdose and treatment.
Other concerns center on naloxone’s primary side effect – withdrawal – and express concerns about the potential risks to responders when victims, experiencing withdrawal symptoms, exhibit unpredictable behavior. Adding to the complexity of the issue, withdrawal symptoms typically compel victims to once again seek the relief of opioid use.
The potency and increased circulation of fentanyl and carfentanyl has created both greater urgency and cost for naloxone distribution. The risk of overdosing with fentanyl or carfentanyl is so high that cities like Baltimore have community-wide alert systems in place to notify organizations when distribution of these drugs have been detected in the area, urging individuals to use in groups so as not to be alone in the event of an overdose. But reversing a fentanyl or carfentanyl overdose often requires several doses of naloxone, which also means that such saves are becoming more expensive.
Many agencies who previously received naloxone donations from pharmaceutical companies or community organizations, or grants to purchase it themselves, are now beginning to ration their supply; as demand has increased, so have prices, and the expense has gradually become a point of contention.
To address the rising costs of naloxone, lawmakers in some states have made deals with manufacturers to provide rebates or discounts to first responders or community organizations. Others states have instituted co-pay assistance programs for individuals to purchase the drug. But many agencies are seeing their supply of naloxone dwindle as local and federal authorities waver on funding.
One Piece of the Puzzle
As naloxone is promoted on the ground, it’s clear that distribution must be accompanied by educational outreach to clarify the widespread misconceptions about the drug and the people who are saved by it. Naloxone is sometimes conflated with controlled substances utilized in medication-assisted treatment and its distribution thereby prompts some unfounded concerns about illicit use when it is in fact an opioid antagonist. Also frequently overlooked is the exceptionally high risk of overdose for relapsed individuals who have embarked on treatment, due to lowered tolerance after abstinence. Efforts to combat the stigma of opioid dependency and overdose are still necessary to ensure that policymakers and the public recognize naloxone distribution as a valid public health prevention strategy akin to vehicle safety restraints and CPR.
Evaluation of harm reduction programs related to naloxone – such as needle exchange programs – demonstrate that they correspond to increased entry into treatment. So although reversing overdoses alone cannot cure opioid dependency and will not solve the country’s opioid crisis, it can be a critical gateway to long term recovery, so long as there is a path with accessible quality treatment on the other side.
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