In my last column, we talked about naloxone (trade name, Narcan) as a safe, inexpensive, and highly effective prescription medication that temporarily blocks the effects of opioids, reversing the life-threatening respiratory depression that results from an overdose. Although a growing number of public health programs are available around the country to provide people at risk of overdose, their families, and peers with overdose prevention training and take-home naloxone doses, much misinformation and many questions remain about it.
Following are common questions about naloxone that come up in my work with clients and family members:
- How do I recognize an overdose?
More than one half of all overdoses are witnessed and it can take one to three hours before a person dies. Recognizing the signs of overdose and acting quickly are essential.
Signs of overdose are unresponsiveness or erratic breathing, bluish-gray skin tone or fingernails, and gurgling or strange snoring sounds. If these signs are present, letting someone ‘sleep it off’ can be fatal, so it’s important to call 911 right away. Even if you haven’t been trained in naloxone administration, there are emergency procedures that lay people can initiate while waiting for paramedics to arrive.
However, naloxone’s effects do wear off within 30-90 minutes, so it’s important that emergency medical attention is sought soon after naloxone is administered. The other reason to call 911 is that, in the case of a suspected or unknown mixed-drug overdose, naloxone will only reverse an opioid overdose, not an overdose from other drugs. Emergency responders may need to respond not only to other drugs’ effects but also to drug interactions and medical problems.
- Is naloxone addictive?
Naloxone has no psychoactive or addictive qualities and few side effects. The drug is harmless if given in error for the wrong type of overdose. And because it attaches to opiate receptors in the brain, thereby blocking the effects of opioids, overdosing on naloxone itself is almost impossible.
- How can we trust a person who is high to respond safely in a life-threatening emergency?
…since 1996, over 10,000 overdose reversals have been performed using naloxone, the majority of these by active drug users.-Barry Lessin
Administering naloxone is simple – via a quick injection into the muscle, a nasal spray, or even simpler, an auto-injector that’s been recently developed. Research suggests naloxone is easy enough for a person to administer without instructions even in a situation as stressful as an overdose.
And naloxone already has an outstanding track record: since 1996, over 10,000 overdose reversals have been performed using naloxone, the majority of these by active drug users. It’s very likely that many of them were high at the time of administering naloxone.
- Won’t surviving an overdose with naloxone encourage someone to keep using?
Although some rehabs and other addiction treatment providers, police departments, and emergency first responders who can administer it, still believe this, it is a myth perpetuated by lack of understanding. Research shows that naloxone not only does NOT encourage drug use, but has been shown to decrease it in some circumstances. By blocking the effects of opioids, naloxone can produce unpleasant withdrawal symptoms. Certainly, no one wants to experience this, especially a drug user. But just because it sends people into withdrawal does not mean addicted individuals will take extra opioids if they know a rescue drug is on hand.
Much of our knowledge about drug users and addiction treatment is hidden behind a high wall of stigma and ignorance, with false assumptions based on the premise that those addicted to drugs will do anything to “get high and stay high.” In fact, the majority of clients I now see in my outpatient practice as well as many others who are in treatment for opioid addiction, became physically dependent after taking medically prescribed prescription drugs and now need to maintain their physiological dependence. (The need to maintain physiological dependence often eventually trumps the desire to feel “high.”) They are high-functioning individuals—employed, professionals, and students—who want to continue being productive while addressing their physiological opioid dependence.
- Will naloxone keep drug users from seeking treatment?
The idea here is to save lives. People can’t seek treatment if they are dead. Naloxone gives people another chance to get help if they choose.
In fact, many seek treatment after surviving overdose. The experience of almost dying and being saved with naloxone often acts as impetus for people to get professional help.
Also frequently reported–and I have had my own clients share this–some individuals stop using because the person who saved them was a sober example, showing them recovery is possible.
- Why is naloxone still so hard to obtain?
The reasons for poor access to naloxone are related to the intersection of stigma, questions about the legal liability of prescribing, and pharmaceutical business market forces.
Stigma of drug use contributes to the unfortunate notion entertained by some that opioid users “aren’t worth saving.” Therefore, necessary resources and procedures for distribution are often ignored.
People most at risk for overdose are new users or people using again after periods of abstinence (suspected as contributing to the recent deaths of some celebrities), as in a return to use after inpatient rehab or after release from prison. Rehabs are only now starting to consider sending patients home with a naloxone prescription. As for prisons, where opioids are often available for illicit use, lives may not be valued enough or funds aren’t made available to provide naloxone for those being released or for current prisoners.
Health care providers in the position of being able to prescribe naloxone are often concerned about legal liability because of fears of malpractice risk. Recently though, organizations have been created to educate and train prescribers and provide reassurance that prescribing naloxone to manage opioid overdose is consistent with the drug’s Food and Drug Administration guidelines.
From the business perspective, because naloxone has limited use and is a generic medication, producing it is not very profitable. As a result, many pharmaceutical companies are unwilling to manufacture it, resulting in a scarcity of the medicine as demand increases. The short supply of naloxone has in turn increased its purchase price, yet another barrier to encouraging its distribution by service providers and other potential administrators with limited funding.
- How can access to naloxone be increased?
Thankfully, 24 states plus the District of Columbia now have naloxone access laws that will make it easier for medical professionals to prescribe and dispense naloxone. These laws will be most effective when naloxone can get into the hands of more people who will be in the position to administer it. Unfortunately, however, naloxone access laws vary widely from state to state.
Some states do allow naloxone to be legally distributed through community programs, health departments, hospitals and other institutions, as well as to lay people who administer it. But not all jurisdictions allow prescribers and those administering it protection from criminal or civil liability, meaning that the laws do not protect them from being sued if problems develop with its use. Such legal gray areas force naloxone distribution programs underground in certain areas of the country.
And making naloxone available over-the-counter would remove barriers and harms associated with underground distribution, level the disparity in access between states, and put naloxone in more medicine cabinets.-Barry Lessin
Allowing doctors to write “standing orders” —an open prescription given to someone likely to witness an overdose in the future, allowing him or her to use naloxone as needed—would obviously allow greater use in emergencies. And making naloxone available over-the-counter would remove barriers and harms associated with underground distribution, level the disparity in access between states, and put naloxone in more medicine cabinets.
More effective laws need to also include third party prescribing, which allows a doctor to prescribe it to a person not at risk for overdose but who is a caregiver to someone at risk. Medical prescribers should be educated about the need to also write a naloxone prescription for patients taking large doses of prescription opioids for chronic pain because it adds another level of safety for such patients.
A hopeful sign that compassion and commonsense are winning out is the bold step taken by Rhode Island, creating the ability for Walgreens pharmacies in the state to sell naloxone to anyone walking into their stores requesting it.
- Where can I get naloxone and training to administer it?
Currently, over 200 community programs nationwide distribute naloxone to people at risk for opiate overdose and their loved ones. Many more parents are getting certified to be trained and opening up their homes for training others.
- I wish I knew about naloxone before. What can I do now?
Learn about the emergency procedures involved in rescuing someone from overdose. This video offers a comprehensive overview of emergency overdose prevention procedures and includes a re-enactment of an overdose reversal.
Advocate for your loved one and demand that naloxone be made available if your family member is in a treatment facility not yet on board. (In any other medical treatment setting most of us wouldn’t hesitate to advocate for effective, life-saving treatment for our families or ourselves.) Such facilities should routinely make naloxone distribution and training a part of family education and discharge planning. Also, if you are a caregiver for someone with chronic pain who’s prescribed opioids, ask the doctor supervising the care to co-prescribe naloxone.
Educate yourself about overdose prevention as a public health issue. This video is an excellent place to start and to recognize that every life is worth saving. Government resources are available for community members, first responders, and prescribers. Safety advice is included for patients and family members recovering from opioid overdose. Find out the status of your state’s naloxone access laws and contact your state and federal legislators, informing them that you want them to consider this life-saving legislation.
On an international level, learn about programs like International Overdose Awareness Day, held every year on August 31, which aims to increase awareness of overdose and spread the message that the tragedy of overdose death is preventable.
A combination of public health responses, proactive medical protocols, and family education and advocacy will get naloxone into more hands and save more lives.
This article was written and edited with support from Anne Fletcher.