I keep NARCAN (a brand of naloxone) in my backpack because I go to places where overdoses can occur. Places like sporting venues, airports and even department stores.
Yes – all these locations have areas such as public restrooms where there is the privacy for an addict to use drugs. Of course, overdoses also happen in private residences. I’ve found that too many people believe that it can only take place in a dark alley, and that’s simply not the case. In this article, I will share with you how to reverse an opioid overdose through administration of naloxone. With it, you can save lives of opioid users – whether someone is overdosing on illicit drugs in a public place or a loved one accidentally overdosing on prescription pain medication. This is about saving lives. While it doesn’t solve the opioid crisis, it does buy time to provide treatment and develop new analgesics to treat pain.
Let’s start by understanding a little more about how opioids function and what naloxone does. This is going to get a little science focused; though understanding how opioids and naloxone interact is critical. Opioids have been around for thousands of years. For generations, the endogenous (naturally occurring) sap or juice of an opium poppy was the source of opium (the drug), an analgesic to reduce pain. Morphine was created from the opium poppy in 1803 and was commercially marketed by Merck in 1827. Over the years, we have engineered, or synthesized, drugs with the same mechanism of action (such as Fentanyl that we discussed in last week’s blog). The mechanism of action is fairly easily understood – once injected, opioids binds to opioid receptors in our nervous system as an ‘agonist’. In other words, they prevent the transmission of pain to our brain. There are side effects, including the release of dopamine (creating a feeling of euphoria – the ‘high’ of an opioid). Our bodies have their own endogenous opioids know as endorphins (derived from ENDOgenous moRPHINe) which act the same way but to a much lesser degree. The release of endorphins can produce the runner’s high that occurs during a race, for example. Another side effect is much less pleasant – opioids can prevent the body from correctly registering the amount of CO2 in our blood, impacting our perceived need to breathe. The higher the dose or more potent the variant of opioid, the greater the impact. This is why opioid overdoses typically are recognizable by slow, labored or absence of breathing. An opioid overdose causes the body to stop breathing and death ensues if no intervention occurs. Even with intervention, it must happen quickly, or brain damage occurs from a lack of oxygen.
Naloxone was first patented in 1961 and was approved in 1971 by the FDA for opioid abuse treatment. It is commonly referred to as a “rescue drug” because it is an opioid antagonist that stops the effects of opioid overdose within minutes (of being administered) by binding more strongly to the opioid receptors than the opioid agonist (e.g., morphine) can. It is not an opioid agonist and it does not make you ‘high’. In fact, there are virtually no side-effects from naloxone when given to someone who is not overdosing from opioids. In August 2016, the American Heart Association (AHA) released an update explaining how and when to use naloxone in conjunction with CPR in an opioid-associated life-threatening health emergency. At Medigram, we’d like to see emergency opioid overdose kits right next to automated external defibrillators (AEDs) as the combination of the two is often more beneficial depending on the cardiac state of the victim.
Time is always of the essence in responding to an opioid overdose and that means having the right tools available and people who know how to use them. I have a friend who is very focused on helping others and who often finds herself in situations where she provides some initial care to injured or altered individuals. Her goal is to ‘run to’ not ‘run away from’ danger. To give her more skills to help people, she began training to become an EMT-B (basic) and I was involved with that pursuit. Within weeks, we both realized that EMT-Bs were not allowed to carry or administer naloxone based on the training and laws in place at that time (2016 in California). A bystander could administer naloxone, but not an EMT-B. We worked with ER docs who treated opioid overdoses and local and state EMS agencies to highlight the urgent need for EMT-Bs to have this ability. Today, virtually every first responder can carry naloxone. But I don’t think that’s good enough yet. Remember how an opioid overdose occurs? Breathing stops, the brain shuts down as it is deprived of oxygen, the heart eventually stops. The time spent waiting for a first responder could make the difference between life and death. Having immediate access to naloxone to reverse an overdose is critical. That means YOU!
Today, almost all states offer the ability to purchase naloxone without a doctor’s prescription. This means you can go to a drug store, speak with a pharmacist and purchase NARCAN. Training requirements vary from state to state. The cost is about $150 for a box containing 2 doses, but your insurance may cover some of that. If you are part of a community group and want to do a bulk purchase, that could be reduced to about $75 per box. To see what your state’s guidelines are – check this out: https://www.narcan.com/#section-how-to-get. When it’s not feasible for most citizens to be prepared, Medigram would like to make sure we’re driving the lowest time to treatment possible notifying the needed parties.
Many people I’ve spoken to are worried about the legal liability if they were to administer naloxone, and even more so if they were also using drugs at the time. All states and Washington D.C. have what are known as “Good Samaritan Laws” to protect individuals who act in an emergency. One of the biggest challenges is that these laws are all very different in what they protect. The fact that it varies from state to state makes it very difficult to feel confident in your use of naloxone without knowing the law for where you actually are. I’d suggest using the Prescription Drug Abuse Policy System - Good Samaritan Overdose Prevention Laws web site to check out your state and any states you travel to - http://pdaps.org/datasets/good-samaritan-overdose-laws-1501695153.
One of the ER docs that I’ve worked with explained to me that when he teaches volunteers and community organizations about naloxone’s use, he always reminds them that it causes an abrupt and complete opioid withdrawal. You should expect many of the same symptoms you see with an opioid withdrawal including agitated behavior, vomiting, hypertension, shaking and drug cravings. After naloxone wears off in about 30 minutes, any remaining opioids in the body will start to take effect again. Because of this, it’s extremely important to keep the victim from taking any drugs despite craving during the time the naloxone is active since there could be a subsequent overdose triggered as the naloxone wears off.
Finally, let’s look at some of the misconceptions and resistance that you may encounter when discussing naloxone with others.
“People who choose to overdose on drugs deserve to die – culling the herd, so to speak”
This is a completely baffling argument given our desire to embrace individuals who choose certain diets that are known to cause heart attacks, certain tobacco products proven to cause cancer, and certain sports known to cause concussions and brain injury. Rather than a rational argument, this is often rooted in a misconception of the individuals affected by Opioid Use Disorder.
“Naloxone will be misused for addicts to get high”
Naloxone is an antagonist that binds to the opioid receptors to stop the effects of opioids. It is not possible to get high from naloxone.
“Addicts should pay for their own naloxone”
Naloxone is not cheap but expecting an addict to pay for it isn’t founded in reality. Some may be able to, but many would sell anything to keep their habit going. Additionally, an addict who has overdosed is not able to administer naloxone to themselves. Costs are also relative. In 2016, according to the CDC, there were approximately 50,000 overdose deaths from opioids. With NARCAN costing $75 per dose at a retail value, that’s $3.75 million. According to public records, the total campaign spending for Pennsylvania’s District 18 special election earlier this year was $17.9 million. With about 229,000 votes cast, that’s $78 per vote. I find it disappointing we will spend more to get a vote than save a life.
“Knowing that naloxone is available will increase addicts desire to be less cautious experimenting with higher doses or stronger drugs”
I’ve only seen one study on the moral Hazard of naloxone use. Its conclusions were generally considered invalid because of the inability to ascertain causality vs. correlation and the inability to control the specific doses / drug combinations of the population in the study. (e.g., it couldn’t factor in the impact of fentanyl laced heroin). All other studies and the US Surgeon General understand the incredible benefits of naloxone.
This week for media, I would ask that you take a few minutes and watch how easy it is to use NARCAN, and please consider picking some up. https://www.youtube.com/watch?v=hGVSaO1oxpg
Next week, we’re going to start addressing addiction and harm reduction.
By: Dean Shold VP, Technology at Medigram
Dean Shold is the VP of Technology for Medigram. Before his current role, Dean was the VP of Infrastructure and Chief Technology Officer for Stanford Health Care, and was previously the VP of Global Data Operations for Zephyr Health. With a degree in computing science and a passion for social good, real time data analysis and mobile computing, he brings a unique background and perspective to the healthcare industry. At Medigram, Dean drives enterprise customer complete solution development, implementation, support, and customer success. At Stanford Health Care, he led a global team of 180+ personnel at 24x7 support to 50+ locations including multiple hospitals. He managed the technology and support budgets and built and reorganized teams to drive performance and reliability. He built a command center based on FEMA's (Federal Emergency Management Agency Guidelines) and oversaw data center performance and builds.
Dean also has deep passion for practically addressing the opioid crisis. His interests are in the scientific and the social sides of the opioid crisis bridging the addict with the researcher and the lawmaker. He is fascinated by how the worlds of legal and illegal opioids intertwine and how our societal biases impact treatment and recovery. In his work, he brings a vision of how Health IT can be leveraged to better understand and address the crisis. This includes examining the following key dimensions in addition to Health IT such as fentanyl, naloxone, harm reduction, detox, treatment and recovery.
Outside of the office, Dean also co-founded a non-profit organization to create novel ways to donate to charities. Dean is an instrument rated pilot and avid music lover. He and his wife, Pauline recharge by exploring harm-reduction organizations, the arts, craft beer and music scenes.
Links to check out:
The official NARCAN website
https://www.narcan.com
The Science of Opioids from Healthcare Triage (9 minute video)
https://www.youtube.com/watch?v=AqDo4LiKz-c
Opioid dependence & opioid use disorder
https://www.youtube.com/watch?v=VldsyyybBRw
John Oliver’s Last Week Tonight segment on opioids
https://www.youtube.com/watch?v=5pdPrQFjo2o
Your Brain On Fentanyl
https://www.youtube.com/watch?v=C0tW8FWBm1g
American Heart Association – Special Circumstances of Resuscitation (Part 10.3)
http://circ.ahajournals.org/content/132/18_suppl_2/S501.long
The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime
https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3135264
Improve Patient Satisfaction Scores, Boost Medicare Reimbursement
http://www.healthleadersmedia.com/leadership/improve-patient-satisfaction-scores-boost-medicare-reimbursement#
SAMSHA’S Preventing the Consequences of Opioid Overdose: Understanding 911 Good Samaritan Laws
https://www.samhsa.gov/capt/sites/default/files/resources/good-samaritan-law-tool.pdf
Prescription Drug Abuse Policy System - Good Samaritan Overdose Prevention Laws
http://pdaps.org/datasets/good-samaritan-overdose-laws-1501695153
National Institute on Drug Abuse – Naloxone for Opioid Overdose: Life-Saving Science
https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/opioid_naloxone.pdf