On an average night at Kennedy Health in New Jersey, the opioid overdose-reversing drug naloxone is dispensed about once every five hours, according to James Baird, DO, assistant medical director of the emergency department.
“We get a fluctuation of overdoses, from one to two per shift to sometimes six or seven in a row. On weekend nights, you get even more,” Dr. Baird says. “There is always someone in the ER suffering from an overdose.”
Naloxone, the generic for Narcan, is the only drug currently available to reverse an opioid overdose. “It works against the opioid and it works immediately,” says Marla Kushner, DO, a Chicago-based addiction medicine specialist. “I prescribe it to all my patients.”
According to the Centers for Disease Control and Prevention, 115 Americans on average die each day as a result of an opioid overdose. Between 1999 and 2016, the CDC reports, more than 630,000 people died from a drug overdose. In 2016, 66 percent of deaths from drug overdose involved an opioid, five times higher than in 1999.
The lifesaving power behind naloxone has prompted new guidelines and practices to make the drug easier to obtain, administer and afford. Here are five things you need to know:
1. You can’t harm a patient
Concerns about harming patients from dispensing the drug are simply not true, Kushner says. “It’s not going to harm anyone that doesn’t need it. It’s only going to reduce the effect of an opioid overdose. It will never make it worse.”
The reluctance to dispense the drug could cost a person their life, according to Dr. Baird, who says that naloxone cannot be given out enough. “Everyone should have access to it and everyone should be trained on how to use it.
“We should be giving it out more, not less,” Dr. Baird says. “You’re protecting the patient. You’re giving your patients a chance to live.”
The most common side effect, according to Dr. Kushner, is opioid withdrawal, which can include body aches, sweating, diarrhea, nausea, vomiting and irritability.
2. How naloxone works
Naloxone works to reverse the effects of opioids such as heroin, morphine, codeine, hydrocodone, opium and methadone. The drug ejects the opioids from their receptors in the brain, according to naloxoneinfo.org. “It attaches to the same parts of the brain that receive heroin and other opioids and it blocks the opioids for 30-90 minutes to reverse the respiratory depression that would otherwise lead to death from an overdose.”
There are four primary methods for dispensing naloxone: IV, nasal spray, injection and a prefilled, ready-to-use auto-injection by Evzio. Addiction medicine physicians are concerned, Dr. Kushner says, about the usage of the IV method given the propensity for relapse for recovering drug users. “Being around needles can be a trigger, so I don’t recommend that method for an IV drug user in recovery.”
And while the nasal method is often considered easiest, it can also take longer to work.
3. Knowledge is power
An overdose can happen anywhere. In South Jersey, Dr. Baird says, the city government offers monthly training sessions for laypeople to learn how to administer Narcan. “Some library staff have been trained to administer and use naloxone because people will use public restrooms to consume, and they’re leaving behind syringes and needles,” Dr. Baird says. “In the same way that you often see AED (Automated External Defibrillator) devices in supermarkets or theaters, in public places, we need the same for Narcan. And when we train our EMTs in CPR, they should be trained in Narcan as well.”
Education around overdose and addiction medicine and how to respond should begin early for physicians, Dr. Kushner says. “I didn’t learn it in medical school and most of my colleagues did not. There are no prerequisites regarding opioids as part of the general curriculum unless it’s chosen as a specialty.” But Dr. Kushner says that she’s working to get medical schools to address these issues sooner rather than later. “It’s not just about opioids, but addiction medicine, alcoholism, all need to be presented.”
Medical schools are taking note. Campbell University-Jerry M. Wallace School of Osteopathic Medicine is one of four U.S. medical schools in North Carolina that will integrate opioid use disorder (OUD) training into their standard curricula. The initiative, funded by a federal grant from the Substance Abuse Mental Health Services Administration and the Governors Institute, will: 1) train physicians on OUD, 2) increase the number of physicians who can prescribe medications to treat opioid addiction and 3) provide resources that support a workforce to treat and prevent opioid addiction.
4. Being a DO is a plus
DOs are uniquely positioned to respond to overdose. “We are obligated to know the whole patient and to work with the whole patient,” Dr. Kushner says. This whole-person approach is key to recovery. “Substance abuse is a perfect example of a primary care disease that affects every subspecialty. Whether you’re an ob-gyn, neurologist or cardiologist, knowing about Narcan can save lives, and it’s so important.”
According to Dr. Baird, the patient suffering from addiction is without a robust infrastructure to help. “It’s privatized. So we have to work with legislation to decrease the cost of treatment and access to treatment,” Dr. Baird says. “What’s really important to consider is that when you give Narcan to a person, it is not the end of treatment but the beginning.” Doctors recommend a continuing treatment plan that treats the underlying causes of overdose or addiction.
The AOA has stated its support of increasing naloxone prescribing and education.
5. The Surgeon General is pro-naloxone
Surgeon General Jerome Adams, MD, MPH, has voiced his advocacy for naloxone and urged more Americans, especially the loved ones of those who have an opioid use disorder, to carry the lifesaving medication. “Knowing how to use naloxone and keeping it within reach can save a life,” Dr. Adams said.
Naloxone is offered without a prescription in a number of states and at major pharmacies. To date, CVS provides naloxone without a prescription in 48 states and Walgreen’s provides the lifesaving drug in 45 states plus the District of Columbia without a prescription. However, two studies published in the Journal of the American Medical Association in November found that these efforts to expand access to naloxone have run into snags as not all pharmacies that can legally stock naloxone are doing so. The research looked at pharmacies in Texas and California specifically.
Typical costs for naloxone range from $20 to $40 per dose while Narcan can cost $130 to $140 for a kit that includes two doses.
Pursuing additional protections—for physicians and other first responders—continues across the U.S. Enacting laws and policy that provide civil or criminal immunity for health care providers or lay providers are key to addressing the opioid crisis. Review a state-by-state comparison to see where your state falls in the debate.
Get Naloxone Now provides useful information for first responders and community members, including where to find training sessions in your area and a list of pharmacies and clinics in the U.S. which provide overdose help.