Naloxone: Lifesaver or Opioid Enabler?
A drug that reverses an opioid overdose and prevents death is often cited by public health experts as a bridge that would connect people to addiction treatment. But evidence suggests it is acting more akin to a revolving door of continued substance abuse.
The overdose-reversal drug naloxone has historically been administered by first responders such as police officers. Now that the drug comes in easy-to-use devices, including an auto-injector and a nasal spray, health officials are urging laypeople carry them to save lives.
In the midst of a massive wave of overdose deaths involving opioids such as heroin, they hope it will be a first step in getting people into treatment. Nearly every state allows for naloxone to be obtained without a prescription, and Surgeon General Jerome Adams recently issued a rare public health advisory recommending that more people stock it.
“This isn’t a panacea or the be-all, end-all,” Adams said. “We know naloxone is the first step of an opportunity to connect people to care.”
But that connection to care, known by people in the medical community as the “warm handoff,” often doesn’t occur. Addiction treatment can be costly or unavailable, doctors aren’t certified to prescribe medications that treat addiction, and some drug users don’t want to participate.
At a public event in November, Adams noted that officials have observed a troubling pattern. Upon leaving a hospital or jail after being revived from an overdose, people with addictions will meet dealers just outside the facility to buy more drugs.
Someone who has received naloxone after an overdose can become agitated because the drug not only takes away the high but brings on painful withdrawal. People with addictions may be revived several times over the course of several years before seeking treatment. Others may die after they are not revived in time despite previous successful attempts over the years.
“Naloxone saves people’s lives all the time,” said Deni Carise, chief scientific officer at Recovery Centers of America, which operates drug and mental health treatment facilities. “It’s not a treatment for addiction. And you really have to separate those things out. It’s a tremendous treatment for an overdose. Then, you need treatment for substance abuse disorder.”
Nationwide data on this trend of repeated overdoses are not available, but people in the medical system often report this pattern. Dr. Jay Butler, past president of the Association of State and Territorial Health Officials, said more studies are needed on why people were administered naloxone as many as eight or 10 times without receiving addiction treatment.
In a phone call with reporters, he acknowledged the controversy over the drug but said naloxone is a key first step to a person becoming free of drugs.
“I have never seen a dead person in recovery,” he said.
One recent working study has aimed to discover whether there is any “moral hazard” associated with people knowing they could be revived from an overdose through naloxone. It examines whether people took on more risk in their drug use when they knew they could be revived.
The paper’s findings suggest that after states made naloxone more available, visits to the emergency room rose, and there was no decrease in mortality. The study was met with backlash by the public health community, which voiced concern that it would be used to limit naloxone access.
But the paper also found naloxone appeared to work best where treatment was available.
“Many people are being revived with naloxone over and over again, and the drug is critical in saving these lives,” said Anita Mukherjee, one of the study’s authors and professor in the department of Risk and Insurance at the Wisconsin School of Business. “But we need to give them treatment so that they are not in the risky position again.”
In an interview, the surgeon general said that because drug addiction should be treated as a disease, then it should receive similar consideration as other chronic illnesses. Patients with peanut allergies would not be told they couldn’t have an EpiPen after previous allergic reactions, he said.
“I don’t see that study telling me we shouldn’t be giving naloxone,” he said. “I think it tells us we are doing a really poor job of handing off care, and we are missing opportunities.”
Naloxone is facing additional scrutiny as the opioid crisis evolves. Depending on what type of drugs people take, one dose of naloxone will not necessarily be effective at awakening them if they are taking stronger drugs such as fentanyl, often unknowingly. In these cases, multiple doses of naloxone need to be administered.
Because of recurring overdoses, multiple doses, and because opioid addiction has become so prevalent, local communities have struggled to afford naloxone. Dr. Leana Wen, Baltimore’s health commissioner, has recommended that the government consider negotiating for the price of naloxone or providing funding for the drug to local communities.
After the surgeon general’s advisory, she said, “Unfortunately, we are having to ration naloxone because we simply don’t have the resources to purchase this life-saving antidote. Every week, we count the doses we have left and make hard decisions about who will receive the medication and who will have to go without.”