The Potential of Naloxone in Alleviating Opioid Mortality

United States Surgeon General Dr. Jerome M. Adams issued a national public health advisory on April 5 encouraging Americans to carry and become trained in the administration of naloxone, a drug used to revive individuals suffering from opioid overdoses.

The first advisory issued by a surgeon general since 2005, the announcement comes in light of the pervasiveness and lethality of the opioid epidemic that has plagued the United States since the 1990s. Opioid addiction has  killed over 250 thousand people in the last decade, at a rate faster than the H.I.V. epidemic at its peak. With more and more Americans overdosing on prescribed opioid painkillers and illicit opioids like synthetic fentanyl and heroin, naloxone is an attractive option for saving the lives of those who would otherwise fail to reach medical centers or professionals in time.

Naloxone is designed to rapidly reverse an opioid overdose; it binds to the opioid receptors of the brain, blocking other opioids from binding to those receptors, and restores regular breathing patterns in the victim for thirty to ninety minutes, resuscitating them and granting emergency responders time to arrive.

The drug can be administered as an injectable, an auto-injectable, or a nasal spray. While the injectable requires professional training in assembly and administration, the auto-injectable can be easily used by family and friends and provides verbal instructions, and the nasal spray is pre-filled and requires no assembly. Hence, while the injection is used mainly by paramedics, emergency room doctors, and first responders, friends, family, and individuals on site may administer naloxone via the other two methods, depending on the state.

Naloxone is considered to be safe: it is not addictive, and it is not harmful to administer it to someone who is not experiencing an overdose. It may force the victim into withdrawal, consequently causing the corresponding symptoms, but it may ultimately save the victim by granting them the time necessary to receive medical attention. Furthermore, most states have passed Good Samaritan laws that protect any individual who chooses to administer naloxone to someone potentially undergoing an overdose.

Consequently, although many police officers, emergency medical technicians, and first responders already carry naloxone, Dr. Adams’s advisory encourages opioid users, as well as their families, friends, and fellow community members, to carry the drug with them in case of an overdose. Information about naloxone can be found on government websites like that of the Substance Abuse and Mental Services Administration, as well as those of independent organizations like the National Institute on Drug Abuse.

In terms of access, naloxone is fairly easy to obtain at any local pharmacy. In some states, both auto-injectables and nasal sprays are available over the counter; others have issued standing orders to the same effect. The price may vary widely from $35 (for generic naloxone) to even $140 (particularly for Narcan, a well-known brand), but most insurance plans cover the cost; public health programs and manufacturer discounts can also lower the price, if not make the drug completely free. Community groups, local health departments, and needle exchanges also distribute low-cost or even free naloxone kits.

However, the price of the drug has risen sharply recently due to the heightened demand, and as a result, police officers and public health departments are struggling to find the financial resources necessary to cover the growing cost. Dr. Leana Wen, the health commissioner in Baltimore, has called on the Trump administration to work with naloxone manufacturers to further lower the price of the drug to make it more accessible to local public health departments, which, as of now, find themselves struggling to provide it to their communities.

All of this is not to say that there is consensus on the likely implications of making naloxone more accessible to and usable by the public. Several government officials have expressed doubts regarding the safety of such a policy measure. Gov. Paul LePage (R-ME), a prominent opponent of naloxone, argued that making it more accessible would simply discourage people from seeking treatment and could even draw more people to opioid use, as naloxone may serve as a safety net in case of an overdose.

Similar criticism of the policy measure has also been sparked by a controversial working paper published in March by two economists: Jennifer Doleac of the University of Virginia and Anita Mukherjee of the University of Wisconsin. The paper reached the conclusion that greater access to naloxone increases opioid use and opioid-related crime, as well as deaths from overdoses in certain places. At its core, the findings point to the phenomenon of “moral hazard”: providing a safety net to people may lead to riskier behavior. Although the authors also argue that these results should not be used to limit access to the drug, the questions their paper brings up is essential to furthering our understanding of naloxone and its potential impact.

However, an examination of the paper published by Vox points to various methodological problems that the paper may possess. For example, the paper measures the effects of increased naloxone access not on drug use directly, but rather on other outcomes that could potentially reflect that behavior, hence potentially wrongly attributing the effects of separate causes to the increase in access to naloxone.

The paper also commits various mistakes in its explanations of its results. For instance, although the authors did find that naloxone access laws lead to more opioid-related emergency room visits, this is likely because more people are able to reach emergency rooms by using naloxone rather than overdosing without receiving medical attention. The increase in opioid-related crime could also be simply because of more individuals carrying naloxone on their persons when committing crimes, an explanation supported by the fact that there was no increase in general crime.

Furthermore, the authors, as well as many critics of naloxone, fail to consider the reality of how drug users think and act. The common preconception is that people will use drugs more frequently and dangerously if they know medical personnel can provide naloxone, but in reality, the withdrawal symptoms caused by naloxone and the potential presence of law enforcement officials both act as deterrents to such decision-making.

Finally, in a finding that seems to contradict the final conclusion, the authors observe that in areas with the most treatment programs, naloxone access laws may reduce opioid mortality. Even in areas like the Midwest and smaller cities, where increases in opioid overdose deaths were observed, the findings are challenged by pervasive error in available opioid death data, as states that have passed these laws are perhaps also more likely to record these deaths more thoroughly and accurately.

Taking into account these shortcomings, it still remains important to take into account the findings of academic studies when it comes to naloxone and drug policy as a whole. One must also keep in mind that, in the long term, solving the issue of opioid addiction must be much more multidimensional and involved than simply expanding access to naloxone. As Dr. Adams said in his statement, “To manage opioid addiction and prevent future overdoses, increased naloxone availability must occur in conjunction with expanded access to evidence-based treatment for opioid use disorder.”

However, although it is not meant to be a cure for opioid addiction, making naloxone more accessible and available to Americans can ultimately be a step towards a real, long-lasting solution to an epidemic that has already taken countless lives. By making treatment and recuperation a possibility for more opioid victims, members of communities nationwide can feel more hopeful that their loved ones can and will overcome their addiction, rather than simply become another part of a bleak statistic.

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