Newsletters
Toxicology Corner: The Naloxone Conundrum
POSTED: April 19th, 2018
POSTED IN: EPIC - The Official Newsletter of MOCEP, March/April 2018, Toxicology,
Written by Evan Schwarz, MD, FACEP
Harm reduction is the idea that we want to try to keep drug users as safe as possible while they come to terms with their disease. It would be great if everyone were instantly ready to quit. However, we know it is not as easy as just wanting this and some people are going to continue to use drugs. Through harm reduction efforts, we try to decrease morbidity and mortality until the person is ready to stop using. Increasing access to naloxone is a form of harm reduction. When you’re not breathing, seconds count. While our EMS is fantastic, it still takes them at least a few minutes to get to the scene of an overdose. Even the best emergency system imaginable will not be as fast as a bystander with naloxone.
A recent study out of Boston demonstrated that community naloxone programs saved lives. These programs consist of educating laypeople on how to administer naloxone and giving it to them. The study demonstrated that over 90% of people administered naloxone by lay rescuers survived. Missouri has recently passed legislation increasing access to naloxone. Anyone can get it from a participating pharmacy without a prescription. Good Samaritan laws were also passed. Until now, it has not been questioned that this approach saves lives.
A recently published paper (https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3135264) argues that increased naloxone access is detrimental and increases mortality. They argue that naloxone increases opioid abuse via 2 mechanisms: 1) saving people’s lives who will continue to use drugs and 2) making drug use less risky so that people will be more likely to use drugs. They claim to support these arguments by looking at the overall death rate and emergency department admissions increases due to opioid overdoses. They compare these rates before and after legislation increasing naloxone access was passed to come to their conclusions. They also state that increased naloxone access may also increase crime, as people with opioid use disorders will have to resort to crime to fund their habit.
While it is always good to re-evaluate even firmly held beliefs as sometimes we find they are wrong, this article has some serious flaws. To start with it is from the economics literature. That is important as in their world they expect this to be a living document. In other words they publish first and then let people chime in and edit this over time. While medical peer review is far from perfect, this is the opposite of our approach. We let people peer review first in order to try to improve quality before publishing the article. The authors also implicitly argue that addiction is just a choice so with a safety net, people will feel more free to use. That’s not how addiction works. While not necessarily true for everyone, the far majority of people with opioid use disorders will use no matter what. It’s what the disease does. In general, I don’t drive more recklessly because I have a seatbelt and airbag that can protect me in case I get into an accident. The authors also bring up this myth of ‘naloxone parties’ as evidence of this. These are parties where people try to use as much as possible before being revived by naloxone. I believe everyone here has revived someone with naloxone. I’m also willing to bet no one has everyone seen someone that was happy about being put into opioid withdrawal after receiving naloxone or having their buzz reversed by naloxone. To believe that naloxone parties are popular or even real, a lot of drug users would have to be looking for this experience.
There are some other flaws in their thinking as well. They see increased ED visits after overdoses as indications that naloxone is causing more drug use. Well, it may just be saving more lives so more people are still alive to go the ED. Additionally, it may be the result of more people doing what we have told them, which is to go to the hospital after receiving naloxone as bystander naloxone should not replace a proper medical evaluation. They also conflate increased passage of pro naloxone laws as evidence that naloxone is therefore available to communities. We know that it takes time between when these laws are passed to pharmacies actually being able to distribute naloxone. Or from the time that community programs are organized until they actually begin to distribute naloxone. Lastly, during this time of increased naloxone access, heroin became much more potent. Or more accurately, the fentanyl and fentanyl derivatives masquerading as heroin increased its potency causing more deaths completely independent of if people had naloxone. Interestingly, they also blame the latest fentanyl epidemic on naloxone, too. Of course, naloxone had nothing to do with this. Fentanyl costs less to produce and can be sold for more than heroin which is why drug dealers are selling it.
These are only some of the flaws without even mentioning the moral implications of not reviving a dying individual when you have the power to do so through the use of naloxone. Importantly, it also is at odds with decades of well-conducted research that comes to the exact opposite conclusion which is that naloxone saves lives. It also feeds into old biases that harm reduction strategies (such as increased naloxone use) encourage drug use. While limited, there is no data to support this idea. In fact, there is some data demonstrating use either stays the same or decreases following increased access to naloxone. Additionally other harm reduction strategies are associated with decreased rates of HIV and Hepatitis C.
For those interested in reading other’s appraisals of this article, feel free to read the following.