Naloxone in the News: Time to Address our Opioid Abuse Problem

Author: Jason Brown, Capt, USAF, MD (Resident Physician, University of Maryland) // Editor: Alex Koyfman, MD

In 2010, the Centers for Disease Control and Prevention declared that prescription drug abuse had become an epidemic. From 1999-2010, deaths from drug overdoses increased 400% with 75% of those deaths being attributed to opioids; a majority of which are from prescription opioids. The CDC reported that in 2012 healthcare providers wrote 259,000,000 prescriptions for opioid painkillers and according to Pharmacy Times, three of the top five prescriptions written in 2012 were for opioids. In addition, we are seeing a steady increase in heroin use over the past decade with a shift in demographics from young males with first time abuse to older, more affluent users who had a previous or concomitant prescription opioid problem. With nearly 17,000 deaths from opioids in 2012, the time is now to address the overdose problem.

Naloxone distribution programs aim to educate people about how to prevent, recognize, and intervene in overdoses to prevent unnecessary deaths. They are designed to operate under the supervision of a physician and work to distribute naloxone to high-risk populations. Research has shown that heroin users who have undergone training are able to recognize an overdose and to determine whether or not naloxone should be administered. Further evidence shows that 87% of intravenous drug users would actively participate in a naloxone distribution program.

There are currently over 200 naloxone distribution programs in the United States, operating in more than 15 states and the District of Columbia. Naloxone is safe and effective in the treatment of opioid overdose and there is little risk in its administration in non-overdose situations. Despite a myriad of evidence to support the use of naloxone by EMS, first-responders, drug abusers, and family members of abusers, there are still numerous obstacles preventing universal, over-the-counter naloxone use.

Naloxone use is hampered by antiquated laws in many states that only permit prescriptions of medications to intended recipients or only to patients who have been examined by the prescriber. There are further concerns for liability to the prescriber, bystanders who may administer the drug, and for bystanders who call 911.

The US Conference of Mayors, the American Medical Association, and the American Public Health Association have coordinated with 23 states and the District of Columbia to combat the above issues in two main ways. The first is to allow prescribers to write for naloxone without legal repercussion as long as it is done with good faith. The second strategy is to pass “Good Samaritan” laws which offer a varying degree of legal immunity to bystanders who call 911 and/or administer naloxone.

Clark et al have shown in a systematic review that opioid overdose prevention programs are effective and the CDC determined that such programs have saved over 10,000 lives since their inception. Coffin et al have also shown that these programs are economical and should become even more cost-effective as awareness and popularity increase.

At this time, it is important to know the law in your state if you are contemplating prescribing naloxone. The more sensible solution is to know what resources you have available in your community. As emergency medicine physicians, we have a great opportunity to act as a resource for our patients. As national groups in medicine, public health, and public policy push for increased availability to naloxone it is your duty to keep up-to-date on the resources available to your patients.

Be a patient advocate and save a life!

References / Further Reading:
-Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005—2009. Pharmacoepidemiol Drug Saf. 2013;22 (4):438—442.
-Centers for Disease Control and Prevention. Number of poisoning deaths involving opioid analgesics and other drugs or substances—United States, 1999—2010. MMWR Morb Mortal Wkly Rep. 013;62(12):234.
-King NB, Fraser V, Boikos C, Richardson R, Harper S. Determinants of increased opioid-related mortality in the United States and Canada, 1990-2013: a systematic review. Am J Public Health. 2014;104(8):e32-42.
-Cicero TJ, Kuehn BM. Driven by prescription drug abuse, heroin use increases among suburban and rural whites. JAMA. 2014;312(2):118-9.
-Kim D, Irwin KS, Khoshnood K. Expanded access to naloxone: options for critical response to the epidemic of opioid overdose mortality. Am J Public Health. 2009;99(3):402-7.
-Alcorn T. America embraces treatment for opioid drug overdose. Lancet. 2014;383(9933):1957-8.
-Green, T.C. Heimer, R. Grau, L.E. “Distinguishing Signs of Opioid Overdose and Indication for Naloxone: An Evaluation of Six Overdose Training and Naloxone Distribution Programs in the United States.” Addiction 103 (2008): 979-989
-Seal, K. H., M. Downing, A. H. Kral, S. Singleton-Banks, J-P Hammond, J. Lorvick, D. Ciccarone, B.R. Edlin. “Attitudes about prescribing take-home naloxone to injection drug users for the management of heroin overdose: a survey of street-recruited injectors in the San Francisco Bay Area.” Journal of Urban Health 80 (2003): 291-301.
-Clark AK, Wilder CM, Winstanley EL. A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict Med. 2014;8(3):153-63.
-Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (December 28, 2010). The DAWN Report: Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD.
-UN Office on Drugs and Crime and WHO Opioid overdose: preventing and reducing opioid overdose mortality Available at: Accessed September 28, 2014.
-U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, “Community-Based Opioid Overdose Prevention Programs Providing Naloxone – United States, 2010, Morbidity and Mortality Weekly Report (MMWR), September 28, 2014/ 61(6);101-105
-Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med. 2013;158(1):1-9.
-Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174.

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