Wednesday, September 28, 2016

Judging the Use of Naloxone and the Quality of Mercy


During this national health epidemic of opioid addiction, I have heard people question the repeated use of naloxone (brand name Narcan) to save the lives of those who have overdosed. Naloxone actually reverses the effects of prescription opioid and heroin overdose. Much of the frustration is about rescuing addicts who often immediately resume using deadly substances after being revived and about the government budget costs involved. There are even those who are outraged that naloxone is used at all because addicts do not deserve the life-saving benefit of the treatment.

In April 2014, the U.S. Food and Drug Administration (FDA) approved a hand-held automatic injector naloxone product that is pocket-sized and can be used in non-medical settings such as in the home. It is designed for use by laypersons, including family members and caregivers of opioid users at-risk for an opioid emergency, such as an overdose.

By June22, 2016, all but three states (KS,MT, WY) had passed legislation designed to improve lay person naloxone access. These states have made it easier for people who might be in a position to assist in an overdose to access the medication, encouraged those individuals to summon emergency responders, or both.

In 2007, New Mexico became the first state to amend its laws to encourage Good Samaritans to summon aid in the event of an overdose. As of June 22, 2016, thirty-five other states and the District of Columbia have followed suit (37total).

Initial evidence from Washington State, which amended its law in 2010, is positive, with 88 percent
of drug users surveyed indicating that they would be more likely to summon emergency personnel during an overdose as a result of the legal change.

Here are some concerns:
  • A retired attorney wrote an op-ed column in The Cincinnati Enquirer examining the costs of treating heroin addiction, the strain on public resources and the rise in “drugged driving” accidents as he urged aggressive punishment. “What social policy is advanced by subsidizing recklessness?” John M. Kunst Jr., of suburban Cincinnati, wrote earlier this year. “Why do we excuse and enable addiction?”

  • Governor Paul LePage in hard-hit Maine vetoed legislation this year to expand access to naloxone, usually under the brand name Narcan. He has explained that when people are receiving a dozen or more doses, they should start having to pay for it. The Legislature overrode his veto.

    (Associated Press. “Just say no to Narcan? Heroin rescue efforts draw backlash. CBS News. September 26, 2016.)
Yet, the simple facts are that addiction is a disease, and although naloxone is not a cure, it delays the final symptom – death – hopefully until treatment and recovery begin. Do we discriminate and withhold treatment from lifelong smokers or those who suffer from alcoholism? No.

The bottom line is naloxone saves lives. According to the Centers for Disease Control and Prevention, naloxone administered by a family member or friend revived more than 26,000 people between 1996 and 2014. There is not question tens of thousands more lives will be saved if it remains readily available.

Why then, the objections to using the life-saving drug? Naloxone distribution programs are designed to improve the health of an unpopular population. And, negative social perceptions of drug users and an abstinence-oriented approach to drug dependence limit the political will to advocate for harm reduction intervention. Drug users have long been stigmatized – they are targets of this discrimination.

(J. Ahern, J. Stuber, and S. Galea. “Stigma, discrimination and the health of illicit drug users.” Drug Alcohol Depend. May 2007.)

Research confirms that naloxone distribution programs are firmly rooted in the principles of harm reduction. They acknowledge the reality that drug use often continues despite an array of prevention and treatment efforts. Though treating substance dependence and stopping substance misuse are the ultimate goals, interventions to reduce the negative consequences of drug use, such as death from opiate overdose, are critical intermediary steps. Reducing morbidity and mortality through expansion of naloxone distribution responds directly to the epidemic of unnecessary opiate overdose deaths.

(Alexander R. Bazazi et al. “Preventing Opiate Overdose Deaths: Examining Objections to Take-Home Naloxone. J Health Care Poor and Underserved, 21. November 2010.)

Let's check some findings:

* Existing data on naloxone distribution in community settings does not support the claim that distributing naloxone encourages drug use. Two studies of naloxone distribution and overdose
prevention programs report a reduction in self-reported drug use.

(S. Maxwell, D. Bigg, K. Stanczykiewicz K, et al. “Prescribing naloxone to actively injecting heroinusers: a program to reduce heroin overdose deaths.” J Addict Dis. 2006.)

* It has been argued that enabling opiate users to reverse an overdose without being admitted to a medical setting delays entry to drug treatment and allows people to continue using opiates without facing some of the negative consequences of opiate misuse.

There is no evidence to support this claim, and individuals who die as the result of an overdose because those around them are afraid to call 911 or because the ambulance arrives too late lose the opportunity to enter drug treatment. Training people to always call for medical assistance remains an important component of naloxone interventions because naloxone has a shorter half-life than heroin, which may cause respiratory depression to return even after an overdose has been reversed.

(C.T. Baca and K.J. Grant. “Take-home naloxone to reduce heroin death.”
Addiction. December 2005.)

* Yet another objection to naloxone distribution is that an opiate overdose is a serious medical problem that must be handled by trained professionals, not by lay people. But, multiple studies have shown that with basic training, drug users are fully capable of recognizing and responding to an opiate overdose.

Bazazi states: “Claiming that naloxone belongs exclusively in the hands of medical professionals represents, at best, unjustified paternalism based on scientifically unsupported perceptions about what is in the best interest of opiate users. At worst, it represents a denial of drug users’ basic human dignity by devaluing their lives.”

(Alexander R. Bazazi et al. “Preventing Opiate Overdose Deaths: Examining Objections to Take-Home Naloxone. J Health Care Poor and Underserved, 21. November 2010.)

Cost? A study reported in the Annals of American Medicine concluded “maloxone distribution was cost-effective in all deterministic and probabilistic sensitivity and scenario analyses, and it was cost-saving if it resulted in fewer overdoses or emergency medical service activations.”

Distribution of naloxone increased lifetime costs by only $53, regardless of the analysis used, for an incremental cost-effectiveness ratio of $438.

And when researchers assumed that heroin users are a net cost to society beyond the scope of any other health condition, they found that distribution of naloxone to reverse lay overdose would result in an incremental cost of $2429 per quality-adjusted life-year (QALY) gained.

The same researchers found in a “worst-case scenario”where overdose was rarely witnessed and naloxone was rarely used, minimally effective, and expensive, the incremental cost-effectiveness ratio (ICER) was $14,000. If national drug-related expenditures were applied to heroin users, the ICER was $2,429.

(Phillip O. Coffin, MD, and Sean D. Sullivan, PhD. “Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal.” Ann Intern. Med. 2013.)


To reduce opioid overdose deaths, particularly in rural areas, the CDC recommends expanding training on the administration of naloxone to all emergency service staff, and helping basic EMS personnel meet the advanced certification requirements. 

To those who argue that the use of naloxone is wrong because addicts do not deserve the treatment or because they may repeatedly need to be revived by administration of the substance or because the cost is unwarranted, I say "let that judgment apply to your own closest loved one and justify the loss."

The Quality Of Mercy

The quality of mercy is not strain'd.
It droppeth as the gentle rain from heaven
Upon the place beneath. It is twice blest:
It blesseth him that gives, and him that takes.
'Tis mightiest in the mightiest; it becomes
The throned monarch better than his crown.
His scepter shows the force of temporal power,
The attribute to awe and majesty,
Wherein doth sit the dread and fear of kings;
But mercy is above this sceptered sway;
It is enthroned in the heart of kings;
It is an attribute to God himself;
And earthly power doth then show likest God's
When mercy seasons justice.

--William Shakespeare

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