Weighing Various Methods of Drug Overdose Rescue

Naloxone for heroin overdose is one of many examples of how complex drug policy can be

I have a post at Stanford School of Medicine’s blog about naloxone hydrochloride, a life-saving medication that can temporarily reverse the effects of an opioid overdose. It’s being made increasingly available to first responders as well as to the broader community. In the hospital, naloxone is usually administered intravenously, but in crisis situations on the street, it is administered either as a nasal spray or as an injection into the muscle. Which route of administration is best depends on the eye of the beholder.

My British colleagues who have pioneered naloxone distribution to opioid dependent people and their families fear that the nasal spray may not work as quickly as an injection. From that point of view one could argue that injectable naloxone should be made the community standard.

However, many people are afraid to give an injection either because they fear needles, they fear injection will harm the person who has overdosed, or they fear the reaction of the person who has overdosed. Even though it can be deadly, opioid overdose is not subjectively unpleasant. Some individuals who are brought out of overdose quickly (e.g., by naloxone injection) are far from grateful and may even be aggressive to their rescuer. This is a fear among some opioid users as well as among some first responders.

That camp believes the intranasal route is more “gentle” and less likely to trigger an aggressive response. If that is true (and no one really knows), should it trade off the possibility that the nasal version may not save every life that would be saved by injection? Should public health departments insist on the injectable version, knowing that a certain proportion of people who otherwise would carry naloxone will refuse to do so?

The syringe for injected naloxone itself also raises complexities. Some addicted people and their doctors believe that carrying a syringe — even one filled with naloxone — can trigger drug cravings. Laboratory studies support this conjecture. But on the other hand, if the injected version works better during opioid overdose, is the greater risk of relapse therefore tolerable?

The debate over how best to administer naloxone in the community is one of many examples of how drug policy only seems simple to the simple-minded. The truth is that as in every other public policy area, some good outcomes are in competition with others and hard choices have to be made.

Author: Keith Humphreys

Keith Humphreys is a Professor of Psychiatry at Stanford University. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans and drugs. He is the author or co-author of numerous books and scholarly articles, and has written for the New York Times, Wall Street Journal, Washington Post, The Guardian (UK), the San Francisco Chronicle and other media outlets. When he is not in the San Francisco Bay Area, he is usually in London, where he is an ad hoc policy adviser to the national and city government, an honorary professor of psychiatry at Kings College, a senior editorial adviser to the journal Addiction, and a member of The Athenaeum. When he is not in the San Francisco Bay Area or London, he is usually in Washington D.C., where he serves as a frequent science and policy advisor to federal agencies, and where he has served previously as an appointee to a White House commission and several Secretarial task forces. From July 2009-2010, he served as Senior Policy Advisor at the White House Office of National Drug Control Policy. When he is not in the San Francisco Bay Area or London or Washington D.C., he is usually in the Middle East, where since 2004 he has volunteered in the international humanitarian effort to rebuild Iraq’s mental health care system. This work has taken him to Turkey, Egypt, Iraq, Jordan and Lebanon to teach and consult with Iraqi health professionals and policy makers.

10 thoughts on “Weighing Various Methods of Drug Overdose Rescue”

  1. One possibility is to let the addicts choose which sort to carry. They are in trouble because they are addicts, not because they are stupid.

    ¨Some addicted people and their doctors believe that carrying a needle — even one filled with naloxone — can trigger drug cravings.¨ That only applies to addicts carying naloxone preventively, not to first responders. You have two distinct issues on distribution.

    ¨Some individuals who are brought out of overdose quickly (e.g., by naloxone injection) are far from grateful and may even be aggressive to their rescuer.¨ Aren´t there other conditions that make patients agressive – alcohol, psychosis, fear? I would have thought that dealing with such problems rather goes with the job.

  2. One possibility is to let the addicts choose which sort to carry.

    A program could do that. The choice it would be making within a fixed budget is to supply less overall, as you would need more training and storage resources than you would if you just had one type. Depending on how the distributors of naloxone delivery systems are arranged, you might also pay a higher cost per unit relative to buying one or the other in greater bulk.

  3. Is selling this over the counter an option? You don’t need to be an addict to overdose. OTC will make it available to people who will experiment with opiates for the first time and casual users. I think a lot of people would like to have it on hand during recreational use. I guess that leads to the counter argument – it makes a drug experience safer. Therefore if someone morally objects to drug use for pleasure, then a safety net could hurt that crusade. It’s like condoms and the abstinence only crowd. The abstinence only crowd depends on the threat of STDs/pregnancy to stop young people from having sex, therefore dislike the greater availability of condoms.

    I am not sure it’s fair to say that increased availability of pharmaceutical-grade opioids is the primary cause of the overdose deaths (from the linked blog post). That makes it seem as if we just decrease availability deaths will drop. A quick google search turns up a study showing that a significant portion of the deaths comes from methadone (http://www.ncbi.nlm.nih.gov/pubmed/21668754). Methadone hasn’t become increasingly available like Oxy has it? Also, the study states that some payer policies mandate methadone as a first line therapy. It might be that the choice to use one opioid over another is more important than overall availability.

    1. Methadone hasn’t become increasingly available like Oxy has it?

      From Aron Hall’s 2008 JAMA Paper on overdose:

      “In the 10 years (1997-2007) since the guidelines were first published, per capita retail purchases of methadone, hydrocodone, and oxycodone in the United States increased 13-fold, 4-fold, and 9-fold, respectively”

      1. Yes, but those numbers are increases relative to themselves. When you start with smaller numbers the rate of increase is larger. The actual numbers are more informative than the rate of increase. For example, methadone prescriptions for pain management grew from about 531,000 in 1998 to about 4.1 million in 2006 (http://www.gao.gov/new.items/d09341.pdf ). Compare that with hydrocodone at about 130 million prescriptions and oxycodone at about 30 million in 2008 (http://www.drugabuse.gov/sites/default/files/rrprescription.pdf ). I might be a bit off in my chart reading abilities, but relative to each other, hydrocodone and oxycodone are much more available than methadone.

        Yet methadone it accounts for a significant portion of deaths. To put it in perspective, more than 30% of prescription painkiller deaths involve methadone, even though only methadone is only about 2% of painkiller prescriptions (http://www.cdc.gov/vitalsigns/MethadoneOverdoses/

        The reason this is important is because it demonstrates that while there may be a correlation between increased availability of opioids and death, to assert that it is the primary cause leads to wrong solutions. If increased availability is the primary cause, then decreased availability must be the primary solution (put second to real solutions like naloxone). But there are more important relationships between the drugs and death, like drug choice and doctor/patient error. It’s my speculation that one of the reasons for the increase in methadone was to combat the fear of increased use of oxy and hydro.

        We don’t want to end up with overall availability decreases, but have more deaths if the use of methadone and hydrocodone trade places.

  4. The debate over how best to administer naloxone in the community is one of many examples of how drug policy only seems simple to the simple-minded. The truth is that as in every other public policy area, some good outcomes are in competition with others and hard choices have to be made.

    You presume that it is up to the government to make “hard choices”, rather than allowing the people to make their own choices.

    This is my basic objection to you. Not everything is actually a public policy choice. The decision to engage in pleasurable activity is one such thing. As noted in the comments thread, it’s straightforward enough to make this product available and allow members of the general public to decide how to use it and whether they will benefit from having it available. The fact that such an approach might not “save” the maximum number of drug users is not the issue; respecting people’s free choices, in a free society, is actually more important than saving every single possible life. This is why risky sex, hang gliding, base jumping, and all sorts of other dangerous risky activities are legal.

    You have never justified, as a matter of first principles, why it is even the government’s business to try to stop people from engaging in risky recreational activities as opposed to simply providing whatever harm reduction can be provided while respecting individual freedoms. And you have never shown why, if this IS the government’s business, the government should allow us any freedom at all to make risky choices rather than simply ordering us to engage only in approved activities. You simply presume that freedom is a problem and authoritarianism is the solution to it.

    And note, this is not straw man libertarianism. I am quite willing to say that particular substances that, for instance, cause significant dangers to the general public rather than the users (e.g., PCP) could remain banned. Freedom isn’t absolute, but it is a presumption and a starting point. The problem with you is your starting point is “how can we stop people from doing fun things that I object to?”.

    1. @Dilan Esper
      > You presume that it is up to the government to make “hard choices”, rather than allowing the people to make their own choices.

      Maybe you should read the comments before posting. In a comment above yours, Humphreys makes it clear that he doesn’t have any objection to letting people choose. It’s just that these programs are giving it away, don’t have unlimited funds, and stocking both kinds (and educating people on both kinds) is more costly. I mean, if you’d prefer that the government (and/or private donors) butt the hell out, stop funding this kind of program at all, and just let the overdosers die, go ahead and say that. But otherwise, yeah, it is a policy decision (either by the government or a non-profit) about which kind to fund (again, both is an option, but a more costly one, which means less resources for actual life saving).

      And, just a suggestion, maybe you should find another post to use to complain about him trying to stop people from having fun, given that there isn’t a single word in this post even hinting at drug-use reduction strategies; it is 100% about, to use your words “providing whatever harm reduction can be provided”. Just saying, people might take your complaint more seriously if there was actually anything in the post that related to your complaint.

  5. What’s going to limit the usefulness of this remedy (as distributed to drug users) is the ability and willingness of drug users to use it.

    So I’d say “Distribute whichever is likely to get more use from a drug addict.” I’m guessing that’d be the nasal spray. Easier to carry and disguise.

    Putting on my amateur scientist hat, I’m also guessing that nasal spray and injection both get into the bloodstream very quickly. (Is intramuscular injection actually at all faster than nasal spray??) So just distribute whichever is most likely to be “ready to hand”.

    Finally, culturally, nasal spray is an easier sell (to the general public) than needles. Needles are scary and nasal sprays are familiar.

    So just ignore the overly technical arguments in favor of needles here 🙂

  6. If the injectables were going to be plausible, they would have to be packaged like epi-pens or similar devices. Because for the average lay person, following the sequence for injecting someone during a life-threatening emergency with an ordinary syringe is pretty questionable. (And how many lives would you lose due to injection screwup that could have been saved by nasal administration?)

    In the US, of course, anyone caught with such a thing would be immediately hauled to jail and the injection tool confiscated…

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