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.