By Umar Aulia ’24
Opioids are the leading cause of overdose-related deaths in the U.S. (Giglio et al., 2015). In recent years, the rise of more potent and dangerous synthetic opioids, such as fentanyl, have greatly accelerated this curve, with synthetic opioids now accounting for the vast majority of all deaths related to drug use in America (National Institute on Drug Abuse [NIDA], 2023). Having served as a frontline first responder in Delaware’s largest city, I have witnessed with my own eyes the damaging effects of drug overdoses on individuals and families, particularly those related to opioids. These substances induce life-threatening depression of the respiratory system when abused, and can quickly lead to hypoxia, hypercarbia, and ultimately death if not treated in a timely manner (Rzasa Lynn & Galinkin, 2018).
U.S. Drug-Involved Overdose Deaths, All Ages, 1999-2021. Adapted from NIDA (2023).
Researchers and health officials in numerous localities, including at Princeton University (Veldhuis, 2024), have turned toward harm reduction approaches in an attempt to combat adverse effects associated with opioid misuse. One of these approaches has been the recent advocacy of bystander administration of the opioid antidote naloxone, frequently referred to by its brand name Narcan® (Giglio et al., 2015). Naloxone is an opioid antagonist that reverses the life-threatening respiratory drive depression associated with opioid overdoses when administered in a timely manner (Giglio et al., 2015). It is routinely carried by first responders, such as emergency medical technicians (EMTs), and has been the standard treatment in emergency departments for opioid-related overdoses for more than three decades (Giglio et al., 2015). When administered by trained medical professionals, naloxone is widely regarded as being safe and carrying minimal risk (Giglio et al., 2015).
A package of intranasal naloxone. Adapted from University of Washington Addictions, Drug & Alcohol Institute (2023).
The proposal of equipping bystanders with naloxone, however, is a relatively recent concept that carries with it unique concerns. University Health Services (UHS) at Princeton University recently implemented a harm reduction initiative aimed at increasing students’ access to the life-saving medication, with Associate Director of Health Promotion and Prevention Services Kathy Wagner expressing the institution’s desire to “ensure the health and well-being of [its] students” (Veldhuis, 2024).
Advocates of bystander naloxone use have presented numerous arguments in favor of the practice, including the possibility that early administration of naloxone prior to emergency responder arrival could increase odds of survival, and have posited that individuals may be hesitant to call 9-1-1 in the event of an overdose due to fears of law enforcement intervention (in Wilmington, DE, for instance, police accompany EMS crews to all overdose-related medical emergencies) (Kim et al., 2009). Indeed, literature has shown that minimally-trained bystanders who administer naloxone properly and in safe circumstances are capable of life-saving feats (Giglio et al., 2015).
Despite these proposed benefits, critics have posed numerous concerns to bystander naloxone administration proposals, questioning whether bystanders can be trusted to safely administer the medication in an emergency situation as well as appropriately respond to any adverse effects its administration may cause (Giglio et al., 2015). Speaking from personal experience as well as after a thorough review of the literature, administering naloxone to overdose patients is not without risks (Wermeling, 2015).
As discussed above, when someone overdoses on opioids, they experience respiratory depression which can quickly lead to hypoxia, a state in which the brain is starved of oxygen (Rzasa Lynn & Galinkin, 2018). First responders possess the tools and equipment necessary to help restore an unconscious individual’s blood oxygen saturation to normal levels prior to administering naloxone, and follow strict protocols that dictate the specific order in which interventions are performed to ensure patient and bystander safety. If naloxone is administered during an opioid overdose while a patient is in a severely hypoxic state, the medication will rapidly reverse the opioid’s effects and there is a risk that the patient will experience a state of altered mental status due to the prolonged lack of oxygen. As a result, the patient may be at risk of becoming agitated, combative, and further harming themselves or bystanders (Doyon et al., 2014; Moustaqim-Barrette et al., 2021; Wermeling, 2015; Williams et al., 2019).
First responders attempting to resuscitate a patient experiencing an opioid-induced drug overdose. Adapted from The New York Times (de Freytas-Tamura, 2017).
Studies have found adverse event rates of up to 20% following naloxone administration, and these effects are thought to be associated with the rapid opioid withdrawal induced by the opiate antagonist (Doyon et al., 2014). In addition to agitation and combativeness, other adverse effects such as seizures are also possible following naloxone administration (Doyon et al., 2014). Given the risk of adverse events occurring if naloxone is not administered in a safe environment by trained personnel, the argument that bystander naloxone administration may bring more harm than benefit––and as a result compromise patient safety––is not without merit.
In addition to questions regarding safety of bystander administration of naloxone, concerns have emerged regarding whether increasing public access to naloxone may encourage further illicit substance use (Seal et al., 2003). The reasoning behind this concern is straightforward: by providing drug users with an antidote which is capable of reversing the adverse effects associated with their illicit drug consumption, critics fear that individuals will feel safer using opioids if they have naloxone available, thereby providing a false illusion of safety associated with the use of extremely dangerous substances (Bazazi et al., 2010; Seal et al., 2003). Proponents of bystander naloxone access have pushed back against this point (Bigg, 2002), but concerns nevertheless remain.
The purpose of this article is not to attempt and provide answers to these difficult questions, but rather to highlight the ongoing debate and controversy surrounding naloxone’s increased availability. As with any public health initiative, the benefits of implementing a practice must be weighed heavily against the potential risks that the proposed implementation may bring. In light of recent expansion of programs aiming to increase public access to naloxone, government and university-level policymakers must continue to examine the practical implications of these initiatives on patient outcomes and continually reassess their efficacy in achieving desired public health aims. Following this approach will undoubtedly allow stakeholders to maximize population well-being while striving to prevent paradoxical situations in which certain practices––however well-intentioned––may end up doing more harm than good.
Umar Aulia is a senior at Princeton majoring in the School of Public and International Affairs, with a certificate in global health and health policy. Originally from Wilmington, Delaware, he is a founder and current editor-in-chief of The Princeton Medical Review. He can be reached at uaulia@princeton.edu.
References
Addictions, Drug & Alcohol Institute. (2023, March 29). NEW: U.S. FDA Approves Narcan (4mg Naloxone Nasal Spray) for Over-The-Counter Purchase/Use. Addictions, Drug, & Alcohol Institute, University of Washington. https://adai.uw.edu/news-u-s-fda-approves-narcan-4mg-naloxone-nasal-spray-for-over-the-counter-purchase-use/
Bazazi, A. R., Zaller, N. D., Fu, J. J., & Rich, J. D. (2010). Preventing Opiate Overdose Deaths: Examining Objections to Take-Home Naloxone. Journal of Health Care for the Poor and Underserved, 21(4), 1108–1113. https://doi.org/10.1353/hpu.2010.0935
Bigg, D. (2002). Data on take home naloxone are unclear but not condemnatory. BMJ, 324(7338), 678–678. https://doi.org/10.1136/bmj.324.7338.678
de Freytas-Tamura, K. (2017, February 2). Amid Opioid Overdoses, Ohio Coroner’s Office Runs Out of Room for Bodies. The New York Times. https://www.nytimes.com/2017/02/02/us/ohio-overdose-deaths-coroners-office.html
Doyon, S., Aks, S. E., & Schaeffer, S. (2014). Expanding Access to Naloxone in the United States. Journal of Medical Toxicology, 10(4), 431–434. https://doi.org/10.1007/s13181-014-0432-1
Giglio, R. E., Li, G., & DiMaggio, C. J. (2015). Effectiveness of bystander naloxone administration and overdose education programs: A meta-analysis. Injury Epidemiology, 2(1), 10. https://doi.org/10.1186/s40621-015-0041-8
Kim, D., Irwin, K. S., & Khoshnood, K. (2009). Expanded Access to Naloxone: Options for Critical Response to the Epidemic of Opioid Overdose Mortality. American Journal of Public Health, 99(3), 402–407. https://doi.org/10.2105/AJPH.2008.136937
Moustaqim-Barrette, A., Papamihali, K., Williams, S., Ferguson, M., Moe, J., Purssell, R., & Buxton, J. A. (2021). Adverse events related to bystander naloxone administration in cases of suspected opioid overdose in British Columbia: An observational study. PLOS ONE, 16(10), e0259126. https://doi.org/10.1371/journal.pone.0259126
National Institute on Drug Abuse. (2023, June 30). Drug Overdose Death Rates. National Institutes of Health. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
Rzasa Lynn, R., & Galinkin, J. (2018). Naloxone dosage for opioid reversal: Current evidence and clinical implications. Therapeutic Advances in Drug Safety, 9(1), 63–88. https://doi.org/10.1177/2042098617744161
Seal, K. H. (2003). 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: Bulletin of the New York Academy of Medicine, 80(2), 291–301. https://doi.org/10.1093/jurban/jtg032
Veldhuis, M. (2024, February 1). Narcan, fentanyl test strips now available through UHS. The Daily Princetonian. https://www.dailyprincetonian.com/article/2024/02/princeton-news-broadfocus-uhs-narcan-naloxone-fentanyl-test-strips-opioids
Wermeling, D. P. (2015). Review of naloxone safety for opioid overdose: Practical considerations for new technology and expanded public access. Therapeutic Advances in Drug Safety, 6(1), 20–31. https://doi.org/10.1177/2042098614564776
Williams, K., Lang, E. S., Panchal, A. R., Gasper, J. J., Taillac, P., Gouda, J., Lyng, J. W., Goodloe, J. M., & Hedges, M. (2019). Evidence-Based Guidelines for EMS Administration of Naloxone. Prehospital Emergency Care, 23(6), 749–763. https://doi.org/10.1080/10903127.2019.1597955
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