Every day we hear news about the seriousness of the opioid crisis in the U.S. The number of overdose deaths from prescription and illicit opioids doubled between 2010 (21,089) and 2016 (42,249), and between 1999 and 2021 increased by 6 times. It’s not a new problem, by any means. Remember Nancy Reagan’s “Just Say No” program over 40 years ago?
Regrettably, the problem just keeps getting worse. The flood of illegal fentanyl into the country over our open southern border and the abuse of multiple other opioids have significantly contributed to the destruction of families, loss of jobs, and worst of all, deaths from overdosing. Overdoses happen from illicitly-obtained opioids as well those obtained by prescription. Addiction is an insidious problem that affects those who have an addictive tendency and the unsuspecting who get hooked after a major physical trauma. Physicians are frequently complicit in the problem when they fail to recognize the developing abuse problem. They have trouble saying “no,” or limiting the number of prescriptions, to an individual.
In one recent year, the CDC reports there were 107,000 drug overdose deaths. Seventy-five per cent of those were from opioids, primarily fentanyl. From 2015 to 2022, fentanyl deaths increased 7.5 times. Unbelievable! The top 10 cities with the most overdose deaths per 100,000 residents are Baltimore MD, Knoxville TN, Nashville TN, Portland OR, San Francisco CA, Philadelphia PA, Louisville Ky, Milwaukee WI, and Denver, CO. Indianapolis IN is eleventh.
Overdoses occur for a lot of reasons, but deaths occur all too often when illicit fentanyl is taken. Fentanyl is very risky to begin with, but when trafficked illicitly by cartels, users don’t know what they’re taking, increasing the risk significantly. Overdoses and deaths are inevitable, and “accidental” overdoses still happen even when patients are taking medication as prescribed by a doctor. The additive effects of taking several drugs that affect the central nervous system can be a deadly mixture.
Thus we have the drug naloxone, or Narcan. It has been used by emergency medical personnel and first responders as an IV, or intramuscularly-administered, drug for decades for opioid overdoses. It is an opioid antagonist meaning it rapidly blocks or reverses the effects of opioids and restores normal breathing in 2-3 minutes by shutting down opioid chemical receptors. When given Naloxone, opioid users are 9 times more likely to survive an overdose. Other studies have shown that of 399 OD events, 89% were reversed by naloxone, and of OD victims who survived, 75% received naloxone in some form.
It is effective against fentanyl, heroin, oxycodone, hydrocodone, and methadone, but has no effect on cocaine or methamphetamines. So, when given to someone who has taken anything besides an opioid, it does absolutely nothing. It is harmless and ineffective. But if opioids are involved, the symptoms are reversed at least 84% of the time.
It is now available over-the-counter in a nasally-administered spray device. There are two brands of OTC naloxone—Narcan and RiVive. Each container holds two sprays containing 4mg of naloxone. When an opioid overdose is suspected, the drug is sprayed in the nostrils of the victim, and if the person has an opioid in his system, 99% of the time a response of some sort will occur. The use of naloxone spray has increased significantly since it can be obtained without a prescription. Unfortunately, its increased availability has given opioid abusers a false sense of security and an overconfidence that naloxone will save them from themselves if they OD.
The effects of nasal naloxone last 30-90 minutes. Some drugs have long half lives meaning they stay in the blood stream for 4-6, or more, hours. Their adverse effects can hang around longer than naloxone causing a relapse of symptoms, so a repeat dose of naloxone may be needed. It’s also recommended that overdose patients be evaluated in the ER after using naloxone to be certain the patient has nothing else to cause additional problems later.
The bottom line is that intranasal naloxone works, is easy to administer rapidly, has no harmful effects, and is safe and cost-effective. The CDC recommends naloxone be given to any comatose patient to rule in or out an opioid overdose—on site, given nasally by friends or relatives, IV or IM by emergency personnel, or in the ER. If opioids are the cause, the patient will wake up. If not, the patient won’t wake up but there is no harm from naloxone.
All 50 states have OTC naloxone available for purchase. Additionally, all states have laws permitting pharmacists to prescribe and administer other formulations of naloxone themselves. These include auto-injectors, intramuscular, and IV formulations making access almost universal. The nasal spray is the least expensive, easiest to carry, and easiest to use thus it is very popular. Opioid users are encouraged to keep naloxone handy where it can be accessed quickly in an emergency.
It is estimated that from 2017 to 2024, “670,000 units of naloxone were used” and “82,000 lives were saved” as a result. It’s great that we have these amazing drugs, but it’s a huge shame that we have to report such large numbers as representative of the opioid epidemic. Opioid abuse and overdose deaths are directly responsible for the recent shortening of average human life expectancy. People are living longer healthier lives except for those millions of folks who fall prey to the ravages of drug abuse and addiction.
References: “Naloxone Drug Facts” Nat Institute on Drug Abuse 2023:1-5.
“Is Naloxone Accessible?” Nat Institute on Drug Abuse 2021 Dec:1-3
“U.S. Surgeon General’s Advisory on Naloxone and Opioid Overdose” U.S.Dept of Health and Human Services 2022 April 8;1-5.
“In Brief: A New OTC Naloxone Nasal Spray (RiVive)” The Medical Letter 2024 March 18;66(1698):47-48.
Qayyum SN, Ansari RS, Ullah I, Siblini D. The FDA Approves the second OTC naloxone —a step toward opioid crisis mitigation. Int J Surg 2023;109:4349-4350.
