Got naloxone? You should: An interview with Nora Volkow, MD, director of the National Institute on Drug Abuse

Naloxone, a narcotic blocker approved by the US Food and Drug Administration (FDA) for the emergency treatment of overdose effects, is currently carried by many first responders, including emergency medical technicians and police officers.

On April 5, 2018, however, the US Surgeon General Jerome M. Adams, MD, MPH, released a statement urging more Americans, including physicians, family, friends, and those personally at risk for opioid overdose, to also carry the lifesaving drug:

“I, Surgeon General of the United States Public Health Service, VADM Jerome Adams, am emphasizing the importance of the overdose-reversing drug naloxone. For patients currently taking high doses of opioids as prescribed for pain, individuals misusing prescription opioids, individuals using illicit opioids such as heroin or fentanyl, health-care practitioners, family and friends of people who have an opioid use disorder, and community members who come into contact with people at risk for opioid overdose, knowing how to use naloxone and keeping it within reach can save a life.”

Naloxone is covered by most insurance plans and is also available at retail pharmacies in most states without a prescription.

MDLinx asked Nora Volkow, MD, director of the National Institutes of Health’s National Institute on Drug Abuse, Bethesda, MD, to weigh in on the Surgeon General’s statement, as well as on how clinicians should proceed with patients.

MDLinx: Please share your opinion of the recent statement from Surgeon General Adams, which emphasizes the importance of the availability of naloxone:

NV: I am in complete agreement with the Surgeon General’s statement. Clearly, expanding naloxone’s availability does not address the root causes of the opioid crisis; the measure is a public health intervention to save lives and increase the likelihood that people who overdose and would otherwise have died might engage in treatment and recovery.

MDLinx: What are your thoughts on ready access to naloxone? How is it beneficial?

NV: Naloxone is a safe medication that can quickly restore normal breathing and save the life of a person who is overdosing on opioids. Thus, the greater the availability of naloxone, the greater the number of overdoses that can be reversed. In addition, since its prompt administration is necessary for successful reversal, greater availability will also improve outcomes. 

MDLinx: What are the advantages to an intranasal formulation of naloxone compared with the intramuscular form? Are there any disadvantages?

NV: The main advantage of the intranasal formulation is the ease and speed with which it can be administered that pretty much obviates any need for professional training. In fact, between 1996 and 2014, at least 26,500 opioid overdoses in the US were reversed by laypersons using naloxone.

The potential disadvantages are indeed very minimal. For starters, there is no evidence of significant adverse reactions to naloxone. It is true that administering naloxone in cases of opioid overdose can cause withdrawal symptoms in opioid-dependent individuals but, while this is uncomfortable, it is not life-threatening.

Another concern that is sometimes raised is that the universal availability of such an effective tool to save the life during an opioid overdose incident might generate a dangerous level of complacency among opioid users. However, the data do not appear to support this notion. A Massachusetts study has shown that a naloxone distribution program reduced opioid overdose deaths by an estimated 11% in the 19 communities where it was implemented without increasing opioid use.

MDLinx: Is there enough awareness among the general public about the availability of naloxone (ie, where it is available, in what types of situations it should be used, and even how to use it)?

NV: I don’t have hard data about the level of awareness among the general public, but I think it would be safe to predict that awareness would be highest among the hardest hit communities.

In more general terms, the knowledge and perception gaps vis a vis the availability and potential benefits of naloxone are quite substantial. While only 3% of patients surveyed reported having a naloxone prescription or being trained to deliver naloxone, nearly 40% had witnessed an overdose. Another study found that 68% of participants recruited from syringe service programs, detoxification, or opioid treatment programs had witnessed an overdose, but only 17% had a prescription for naloxone.

MDLinx: What can clinicians do to increase the knowledge of naloxone and its availability to the general public?

NV: Here also, there seems to be a significant knowledge gap that doctors can help bridge. A survey given to chronic pain patients receiving prescription opioids found that nearly 1 in 5 had experienced an overdose and more than half engaged in high-risk behaviors, including combining opioids with alcohol.

Physicians should also educate the patients who are treated with opioid medications about the dangers of combining them with benzodiazepine medications and of using higher doses of opioid medications than prescribed, for they increase the risk for overdose.

Educating doctors and patients about safer prescribing and use practices continues to be a key element of any multipronged campaign to effectively address opioid misuse and overdose.

MDLinx: Are there any other points you would like to stress for clinicians?

NV: Naloxone should be viewed as the first step of an intervention to save a life after an overdose and should be followed with a treatment referral.