The Realities of Naloxone: How Medics Can Open the Door to Recovery

Recent survey numbers indicate the tide may be slowly shifting in America’s battle against opioid addiction. Recent findings from the 2018 National Survey on Drug Use and Health showed a significant decrease in prescription opioid misuse across all age groups.¹ The survey also revealed a decline in overall heroin use from 2016–2018, particularly in young adults.

On a separate front, the CDC released preliminary data showing that 2018 was the first year in almost 30 years in which the number of drug overdose deaths decreased.² In 2017 there were 70,000 overdose fatalities, but that number shrank (slightly) to 68,000 in 2018. Additional CDC statistics showed the number of naloxone prescriptions doubled from 2017 to 2018,³ suggesting the opioid overdose reversal drug is indeed saving more lives.

Although curbing misuse, prescribing fewer opioids, and preventing overdoses show efforts are beginning to pay off, that’s all little comfort to the many paramedics and other first responders called upon to treat overdose patient after overdose patient. Crews will arrive on scene, administer naloxone, stabilize the patient and—if the patient doesn’t refuse treatment—take them to the ED for definitive care.

Sometimes the same EMS crew—or the crew manning the next shift—will be dispatched for an overdose, only to find it’s the same patient to whom they gave naloxone earlier that day or week. For EMS personnel addiction can seem like a never-ending cycle of overdose and relapse.

An Alternative to ‘Dope Sick’

As promising as naloxone is, it has a downside when used alone. The medication does nothing but reverse overdose. It prevents death, but it doesn’t necessarily save lives—it simply extends them.

Within a short time of the overdose patient’s revival, the drug that saved them actually makes them sick—“dope sick,” that is. They begin to experience intense opioid withdrawal symptoms like nausea, diarrhea, cold sweats, body aches, and intense feelings of depression and anxiety. This overwhelming and often unbearable experience can lead many patients right back to where they started: using opioids to lessen their suffering, putting them at risk of yet another overdose. 

After EMTs and paramedics turn over a stabilized overdose patient to the ED at Yale New Haven (Conn.) Hospital, the ED staff considers whether the patient is a candidate for treatment that may potentially end the deadly cycle of relapse after overdose. Patients who express a readiness to stop using opioids receive ED-initiated buprenorphine treatment and a referral to primary care for treatment of their opioid use disorder.

Yale investigators published data showing the efficacy of this intervention in JAMA in 2015.⁴ Study authors concluded, “ED-initiated buprenorphine, compared with brief intervention and referral, significantly increased engagement in formal addiction treatment [and] reduced self-reported illicit opioid use.”

Why Buprenorphine?

Buprenorphine is one of three types of drugs commonly used in medication-assisted treatment for opioid use disorder. It helps wean patients off opioid use and reduce withdrawal symptoms.

Buprenorphine medications like Suboxone and Subutex were approved by the FDA in 2002 and work by binding to and activating opioid receptors in the brain to minimize withdrawal symptoms. Because buprenorphine’s euphoric, reinforcing effects are relatively less intense than those of the full-agonist opioids being abused, the risk of compulsive use is much lower. An equally important benefit is that buprenorphine blocks other opioids from binding to receptors in the brain and in doing so discourages further drug use.

On its own buprenorphine has limited effectiveness in terms of comprehensively treating opioid use disorder. Rather, it steers patients away from using illicit or more dangerous opioids and buffers them from the ups and downs of frequent withdrawal that might otherwise occur with the abused drugs. This can help them better focus on the therapeutic side of recovery. Used in conjunction with behavioral therapies, it becomes an indispensable tool in efforts to free patients from the grip of their drug addiction.

While it’s considered safer than other opioid addiction treatment drugs like methadone, as an opioid itself buprenorphine being dispensed to patients brings with it some potential for diversion and misuse. But the reason behind that misuse may surprise you: A 2016 report from the DEA found most misuse is linked to “the failure to access legitimate addiction treatment.”⁵ It went on to say this could be improved by “increasing, not limiting, buprenorphine treatment.” As it turns out, the biggest danger associated with using buprenorphine is simply not following up with additional formal addiction treatment. 

New State Regulations

Last summer the health commissioner of New Jersey authorized paramedics to carry and administer buprenorphine, which they’re encouraged to use after an overdose patient is revived and refuses transport but expresses a willingness to kick their drug habit. Patients are advised how to safely administer the buprenorphine at home and then expected to follow up for more definitive treatment. 

A recent position paper from the major metropolitan EMS medical directors (better known as the Eagles) reminds us that addiction is a “chronic, relapsing disease that has multifactorial causes requiring medical, psychological, and logistical interventions to render more definitive long-term treatment and recovery.”⁶ EMS, they conclude, should play a role in “identifying and using the appropriate resources that will provide viable, evidence-based pathways toward sustained recovery.”

If buprenorphine makes it possible to fend off a second overdose and facilitates a gradual transition away from addiction, paramedics could play a vital part in not just stopping deaths but truly saving lives. 

References 

1. Substance Abuse and Mental Health Services Administration. 2018 National Survey of Drug Use and Health (NSDUH) Releases, www.samhsa.gov/data/release/2018-national-survey-drug-use-and-health-nsduh-releases.

2. Centers for Disease Control and Prevention, National Center for Health Statistics. Provisional Drug Overdose Death Counts, www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

3. Guy GP Jr., Haegerich TM, Evans ME, et al. Vital Signs: Pharmacy-Based Naloxone Dispensing—United States, 2012–2018. MMWR, 2019 Aug 9; 68(31): 679–86.

4. D’Onofrio G, O’Connor PH, Pantalon MV, et al. Emergency Department-Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA, 2015; 313(16): 1,636–44.

5. U.S. Department of Justice, Drug Enforcement Administration. Economic Impact Analysis of Implementation of the Provision of the Comprehensive Addiction and Recovery Act of 2016 Relating to the Dispensing of Narcotic Drugs for Opioid Use Disorder, https://docs.house.gov/meetings/IF/IF14/20180517/108343/HMKP-115-IF14-20180517-SD004.pdf.

6. Erich J. EMS vs. the Opioid Crisis: What More Can We Do? EMS World, www.emsworld.com/article/1223062/ems-vs-opioid-crisis-what-more-can-we-do.

Ryan Kelley, NREMT, is a nationally registered emergency medical technician and the former managing editor of the Journal of Emergency Medical Services. In his current capacity as medical editor for American Addiction Centers, Kelley works to provide accurate, authoritative information to those seeking help for substance abuse and behavioral health issues.