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The Crossing of Policy and Medicine

The 411 on the life-saving drug Narcan and how it impacts public accommodation agencies like special districts

In 2015, the U.S. Department of Health and Human Services recognized opioid-related overdose as a major public health concern, contributing to worsening overall survival among middle-age white Americans and as an increasing cause of mortality among all racial and age categories.

As a result, regulatory and legislative reforms have sought to provide greater access to naloxone medication, an opioid antagonist used to reverse overdoses via narcotics like heroin and prescription opioid analgesics like oxycodone.

Originally approved by the US Food and Drug Administration (FDA) in 1971, naloxone was strictly reserved for use by EMS or ER medical personnel until 2014 when the FDA approved the use of naloxone by lay rescuers as well as health care providers. Naloxone prescriptions have since become more prevalent in workers’ compensation and in 2016, NARCAN, a “single-dose, ready-to-use nasal spray” became a new outpatient option.

As public entities, Colorado special districts hold unique positions within their communities to educate on opioid prescriptions as well as naloxone access. Many states have adopted legal frameworks supporting wider access to naloxone rescue kits, even making these medications available at retail pharmacies without an individual prescription via a standing,
state-wide prescription.

Passed in April 2015, Colorado’s Senate Bill 15-053 specifies that “the chief medical officer of the Colorado Department of Public Health and Environment (CDPHE) may issue standing orders for naloxone to be dispensed by pharmacies and harm reduction organization employees and volunteers to help expand statewide naloxone access to those who need it most.”

Colorado’s standing orders allow pharmacists and harm reduction organizations to provide naloxone to the following:

    • A family member, friend or other person in a position to assist a person at risk of overdose
    • An employee or volunteer of a harm reduction organization
    • A first responder
    • An individual at risk of overdose

Additionally, the CDPHE also provides an instructional video on how to administer NARCAN on their website.

What is particularly remarkable about naloxone, whether it’s administered intravenously (by injection) or intranasally (by nose spray), is that it has no effect in people who are not taking opioids. Its ability to reverse overdose effects such as arrested breathing has led it being dubbed the “lifesaving drug” and in 2015, the American Heart Association updated its guidelines for cardiac or respiratory arrest associated with opioid overdose to include the administration of naxolone as well as recommendations for training and distribution.

In April of 2018, Surgeon General Jerome Adams issued the US Public Health Service’s first advisory in more than a decade, imploring the American public to seek training in naxolone administration. Notably, the advisory also states, “Naloxone may be covered by your insurance or available at low or no cost to you.” Participation from the public is crucial in staving the opioid epidemic; the CDC reports that from 1996 to June 2014, layperson administration of naloxone has reversed 25,463 overdoses in the United States.

Opposing Viewpoints

There have been several dissenting voices concerning wider naloxone access. For example, Governor Paul LePage of Maine continues to block a bill allowing pharmacists to dispense naloxone without a prescription despite the state’s Board of Pharmacy voting unanimously of its approval in late 2017.

Governor LePage and other policymakers have expressed concerns about ‘risk compensation,’ that allowing access to naloxone would encourage opioid abuse. More recently, a pair of economists from the University of Virginia and the University of Wisconsin published a working paper in March 2018 that suggests increased access to naloxone may also increase drug-related theft and emergency room visits.

Current research seems to suggest that these concerns may be unfounded. Several studies that specifically investigate wider opioid abuse from naloxone access among heroin users have found no clear evidence of it. According to these studies, this is likely due to opioid abusers being “very averse to naloxone induced opioid withdrawal.”

Also, those same observational studies have shown dramatic reductions in opioid overdose rates as well as opioid-related department visits, leaving researchers to conclude the following: “If there is any substantial increase in risky behavior due to risk compensation, it is outweighed by the important benefits of [opioid overdose education and community naloxone distribution].”

However, in 2017, the sheriff of an Ohio county released a statement to the press, refusing to equip the county’s deputies with NARCAN, reasoning that administering the drug endangers law enforcement officers as it aggravates the opioid abusers into violence upon revival.

The Ohio sheriff also cited reasons of cost as well as the drug’s ineffectiveness in curtailing opioid abuse. While the sheriff’s decision seems mostly informed by his department’s personal experience with repeat drug offenders, there are vaster implications to first responders with the advent of new synthetic opioids like fentanyl or carefentanil. The increased use of fentanyl in mixtures of street drugs has given law enforcement more cause for concern as the opioid is far more lethal than heroin, even in extremely small doses.

In Baltimore, a deputy and two paramedics received treatment for potential exposure to heroin and fentanyl after responding to a drug overdose.

It still remains unclear as to how the deputy exhibited overdose symptoms, leading some to opine whether the exposure came from transdermal (skin) contact. There have been other reported instances of first responders receiving hospital treatment after coming in contact with opioids, resulting in the DEA issuing safety guidelines for law enforcement personnel.

We highly recommend that you visit the CDPHE’s website on opioid overdose prevention before attempting overdose reversal via NARCAN or any naloxone rescue kit.

You can find more information here: https://www.colorado.gov/pacific/cdphe/opioid-prevention.

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