[The Addiction Legal Resource Team is proud to unveil a three-part series on Naloxone, a drug that reverses the effects of an overdose. While the role of Naloxone as a tool to combat the opioid crisis is undisputed, this series does not intend to address every aspect of the drug. Instead, over the next three weeks, the ALRT will release three different pieces that will explore how this drug may be used as a tool to fight the opioid crisis.]

Unintentional drug overdose is a prominent cause of preventable death in the United States. As the opioid crisis continues to worsen, the United States’ government has persisted in doubling its efforts in developing strategies for prevention and harm reduction. One of the most prominent efforts is to increase access to naloxone. Naloxone is a short-acting opioid antagonist used to reverse opioid overdose. Administering it intranasally (IN), intramuscularly (IM), intravenously (IV), or subcutaneously (SC), naloxone effectively displaces opioid agonists from opioid receptors, thereby reversing respiratory depression, a notable physical symptom in opioid overdose that, if left untreated, may lead to coma or death by decreasing oxygen to the brain and other vital organs.In light of the acute benefit of naloxone – reversing the effects of an overdose – such reversals are obvious, immense life-saving benefits to persons saved, their loved ones, and their communities. All 50 states, as well as the District of Columbia, have implemented an access law for naloxone. Additionally, several states have enacted legislation to permit laypersons to administer naloxone in emergency situations, thus giving rise to the concept of “take home naloxone” (THN).  In order to facilitate access to this drug, 35-40 of these states have further provided immunity to health care providers for prescribing, dispensing or distributing naloxone to a layperson. 

Several barriers to increasing access to naloxone have been identified. These include awareness and education on naloxone and its safe administration, stigma and reluctance to call for help. However, these barriers may be addressed through education programs such as the overdose education and naloxone distribution (OEND) program. OEND programs have been implemented to train laypersons in how to identify and respond to an overdose event through the proper administration of naloxone. Studies suggest that risk of mortality from overdose may be reduced by providing OEND to a variety of participants. By raising awareness and knowledge on effective administration of naloxone, witnesses and peers at the scene of an overdose event may be able to effectively respond immediately, before emergency medical services arrive. It has been a concern that peers may be reluctant to take naloxone home or carry it on their person for fear of possible problems with authorities and the stigma associated with it. However, with the proper training and education provided, the community can work together to change or remove this negative perception. Furthermore, the possibility of having a peer administer naloxone in an emergency situation could remove the potential barrier of emergency medical services not being called due to fear of the repercussions of illicit drug use. Although it is important to reiterate that naloxone should not be viewed as a substitute to emergency medical treatment. Arguably, these programs then give the potential for a wider coverage of current, at-risk populations. 

With the focus increasingly on the potential for success in opioid overdose prevention and harm reduction, it is important to consider potential downsides to the increase in access of naloxone. In a qualitative study on risk perception of peer take home naloxone, a question is raised on whether increasing access to naloxone may inadvertently harm such efforts. Potential areas of concern with increasing access to naloxone include:

Increased Risk to Recipient

To appropriately perform resuscitation and administer THN in the event of an opioid overdose, users would need to be able to correctly identify the signs of an overdose, recognizing the difference from opioid-induced intoxication. Such indicators of an overdose include cyanosis (a bluish discoloration to the surface of the skin due to low levels of oxygen in the blood), unconsciousness that cannot be easily roused, and respiratory depression. Should this difference not be recognized, administering THN would have the potential to harm the recipient by inducing a state of acute opiate withdrawal, which would cause severe discomfort to the recipient. Furthermore, users would have to be aware of, educated and trained on the possibility of a THN resuscitated drug user slipping back into respiratory coma after the administered naloxone ceases to have a pharmacological effect.

Potential for Misuse or Malicious Use

Providing an increased access to naloxone raises the concern for a potential of misuse, thereby inducing risky drug behaviors. While increasing accessibility may make a peer more willing to take responsibility of administering naloxone, an argument can be made that providing naloxone over-the-counter could potentially induce drug users to continue opioid use, as naloxone may be perceived as a “safety-net” that could cast over the fear of opioid overdose. Furthermore, it is possible that without the proper training and understanding in these situations, users may incorrectly view naloxone use as similar to that of an Epi-Pen. In other words, users may incorrectly view it as a quick fix, without considering the possibility of causing more harm to the recipient. It is important to note, however, that the possibility of a potential for misuse is surrounded by vehement debate within the legal and health care community. More research and studies would need to be conducted in order to develop a more concrete cost-benefit analysis on the issue.

While it is acknowledged that providing naloxone aids in the efforts of prevention and harm reduction with regards to opioid crisis, increasing its’ access to laypersons opens the door for discussion on possible barriers to its access, as well as inadvertent harms that have the potential to counter such efforts.