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Narcan: Widening access to overcome opioid overdoses

I often recommend books or podcasts for you when they address timely topics in mental health. The May 4, 2023, episode of The Daily podcast was one such episode that I think you should listen to. On that episode, Jan Hoffman, a health law and affairs reporter for The New York Times, was interviewed about Narcan, its history, current and future use, and how we might all take advantage of this life-saving intervention for those who battle opioid addiction. The episode was titled “What If You Could Save Someone From an Overdose?” The facts and history in this commentary are pulled from that podcast episode, and the associated musings and recommendations at the end are mine.

Narcan, as you probably already know, is now available in a nasal spray form and can potentially reverse an opioid overdose, waking a person up and literally saving their life. We are currently losing about eighty thousand lives per year due to opioid overdoses, so this is a staggering problem that continually needs our collective attention. Narcan should be available on shelves this summer without a prescription, so the landscape is about to change in a major way.

You might have heard of laudanum. This was a past preparation of opium and alcohol that was prescribed similarly to morphine to alleviate pain, help with diarrhea, and for other purposes. It was popular around the turn of the century. If one overdosed with this or similar preparations, the result might be decreased respiration, decreased blood pressure, somnolence, and even death. Good medicines, bad potential side effects.

In 1961, Naloxone came on the scene as a way to offset or reverse these potentially deadly side effects. In 1971, injectable Naloxone was available primarily to hospitals and ambulances, so there was the possibility of life-saving interventions in the health care setting. The problem was that by the 1990s, IV drug use was rapidly increasing, and more needed to be done. Needle exchange and other novel programs rolled out. Dan Bigg of the Chicago Recovery Alliance was one of the proponents of giving opioid users access to Naloxone as well as clean needles and syringes. That started to make positive inroads into the situation until, in the 2000s, oxycodone and related drugs became substances of abuse in poor rural areas of the Northeast in the United States. The situation got so bad that in 2015, the FDA approved Narcan nasal spray, a faster and more efficient way to administer this life-saving antidote to opioid overdose. It could be administered by police, firefighters, EMTs, and others on the front lines, but there was pushback. Some thought, “We are police and firefighters. Why should we take the time to address overdoses in these people who continue to go back to using?” You can see how judgmental this attitude was, but there was already much stigma associated with drug abuse, and the existence of Narcan did not make that disappear. The crisis was still not being taken as seriously as it needed to be. What changed? The opioid crisis itself.

From the rural areas of the Northeast in the U.S., the abuse of opioids moved south, west, and into the major cities. More people were exposed to the use of these highly addictive drugs. Kids, teenagers, post-op patients, those who got teeth extracted at the dentist, those who broke bones in accidents—all were now exposed to a potentially addictive substance, and many got into trouble. Addiction skyrocketed. First responders saw increased situations in which they had to use Narcan, so much so that “to Narcan someone” became a verb, much like “to Google something” did in the search world. Did companies that manufactured these drugs respond in kind, to make them more accessible, affordable, and available? As Jan Hoffman stated on The Daily, at first, the response was “crickets.”

Companies are in business to make money, and unfortunately, over-the-counter drugs are not the drivers of profit. Interventions to make this life-saving drug more widely available faltered. In the meantime, something called the COVID-19 pandemic reared its head starting in 2000. We saw a massive shift in social contacts, group activities, and associated things like AA and NA meetings and treatment interventions. The results of all that? Increased opioid and other substance use, increased isolation, and increased overdoses and death. The good news now? Over-the-counter Narcan will be more widely available this summer. The cost may still be prohibitive to some, as it may settle at around $40 for a two-dose pack. It will be available for individuals to buy, but there will still likely be a stigma attached to that process. The thing that may tip the scales on this issue is that parents and families, hotels, airlines and airplanes, restaurants, and other venues may soon stock Narcan nasal spray, something that can be easily used by anyone in any setting where an overdose is suspected without medical direction or supervision. Note that you do not have to justify to a pharmacist even now why you want to purchase Narcan. You just have to ask for it. That may become even easier as 2023 goes by. If over-the-counter Narcan is easily obtainable, that face-to-face, “why do you need it” stigma-laden interaction may soon be avoided. There may still be barriers to purchase, as high-cost shelf items in a pharmacy are often subject to shoplifting, may be behind locked plastic covers that have to be removed by pharmacy personnel, etc. Even with all of that, availability will be improved, and that will save lives.

Who will use it? Will we all be willing to see someone in the community, on the subway, on an airplane, in a hotel lobby that appears to be nodding off and rush to give them Narcan to save their life? The acceptance of this intervention, much like the acceptance of those who use the drugs and become addicted, will need to further evolve. Jan Hoffman alluded to the fact that we must all answer “the bystander question” for this to work in the long run.

Will you get involved? Will you buy Narcan over the counter? Do you care about people who use drugs, and will you act to help someone that you think is overdosing? These questions are important for all of us to consider, and I challenge you to think seriously about them. I know I am going to. What is normal due diligence in caring for others in our community when a potentially life-saving intervention is available to all of us, if we will only choose to use it?

Greg Smith is a psychiatrist.


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