Surgeon General's Naloxone Advisory Fuels Passionate Debate

Megan Brooks

April 12, 2018

The recent advisory from the US Surgeon General Jerome M. Adams, MD, urging more Americans to routinely carry the opioid overdose reversal agent naloxone has generated strong opinions among the medical community both for and against it.  

One of many comments to the Medscape Medical News article on Adams' announcement  called the advisory "classic government reacting to a problem they created." Another advised leaving naloxone, which is sold under the brand name Narcan (ADAPT Pharma), among others, to the professionals trained and experienced to administer it when indicated.  One reader cited a lack of data indicating that increasing the availability of naloxone will decrease the number of overdose deaths.

And another thought getting more Americans to carry naloxone will only increase profits for companies that make it. "Save lives? I doubt it. Add to overall bloated health care costs? No question," the reader commented.

However, other readers welcomed the advisory. One called it a "positive action" to the problem; several thought it would save lives and noted that the benefit-to-harm ratio clearly supports bystander administration of naloxone. "Hell yes make the drug available as liberally as can be," one reader wrote.

Another reader found it "shocking" that so many of the comments show a lack of support for the American Medical Association (AMA) task force, which encourages physicians to co-prescribe naloxone for all patients at risk for overdose and supports the Surgeon General's advisory.

A Time for Reflection

Personal opinions aside, Andrew Kolodny, MD, codirector of opioid policy research at the Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, thinks it's important to stop and reflect on this advisory.

"What I think might be most significant is that the surgeon general of the United States is calling on Americans to carry an opioid overdose antidote. That really speaks to how severe the opioid addiction epidemic is in this country and I think we need to stop and reflect on that for a moment," Kolodny noted in an interview with Medscape Medical News.

An estimated 2.1 million people in the United States have an opioid use disorder, and death rates due to opioids (including prescription opioids, heroin, and fentanyl) have increased rapidly. Since 2010, the number of opioid overdose deaths has more than doubled, from more than 21,000 to more than 42,000 in 2016, according to the Centers for Disease Control and Prevention.

Naloxone, which is delivered by nasal mist or injection, can reverse the effects of an opioid overdose until emergency responders arrive. It is easy to use, safe to administer, and widely available, the  Surgeon General said in his advisory. The cost of naloxone is covered by most health insurance plans; for people without insurance, it may be available at low or no cost through local public health programs or through retailer and manufacturer discounts.

Howard Mell, MD, spokesperson for the American College of Emergency Physicians, said much like automatic external defibrillators, "it's a matter of putting the Narcan where it needs to be."

"It becomes a question of, Are you going to encounter someone who has overdosed? For people who might, it is really important for them to have Narcan. For someone who is unlikely to encounter someone who has overdosed, then it's probably an overstep. I don't think everybody in the country has to carry Narcan," Mell told Medscape Medical News. "Workplaces, schools, shopping mall security probably should have it on hand."

He agrees getting more people to carry the drug won't solve the crisis. "Putting a nation awash in Narcan may make some of the effects of the crisis less, but it is not going to solve the crisis."

A "Teachable Moment" for Doctors

Kolodny agrees. "Making naloxone available now makes sense," he told Medscape Medical News, but it won't make much of a dent in the problem. "The way to have a greater impact is on more upstream interventions, like interventions to prevent more Americans from becoming opioid addicted, which really involves more cautious prescribing, as well as interventions to see that the millions who are addicted are accessing effective treatments," he said.

"Just to rescue someone with naloxone and hope that someone is around the next time they overdose, isn't enough, if that person isn't getting treated. Also, many deaths, probably most, occur when people are alone and there really is no opportunity to rescue them," Kolodny said.

Still, "I see no downside and maybe it will save more lives," he added.

In line with AMA recommendations, he thinks patients on high doses of opioids should be provided with naloxone. "It could be a teachable moment. Giving them an antidote for overdose might help motivate them to start to come down and possibly off of opioids," Kolodny said.

A "Warm Handoff"

Pennsylvania is one of several states hard-hit by the opioid crisis. The state's Physician General, Rachel Levine, MD, told Medscape Medical News the Surgeon General's advisory is "an important step to help stem the tide of the opioid crisis that is affecting the entire country."

In April 2015, Levine signed a standing order allowing police officer, firefighters, and other first responders in her state the ability to obtain and administer naloxone to someone who has overdosed. 

In October 2015, she signed a second standing order that allowed anyone who thought they needed it to have naloxone on hand. "This standing order is on file at pharmacies across the state. Naloxone can be thought of as like a defibrillator for a heart attack. It is essential to have on hand in case you need it," Levine said.

She too believes that doctors should be counseling patients to have naloxone on hand at all times.

"Naloxone is necessary, but it is not sufficient" to solve the crisis, Levine acknowledged. "After naloxone is administered, it is important that a warm handoff, which is a facilitated referral for treatment, occurs to get the patient into treatment. This effort involves first responders, emergency department doctors, hospitals, and treatment facilities ensuring that a patient who overdoses gets into treatment," she said.

Pennsylvania has developed a warm handoff  clinical pathway to make sure those with substance use disorder get into treatment. The state has also just wrapped up a series of regional warm handoff convenings across the state, "to bring together all the stakeholders in this process to determine how it can be improved upon to ensure that those who are in need of treatment receive it," Levine said.

Pennsylvania is working under a disaster declaration for opioids, which was originally signed by Governor Tom Wolf on January 10 and was renewed on April 4. "This declaration has created the Opioid Operational Command Center, which brings together members from a number of state agencies to work together on this crisis," Levine noted.  The disaster declaration focuses on three parts of this crisis: prevention, rescue, and treatment.

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