September 27, 2011, 6:15 pm
Drugs, Risk and the Myth of the ‘Evil’ Addict
By MAIA SZALAVITZ
My column on making Naloxone available over-the-counter to reverse overdoses drew many plaudits and two main strands of criticism. One group argued that addicts aren’t worth saving and we need to cut the drug supply; the other said that Naloxone, also known by its brand name, Narcan, is too risky to be available without a prescription.
Let me address the second argument first.
Prejudice against people based on the substances they use is one of the few remaining acceptable biases.The health advocacy group Public Citizen has asked the Food and Drug Administration to authorize over-the-counter sales and has received a response that details the agency’s requirements for reclassification. A meeting on the topic of how best to expand access is expected to be held by the agency next May: according to its letter, the F.D.A. would probably want expensive clinical trials before granting over-the-counter status. It is not clear how that would be funded or whether it would allow alternative approaches.
The National Institute on Drug Abuse is providing a small grant to develop a sort of Naloxone “epi-pen,” similar to the one used by people with severe allergies. Instead of by injection, however, the device would deliver the Naloxone nasally. Clinical trials of this device might satisfy the F.D.A.’s requirements for over-the-counter authorization.
Meanwhile, peer-reviewed, published research has shown that broad distribution is safe and that fears about Naloxone causing deadly side effects are unwarranted. Both actual street-level experience and studies align to support wider use, but some physicians remain uneasy.
For example, one reader, who identified herself as a doctor, wrote in an e-mail:
The article leaves readers with the distinct impression that Naloxone administered once by a bystander can safely treat a narcotic overdose. However, Naloxone has a relatively short half-life and its effects can wear off well before the effects of the narcotics themselves; this is particularly true for long-acting formulations such as extended-release prescription painkillers or methadone.
A person who has overdosed on one of these drugs and been given Naloxone may awaken briefly, appear normal or even show signs of clinical withdrawal, and then re-enter a state of overdose as the Naloxone wears off. Naloxone is ONLY a temporary bridge and any user who has received Naloxone after an overdose must still be brought in for medical evaluation and observation.
The writer is correct — and that’s why everyone who is prescribed Naloxone is also told to call 911 and continue monitoring the victim for several hours even if he or she refuses additional medical care. It’s also why many states, including New York, have passed or are considering passing “Good Samaritan” laws to encourage people to call for help during overdose by removing the threat of prosecution for drug possession.
Information about calling 911 immediately after use should absolutely be put on packaging if the drug were made available over the counter.
Even more reassuring is the fact that research has shown that those who refuse additional medical care are not at greater risk of dying than those who are hospitalized. One study included 592 patients treated with Naloxone on the scene by emergency medical service teams in Texas, who then refused further medical care. None of them died within two days of the incident, meaning that they couldn’t have slipped back into the original overdose.
Other readers, like Babs from Australia (6) reported concerns about allergic reactions to Naloxone, but this has not actually been reported in the medical literature. In fact, some research suggests that Naloxone may actually help fight allergic reactions related to other drugs, which seem to be mediated in part by the body’s natural opioids.
Naloxone overdose was another fear raised in the comments. However, as with marijuana overdose, life-threatening Naloxone overdose is more theoretical than real. Since all it does is remove opioids from their receptors, once that’s done, it has no other physiological effect and is as safe as any other nontoxic ingestible substance.
A few readers suggested that Naloxone could precipitate life-threatening withdrawal symptoms in the most heavily addicted victims. But opioid withdrawal — unlike, I might add, alcohol or Valium withdrawal — is not itself life threatening. It’s stressful, sure — but not more than ordinary unpleasant experiences like, say, having flu-like symptoms.
Reports of Naloxone producing potentially dangerous high blood pressure by inducing withdrawal have not resulted from street experience. This sometimes happens in the hospital or in ambulances, where much larger doses are given routinely and other medications are available to stabilize the patient.
On the street, Naloxone is distributed in packages with smaller doses, and these have been found adequate to save lives without producing intense withdrawal. This has two important effects: first, it prevents the addict from being driven to seek more drugs to treat the withdrawal and potentially overdose again. Secondly, it doesn’t produce the extreme high blood pressure that might require medical intervention. Moreover, the slight possibility of high blood pressure if too much Naloxone is used is a far lower risk than the certainty of death if none is administered.
This brings us to the second set of anti-naloxone arguments: first, those that argue we should fight addiction not with Naloxone but by trying to reduce the supply of opioids.
My view, which is shared by many others, is that trying to sharply cut the prescription opioid supply will hurt some pain patients and is unlikely to stop addicts. In Washington State, for example, plans to reduce abuse and overdose by tightening restrictions on prescribing pain medication have already produced an unintended effect: legitimate pain patients are reporting reduced access to the medications they need to function at home and at work.
A look at history will show that supply side efforts to cut addiction have for the most part yielded failure and unintended consequences. Cut off one source of drugs and another —often a more violent one that provides a stronger and more dangerous form of the substance — soon appears.
So what about the idea that we just shouldn’t bother — that addicts deserve to die because they have violated the law and aren’t taking responsibility for the consequences of their actions?
The same argument was used not so long ago to support letting drinkers die during Prohibition. When alcohol was illegal, the American government actually forced industry to poison industrial alcohol making it even more toxic, in an attempt to prevent people from drinking. Thousands were killed as a result. I’d imagine Americans would have a quite different response today in terms of their view of the value of the lives of drinkers if the Obama administration proposed such an alcohol policy.
Many in society demonize those who use intoxicants that we have chosen to stigmatize: prejudice against people based merely on the substances they choose to ingest is one of the few remaining acceptable biases.
So, for example, SusanM719 from New Jersey (9) wrote: “Why is this a concern? Is it really in the social interest to save the lives of junkies who overdose, or those who choose to end their own lives? Let’s focus on something more for the common good!”
Could we imagine the same thing being said about a teenager or college student who had overdosed on alcohol?
Another reader compared handing out Naloxone to giving free child porn to pedophiles. The sheer hostility and irrationality of these responses — not to mention the fact that Naloxone could also save pain patients and children who accidentally take their caregivers’ pills — shows the intense stigma that addicts face.
One former drug injector, jcfried from California (53), wrote to defend his right to life by noting that he quit and now successfully manages a software development team at Apple.
He wrote: “[T]he myth of the dirty evil drug user is nonsense. We are just like the rest of you “fine” people who won’t lift a finger to help us. This medication should be over the counter or at least easily accessible. Let’s keep these addicts alive long enough to get the help they need. It won’t hurt you and it may save them.”
I don’t believe we should be judged solely by our accomplishments; I think whether Mike Kinzly saved 14 lives or none, he deserves to live, as does jcfried, whether he’s employed or not, just like any other human being.
I am also a former cocaine and heroin user. Maybe I should have been left to die if I’d overdosed. Maybe I shouldn’t have been taught to protect myself from H.IV. It’s only because some people cared enough to help me recover that am I now able to believe my life has some value.
David Bornstein is off.
Maia Szalavitz is a neuroscience journalist for TIME.com and a co-author of “Born for Love: Why Empathy Is Essential—And Endangered,” with Dr. Bruce Perry, and the author of “Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids.” Follow her on Twitter: @maiasz.