NALOXONE AVAILABILITY: ANOTHER POSITIVE CHANGE

BY DAN BIGG

Naloxone is a miracle of a drug -- it can bring a person not breathing due to opiate intoxication back to life very quickly. Naloxone availability-ideally over the counter-and its legal possession is a positive change critical to our ability to effectively reduce the epidemic of opiate overdoses in the US. In order to make this a reality, we must confront biases and tendencies towards oppression of people using opiates as well as our own limitations in harm reduction thought.

When administered properly, naloxone quickly reverses the respiratory depression associated with an opiate overdose and lasts for a period of about an hour. If given to someone with a tolerance to opiates it can also stimulate withdrawal symptoms, as well as helping them start to breath in the event they've used too much. Naloxone has no impact of its own other than the reversal of opiate effect. It will not reverse an OD caused by non-opiate drugs, nor automatically mean that you will not die of an opiate OD, but it can seriously help to increase the odds of survival and rapid recovery.

The major benefit of widespread naloxone availability should be fewer premature deaths from opiate overdose. Additional benefits are also likely from increases in overdose awareness and preparedness, which in turn can lead to the greater practice of overdose prevention measures (modulated injections, more consistent use of care partner injecting dyads, etc.) as well as increased capability and competence in preparing for and treating ODs. The rationale behind this is clear upon close examination of three points: 1) possession of naloxone inevitably leads to thinking about overdose, and of course, drug-taking practices that lead to dangerous situations, 2) the use of naloxone is an unpleasant experience for most people-even if it is saving your life-and there is no desire to use it again and 3) having naloxone on hand means that users potentially have a life-saving tool at their disposal for immediate lifesaving intervention.

The fear that by offering people greater control over their lives -- what I would call the essence of harm reduction -- leads to greater risk taking is fallacious, as we have learned through years of experience with syringe exchange. Just as providing sufficient access to sterile syringes doesn't necessarily increase people’s drug use, having the antidote to opiate overdose has not lead to users taking too large a quantity of opiates. Quite the opposite, in fact, as giving users access to a tool which can prevent unnecessary deaths helps to develop and encourage self-reliance; self-reliance which is expressed in the form of more deliberate drug-taking and strategies for preventing and dealing with overdoses. This only goes to prove that many distant and removed fears of failure are more evidence of bias, and less powerful than a single observed success in the practical world of the harm reductionist.

There are potential risks arising from naloxone distribution, including ineffective use that might delay or prevent sufficient OD treatment. However, negative effects of naloxone use on a person who's no longer breathing are almost always less harmful than the alternative: death that results from the lack of oxygen. In addition, thorough knowledge about opiates, naloxone use and CPR/rescue breathing techniques are excellent tools that can reduce potential harm from opiate ODs and prevent the aforementioned incorrect use from happening in the first place. Obviously, the more training and assistance we can offer people as they become more "overdose competent," the better. However, this does not mean that we should deny access to naloxone until someone achieves a certain level of comprehensive overdose treatment competence.

Today it is hard to find anyone other than paramedics and ER doctors who has access to naloxone. These health care professionals sometimes use it in ways that punish opiate-dependent users-by administering too much in bringing the patient out of an OD, thereby putting him or her into full withdrawal, or simply administering naloxone in cases of non-OD opiate intoxication. It has been suggested that no competence exists to use naloxone outside of the realm of medical professionals. This statement is shortsighted and paternalistic: If the medical profession, in all its wisdom and compassion, were able to handle opiate OD's by themselves, then thousands of people who currently die each year would instead be alive. I believe harm reduction theory suggests that improvements, such as described here, are possible-and essential!

The serious alienation/isolation illicit drug users face from society in general-and EMTs, health care providers and police in particular-as well as a medical system which restricts users' access to naloxone, currently obstructs the potential lifesaving impact of this drug. In certain parts of Chicago (poor areas) and with certain calls (illicit drug user related) you might as well be on an island when trying to get emergency medical help. Similar situations apply to users living in squats and on the street. In Italy, to counter such problems, thousands of vials of naloxone have been distributed to opiate users by street outreach workers. In the US, a very small number of opiate users have been collaborating with outreach workers to learn about preventing and managing ODs. They have also been given naloxone as part of this training. They appear to be using it to increase their feeling of empowerment, to care for others around them and to save lives! There are people alive today who wouldn't be if some non-medical opiate users hadn't been allowed access to naloxone. Naloxone should be an OTC medication available freely or at minimal cost to everyone who wants it.

As it is, limiting naloxone's availability to medical providers deprives opiate users of hands-on access to an important life-saving tool. Its distribution would potentially prevent thousands of deaths from opiate ODs each year, and it would afford widespread opportunities to bring users the information and practical skills they need to successfully deal with, what are for them, relatively common life and death situations. The future role for naloxone in harm reduction practice includes over-the-counter availability and wide dissemination of instructions for its proper use. Hopefully this empowerment to manage opiate overdose will be integrated into all places where opiate users are reached and harm reduction is practiced. Ideally, it would be part of a training on naloxone's benefits and limitations, as well as certification in CPR, rescue breathing, etc.

As for calling 911 and solely using CPR-the recommended intervention for lay people: does a typical heroin user have breathing equipment, training, stamina or bottled oxygen and the necessary airway tools to intervene successfully in a respiratory arrest? Is there a medical person in the same circumstances who would be able to perform rescue breathing (without using special equipment) for the length of time needed? I believe the emergency care system is very good, but it does not adequately address the problems illicit drug users all to often encounter when using the system get to help for an OD: excessive response times due to prejudice against drug-related calls, a punitive approach to overdose treatment and the frequent coupling of police presence with EMT response. I am proposing these changes to make the system better than it currently is. Anyone who has lost a loved one to opiate overdose should take notice that these premature deaths can be easily and cheaply avoided if we are willing to face the realities of opiate use and work to give people another tool to preserve life.

Understanding and possessing naloxone is definitely part of 'any positive change' for opiate users. The more capabilities the user has to manage opiate ODs, the more options he or she has for reducing drug-related harm. Naloxone information, training and availability broadens the options harm reductionists can offer those looking to reduce drug-related harm in their lives. Sterile syringes, naloxone education and access, better veincare/safer injection information, CPR and first aid training, and as many other options as conceivable should be promoted and expanded as possibilities within the harm reduction movement. Our greatest strength is our willingness to entertain improvements in spite of societal requirements for perfection. I hope we do not loose this perspective as we move to include naloxone or other medical interventions among the possibilities for reducing drug related harm.

I have heard some harm reductionists say naloxone is not a good idea because it incorrectly promises to "solve the OD problem." I have always felt the beauty of harm reduction is in its ability to learn from the past. Harm reduction has learned that no single approach works for everyone, that any improvement is better than none, and that the greater the level of empowerment and number of options for improvement the better. Anyone who claims to solve every facet of a problem as complex as drug addiction or misuse, overdose, etc. has failed to learn from the past and seems unable to appreciate the power of any positive change. Generating as many options to handle overdose as possible is harm reduction's work.

Similarly, access to sterile syringes does not 'solve the disease problem' among injectors, as many opponents claim it should, but many of us have fought for the availability of sufficient sterile syringes to help reduce disease risk from injection. Criticism of this variety is contrary to the recognition and practice of improvements in a person's life as they prescribe them for themselves. Ultimately, the best criticism of the current approach to overdose treatment is the thousands of people who do die of opiate ODs each year in spite of the miraculous options available.

It doesn't seem like we can wait for the medical system to respond. All these issues-overdose, opiates, naloxone-have been around for decades and there is still no medical solution offered beyond the emergency care system. Clearly, there's little difference from other take-home injectables like epinephrine for allergic reactions, insulin for diabetes, etc. once you strip away the bias against drug users. What is novel is helping drug injectors to reduce OD risk through medical means as is done with allergics, diabetics, etc.-and such assistance is long overdue. The physician's Hippocratic oath would seem to dictate naloxone's use, but apparently biases against people using opiates have kept it from progressing as a take-home medical approach for years.

Opponents of naloxone distribution don't answer the hard question of cost efficacy, as most medical providers often don't. Hepatitis B vaccination has been medically recommended for injection drug users since 1982 but is still largely ignored. Why? I would contend that biases against drug injectors and high medication prices have limited this intervention far more than sensible public health practice would suggest. Only good research will answer the question of cost effectiveness with the OD treatment issue. In the mean time we should do all that we can with all of the options available to us. Certainly, our meager resources would more effectively train and provide naloxone use than. CPR training. A 10ml multi-use vial of 0.4mg/ml naloxone (generic Narcan) costs less than $3.00, and the information needed to use it well is easily shared. CPR is very resource intensive and generally not very effective for lay people to do in cases of opiate overdose, primarily due to the difficulty in doing in correctly and for a sufficient length of time without equipment.

Ideal vs. reality. What is happening with OD management today? It appears that if not for naloxone and injection rooms (which have shown major reductions in lethal ODs) as the lightening rods, little discussion would be happening now. Many opiate users were talking about OD treatment after the Pulp Fiction thing. Imagine the talk on the street if the movie had portrayed a real treatment for opiate OD - the priority of breathing and naloxone's correct use. Hollywood screwed up this opportunity, and I can't help but think that it did it so to avoid the charge that was leveled against the movie anyway-that it glamorized drug use. In the end, Quentin Tarantino dissed the lives of drug users. (In Trainspotting naloxone was used in a sadistic way only after the person was dragged to the ER — this is reality but not all that is possible.)

The people most excited about naloxone empowerment and provision are people using opiates. The enthusiasm among many opiate users-resulting from their awareness of naloxone's possibilities-should be the most significant guide for harm reductionists about its use. Finally and ultimately, your struggle about naloxone availability should include the ultimate test of validity: If you were using an unknown quantity of heroin (as is almost always the case) would you want your injection partner to have naloxone among his/her other options for intervening in case of your overdose? Why not help show all your fellow brothers and sisters the same respect?

---Dan Bigg is the Director of the Chicago Recovery Alliance and holds a CRADC addictions certification. Dan has been involved in both the addictions treatment system and the practice of harm reduction since 1984.