Distributing naloxone and training people to use it can cut the death rates from overdose nearly in half, according to a new study.
Around 15,000 people die each year by overdosing on opioid pain relievers such as Oxycontin, a rate that has more than tripled since 1990. The government has tried numerous strategies to reduce the death toll, including imposing stricter regulations on prescribing the medications, prosecuting owners of “pill mills” who dispense the drugs without proper medical evaluations, and tracking databases to monitor prescribing and discourage “doctor shopping” among addicts.
But those policies have not had a significant effect on death rates from overdoses, according to the study’s lead author Dr. Alex Walley, the medical director of the Massachusetts Opioid Overdose Prevention Pilot at the state’s department of public health. So he and his colleagues wanted to study the impact that an antidote, the nontoxic and non-addictive medication known as naloxone (Narcan), might have on these rates.
Community-based naloxone distribution and training programs have existed in the U.S. since 1996, and have provided the drug to over 50,000 people, leading to 10,000 successful overdose reversals. But studies have not focused closely on how introducing such programs could curb deaths from overdose.
The new study, published in the BMJ, followed the expansion of Overdose Education and Naloxone Distribution (OEND) programs in Massachusetts, a state where overdoses from opioids have killed more people than car crashes each year since 2005. The programs were offered at emergency rooms, primary care centers, rehabilitation centers, support groups for families of addicted people and other places that might attract those at risk.
Most overdoses occur in the presence of witnesses: usually, people who are getting high together, but sometimes family members who don’t know that their loved one has relapsed and is using in secret. And since overdose victims typically don’t die immediately, training either friends or family of at-risk individuals on recognizing and intervening in an overdose situation can potentially save lives.
The study involved 2912 people in 19 different Massachusetts communities — each of which had had at least 5 opioid overdose deaths between 2004 and 2006. The participants were trained to recognize overdose, call 911 and administer naloxone using a nasal inhaler. If the naloxone didn’t work, they were instructed to try another dose and perform rescue breathing until help arrived. The state’s OEND programs began in 2006 and were expanded throughout the study period, which followed the trained participants until 2009.
During that time, 153 naloxone-based rescues were reported for which there was data on outcomes, and in 98% of those cases, the drug revived the victim. Even more importantly, the study found that the high levels of participation in an OEND program was associated with lower death rates from overdose. Communities in which 1 to 100 people were enrolled in the program per 100,000 in the population had an overdose death rate that was 27% lower than those without such programs. But communities with 100 or more people per 100,000 who had been through an OEND program saw death rates fall by 46% compared to those with no programs. The study controlled for population factors such as poverty and the presence of high numbers of “doctor shoppers” that could have skewed the overdose death rates when calculating the results.
“This study provides observational evidence that OEND is an effective public health intervention to address increasing mortality in the opioid overdose epidemic,” says Walley, “OEND implementation seemed to have a dose related impact, where the higher the cumulative rate of OEND implementation, the greater the reduction in death rates.”
Another recent study of OEND found that the programs are cost effective, showing that one life could be saved for every 36 to 227 kits distributed, depending on the way the costs and benefits were estimated. Even at the higher end, the benefits more than paid for the costs of drug and the training. The training itself is relatively simple, so that most people can be prepared to respond with naloxone in about an hour or less.
There are still practical barriers however, to widely distributing naloxone and implementing more OEND type programs. Advocates have argued that the medication should be made available over-the-counter since it has little potential for abuse and is nontoxic. The Centers for Disease Control (CDC), the director of the National Institute on Drug Abuse and even the drug czar’s office support making it more widely available, and unlike the case with needle exchange programs, there has been no organized opposition to OEND. But the Food and Drug Administration (FDA) has no precedent for allowing over-the-counter sales of such a drug: naloxone is a generic medication approved in an injectable form. Without a company to submit an application for its use in the intranasal version, the agency isn’t likely to OK over-the-counter sales.
“I think that a concerted effort by federal public health agencies, such as CDC, FDA, and Substance Abuse and Mental Health Services Administration is appropriate to investigate the over-the-counter accessibility of naloxone rescue kits,” says Walley. “I believe in the future naloxone kits can be available in the community and in people’s homes in a similar way that automated electronic defibrillators are now available in public to be used even by untrained bystanders.” That, he says, would be a major step toward averting many more deaths from opioid overdose.