Some good news in the opioid epidemic as we try to save lives

In recent years there has been a dramatic increase in usage of and harms from opioid medications. Perhaps you have seen media reports or followed high-profile lawsuits about it: Medications intended to relieve suffering also led to dependence and misuse. What you may not know is that over 80,000 people in the U.S. died from overdosing on opioids in 2021. Recognizing this epidemic, the Food and Drug Administration (FDA) made a very important decision earlier this year to allow people to get a life-saving medication to reverse an overdose over the counter without a prescription. It is called Narcan – an easy to administer formulation of the drug naloxone.

As a physician, I have provided this treatment since some of my early days. In fact, saving a life with naloxone was one of the first “code blue” emergency situations I was in charge of as a medical resident. Administering naloxone has become a common occurrence for emergency responders, but I’m writing to tell you that naloxone isn’t just for health professionals. It isn’t just for those with an opioid prescription either. With a little bit knowledge anyone can recognize the signs of opioid overdose and give this life saving treatment.

Naloxone is a medicine used during emergencies to reverse the physiologic effects of opioids including heroin but also pain medicines such as hydrocodone, oxycodone, fentanyl and morphine. Too much of an opioid can slow or stop breathing which is a life-threatening emergency. If naloxone is given soon enough, it may save a life. It might sound intimidating to intervene in an overdose situation, but the formulation approved for over-the-counter use is given as a nasal spray that can be learned to use easily with the assistance of instructions included with the packaging.

When I was in my training as a physician, I used to enjoy hearing the more dramatic stories shared by teaching physicians, and as my training progressed, I accumulated a few stories of my own. In our last year of training, we were expected to run the “code blues,” the most serious of medical emergencies in the hospital. I still remember many of these code blue events, including the very first that I led.

 My team had finished rounding in the morning and were busy checking off the many items we needed to complete for our patients that day, when I heard the code blue announced on the hospital’s speaker system overhead. Code blue announcements were a frequent occurrence, but knowing I was leading the codes that day, I immediately stopped what I was doing and listened intently for the room number.

I took off at a brisk jog down the hall. Team leaders carried a key that allowed us to get first priority for elevators, but even so it was always faster to take the stairs. I flew down the four flights and I was the first one there. I looked to the hospital bed expecting to see an unconscious patient in need of CPR (cardiopulmonary resuscitation), but I was surprised to see a young man awake and sitting up in bed.

Perhaps I had gone to the wrong room, I thought. Sensing my confusion, the patient lifted one arm and pointed to the bathroom. Turning I saw someone dressed in street clothes and lying on the floor. He was not breathing. I felt for a pulse, and it was there – weak and slow but there. His skin was cold and clammy. I opened one eyelid and saw small and pinpoint pupils. I called for a dose of naloxone, the reversal agent for opioid overdoses. The medication was given, and as the team prepared to perform rescue breathing with a bag-mask system, the young man began breathing on his own and a moment later was sitting up, awake.

It was a close call, and I was relieved to see him doing well after coming so close to a very different outcome. I was also relieved that I had made the right call. In retrospect, what I had done wasn’t very impressive.

The signs of opioid overdose are easy to recognize for those who know what they are. The medication is easy to administer and works quickly. Even if I had gotten the diagnosis wrong, the medication is harmless to those without opioids in their blood stream.

Approving naloxone for over-the-counter availability is a timely decision since our country is in the midst of an opioid epidemic. Between 1999 and 2019, the number of overdose deaths involving opioids increased more than 500%. Estimates of opioid misuse in the U.S. range between 3-4% of adults.

To date the federal and state governments have taken many steps aimed at improving safe prescribing. This includes rules for clinicians on the prescribing of these potentially dangerous medications as well as better transparency of controlled substance prescriptions between pharmacies and prescribers. Emergency medical responders have also responded with training on the management of overdoses as well as carrying naloxone. All of these reforms have helped but they focus on healthcare professionals.

Now, people who rely on pain medications, people who have addiction issues, and their loved ones and the public can all choose to get a naloxone take home kit in case of an emergency.

This is means a life-saving medication is accessible to everyone without a prescription. The branded version that is available over the counter is easy to use – just a spray into the nostrils. It does not require years of training or a degree as a health professional to administer. This is important because most opioid overdoses don’t happen in a hospital with health professionals around. They are often unpredictable and unexpected.

Recently, someone else’s story about naloxone was relayed to me about a woman who carried the medication in her purse because her aging parent relies on prescription pain medicine, so there is risk of inadvertent overdose and respiratory compromise. She was taking a walk in her town and a teenager was shouting that his friend had overdosed. A small crowd had gathered around the teen on the sidewalk who was barely breathing. The woman handed the Narcan to a man there who said he knew how to use it and they revived the teen. Just having the bottle in her purse at the right time may have saved this young life.

A little bit of knowledge can help you recognize the signs of opioid overdose. They include appearing tired or sleepy, cold and clammy skin, small and pin-point pupils and slow or absent breathing. This last sign of opioid overdose is the most important because when breathing stops life is threatened.

Narcan comes with detailed instructions of how to apply the device to the victim’s nostril and spray the medication. From the nasal mucosa it is rapidly absorbed and takes effect. Even the fastest emergency responses can take many minutes, but now, it is possible for you can do something about an opioid overdose while waiting for professional help to arrive.

Like a fire or a motor vehicle accident, opioid overdoses are unexpected, but that is why we have fire extinguishers and safety belts. Now we have over the counter Narcan. Taking a few minutes to prepare for the unexpected could make all the difference for a loved one or a stranger. This December, in a season of giving, consider giving the gift of a second chance.

Peter Barkett, MD, practices internal medicine at Kaiser Permanente Silverdale and writes a regular column for the Kitsap Sun. He lives in Bremerton.