The Doctor Weighs In

By Pat Salber

If you haven’t spent time in emergency rooms or drug treatment centers, then what I am about to tell you may seem (to use 60’s jargon) really far out. But, stay with me to the end. I think this new approach to opiate overdose has the potential to save lives – and, at the end of the day, isn’t that what we believe medicine is all about?

For those of you who haven’t taken care of people who have overdosed on heroin or other opiates, there are a few things you should know:

• Heroin, when injected in large enough doses, suppresses critical brain functions and can shut off the drive to breathe. When that happens, unless the person is given an antidote to the effects of heroin on the brain, such as naloxone, the person will die for lack of oxygen (anoxia).
• Naloxone is usually administered by injection in order to resuscitate an individual with a heroin overdose.
• Naloxone administration is usually administered only by health professionals (paramedics, emergency physicians).
• The person who overdoses at home or on the street will only be successfully resuscitated if someone is with them who can call 911 and if 911 responds rapidly enough so that naloxone is administered before anoxia causes overwhelming brain damage.
• Naloxone is relatively safe when administered in the setting of a heroin overdose (i.e., it produces more good than harm)

So, given all of this, it is reasonable to ask: why not give people at risk (e.g., heroin addicts (and/or their families, friends, co-habitors, etc.) prescription naloxone to be administered “in case of emergency?” We give families, friends, co-habitors of insulin-using diabetics prescription glucagon, an antidote to administer in the case insulin shock (aka, extremely low blood sugar due to insulin injection).

Well, would it surprise you that, maybe, just maybe, folks feel differently about victims of insulin overdose than they do about victims of heroin overdose – even though the underlying risk factors for both are have genetic determinants?

A brief article in the NY Times Health section (Dec. 11, 2007, ) by Dan Hurley provides us with some reactions to a proposal by “growing numbers of researchers and public health officials advocating a daring new strategy to put an injectable antidote for heroin overdoses directly into the hands of addicts.”

As usual, the story opens with the story of one individual, but one uniquely positioned to educate us about heroin addiction. Mark Kinzly, an ex-addict working in a needle exchange program, tells the story of overdosing on heroin after 11 years of not using the drug. He was watching a ballgame when he passed out in a colleague’s apartment. His colleague, also working in the addiction field, “dialed 911 and then injected naloxone.” He saved Mr. Kinzly’s life – and, is, therefore, in my book,  a medical hero.

Dan O’Connell, director of HIV Prevention in the New York State Health Department, which supports “in-home” naloxone programs, says:

“From a public health perspective, it is a no-brainer. For someone who is experiencing an overdose, naloxone can be the difference between life and death.”

I agree.

I have a hard time coming up with any downsides to the naloxone programs. Naloxone is safe. Heroin overdoses are deadly. Naloxone doesn’t “cause” heroin addiction, it just saves addicts from fatal overdoses.

But bias and beliefs, of course, always come into play in any public policy discussion. Dr. Bertha Madras, deputy director for demand reduction at the White House Office of National Drug Contrrol Policy is quoted in the Times as saying of the naloxone program:

“It’s based on what some people would consider the right thing to do.

[SO????]

“But the studies supporting it are so sparse it’s painful.”

[OK, Bertha, tell me what kind of study you want to do here? We know the first line antidote for heroin overdose is rapid administration of naloxone. We know that delay in administering naloxone is associated with brain damage and, in some cases,death. So are you suggesting we design a study to compare the outcome of delayed naloxone administration (via paramedics) with quick naloxone administration via a roommate in the face of overwhelming evidence that naloxone has no significant side effects when administered to reverse a heroin overdose?? I wonder if you could even get that kind of study approved by an Institutional Review Board (IRB)?]

I think the real issue here is that Dr. Madras seems to be more worried that naloxone in the home could mean that some addicts may feel more comfortable with the risks of their addiction and therefore will not be amenable to reform. She is quoted again as saying, “in the absence of scientific evidence we don’t engage in policies that bring more harm than benefit.”

I am a #1 fan of evidence-based medicine, but Dr. Madras doesn’t quite apply it correctly here. The evidence has unequivocally demonstrated that rapid administration of naloxone reverses fatal outcomes of heroin overdoses. It also documents that it is a safe antidote to a heroin overdose. Where there is no evidence base is her (presumed) premise that somehow having naloxone in the home of an addict will lead to fewer recoveries from addiction than would occur in homes of addicts without access to heroin.

According to the NY Times article, a study in San Francisco’s 2005 pilot program found that of 20 overdoses witnessed by addicts trained to administer naloxone and CPR, all 20 survived. Dr. Sharon Stancliff, medical director of the Harm Reduction Coalition which operates a naloxone distrubution and training program in New York and San Francisco [those hot beds of bleeding heart liberals] found-

“We are just beginning to get really good evidence that it’s [a naloxone program] associated with a significant reduction in ovedose deaths….and we know it’s safe. We’re not seeing any bad outcomes."

Come on guys, open your minds and your hearts. This is an innovation that has the potential of saving lives. No, it doesn’t cure addiction. But it does keep an addict alive and, therefore, open to the possibility of overcoming his/her addiction.  Ask any mother, father, sister, brother, spouse, child, or friend of an opiate addict.  I think you will learn that saving the lives of their addicted loved ones is definitely a goal we, as a society, should shoot for…Thank heavens for innovators and free-thinkers such as the folks who thought up this approach…they benefit us all in ways we could never fully imagine.

If you would like to read more about this topic there is a good review in the Annals of Emergency, February, 2007