“First, do no harm” is one of the promises most medical students make as they become doctors.
In that sense, the plan laid out last week by the U.S. surgeon general involving opioid overdose antidotes fits the bill.
However, whether that proposal is practical and whether it’ll even make a dent in the nation’s opioid epidemic is a matter of debate.
Last Thursday, Dr. Jerome Adams issued a national advisory urging a large portion of the nation’s population to carry with them overdose antidotes containing the drug naloxone.
The targeted groups include people who take prescribed opioids for pain and those who are misusing prescription drugs and illicit opioids, as well as their family members and friends.
It was the first national advisory issued by a surgeon general since 2005, when pregnant women were urged not to drink alcohol.
In his advisory, Adams urged patients and the public to learn the symptoms of an opioid overdose and to be trained in how to administer naloxone.
Adams also urged physicians, pharmacists, and other medical providers to learn to identify people who are at high risk of opioid overdoses and then prescribe or dispense the antidote drug to them.
“You have an important role to play in addressing this public health crisis,” Adams told both patients and the public.
In his message, Adams cited statistics from the Centers for Disease Control and Prevention that show that more than 42,000 people in the United States died from opioid overdoses in 2016, up from 21,000 in 2010.
Adams also pointed out that 77 percent of opioid overdoses happen outside of medical facilities. More than half occur at home.
Experts in the medical community say the surgeon general’s initiative certainly can’t hurt. First and foremost, naloxone is a safe drug that’s relatively easy to use. Without a doubt, it saves lives.
“Surgeon General Adams, physicians, first responders and public health advocates all recognize that naloxone is a literal lifesaver and a vital tool in our fight against the opioid epidemic,” said Dr. Patrice Harris, MA, chair of the American Medical Association Opioid Task Force, in a statement sent to Healthline. “Patients, family members and friends should not hesitate to ask their physicians to prescribe naloxone so they can save their own or their loved one’s lives.”
“It’s nice to see the surgeon general come up with this very important policy,” added Jon Zibbell, a senior public health analyst in the behavioral and urban health program at RTI International research foundation in Washington, D.C. “It’s something you can look at as a public health crisis that can affect anybody.”
Dr. Caleb Alexander, the co-director of the Johns Hopkins Center for Drug Safety and Effectiveness, says the campaign, if nothing else, can educate people.
“Advocacy raises awareness. It plays an important role,” he told Healthline.
However, Alexander said reducing the number of opioid prescriptions and getting people who are addicted to the drugs into treatment programs are more effective tools.
“There are no magic bullets,” he said. “We shouldn’t rely on naloxone to get us out of this mess.”
“It’s a good step in the right direction,” added Dr. Indra Cidambi, an addiction medicine specialist and the medical director at the Center for Network Therapy in New Jersey. “But what happens [after administering naloxone] is the most important.”
Two antidotes available
There are two naloxone-based drugs approved by the U.S. Food and Drug Administration for the general public to use to try to reverse the effects of an opioid overdose.
The best-known and most commonly used is Narcan. It’s a nasal spray manufactured by Adapt Pharma.
The other is Evzio, an auto-injector manufactured by Kaleo Inc.
Within hours of the surgeon general’s advisory, Adapt Pharma sent out a press release announcing a strengthened partnership with CVS Health, Walgreens, and Harvard Pilgrim to improve access to Narcan.
The antidote is already available at CVS stores in 49 states without a prescription.
“We’re very encouraged by the proposal,” Mike Kelly, Adapt’s president of U.S. operations, told Healthline. “It’s something we’ve been trying to get people to do.”
Kaleo executives also sent out a press release the day the plan was revealed. Among other things, the company announced a new initiative to expand access for the public to Evzio.
The initiative is a “virtual standing order” where residents of six states (California, Arizona, Colorado, Missouri, Nevada, and Ohio) can obtain Evzio for no cost and without a prescription by calling a toll-free number.
This is in addition to the company’s current program called EVZIO2YOU, where people in the United States with commercial insurance and a prescription can get Evzio at no cost.
“The surgeon general’s call to action is a bold and necessary move to encourage everyone to learn about the signs and symptoms of an opioid overdose and arm themselves with potentially lifesaving naloxone,” a Kaleo representative told Healthline in an email.
If the public heeds the recommendations by the surgeon general, both Adapt and Kaleo would likely reap a financial windfall.
However, representatives from both companies say the initiatives are about more than just sales and profits.
“We don’t view this as a windfall. We view this as an obligation,” Kelly said. “We believe in broad awareness and broad access.”
“Our commitment to expand access to Evzio is about ensuring that patients who need naloxone can get it,” the Kaleo representative added. “And these new initiatives are in line with our ongoing commitment to patients and affordability.”
Kelly said officials in the surgeon general’s office had been in contact with Adapt executives to garner input for the proposal. He said the company was aware of the antidote plan a few days before it was announced.
Kaleo representatives said they also met with various administration officials to provide input.
How would this work?
Virtually everyone agrees that Narcan and Evzio saves lives.
In fact, the city of San Francisco has been educating the public and organizations about Narcan since 2003.
The city has also formed partnerships with community organizations and has trained more than 10,000 people on how to recognize an overdose and then administer Narcan.
The city also makes the antidote available for free at more than 15 locations.
As a result, San Francisco has one of the lowest fatal overdose rates in the United States.
The big question is whether this approach can work on a nationwide basis.
There are a number of issues surrounding the surgeon general’s proposal.
Among them is the practicality of getting millions of people to carry an overdose antidote.
Zibbell told Healthline there are two groups to target.
The first is the people who misuse prescription and illicit opioids as well as their family members, friends, and people they encounter in daily life.
The second is members of the general public who are willing to assist someone who is overdosing.
“There is evidence that it is really effective when you get naloxone into the hands of lay people,” Zibbell said. “Make it so anybody who wants it can get it.”
No one disputes that Narcan and Evzio are safe.
Narcan is a nasal spray that’s pretty easy to use. Evzio is an injector that has voice commands that walk a rescuer through each step.
Experts also told Healthline that giving an antidote to someone who isn’t overdosing won’t harm them.
They also said there are no health dangers if a child or someone else accidentally uses the antidote on themselves.
“Narcan is safe and effective,” said Alexander.
Dr. Nora Volkow, the director of the National Institute on Drug Abuse (NIDA), agrees.
“If you were (accidentally) injected with the drug, you’d feel nothing,” she told Healthline.
Will it make a difference?
Even if most everybody carries an antidote and uses it properly, there’s some debate over whether the surgeon general’s plan would have a measurable impact on the opioid crisis.
For starters, there are those who say antidotes such as Narcan and Evzio actually set back efforts to reduce opioid use disorders.
Their argument is that people with an opioid addiction might not enter treatment programs if they figure they’re going to be saved if they overdose.
That contention as well as other reasons prompted a sheriff in Ohio to tell his deputies last summer to stop carrying Narcan.
In another part of Ohio, a city council representative said police in his town shouldn’t respond to a home if the emergency involved a third overdose by the same person.
Alexander finds these theories to be illogical.
“That makes about as much sense as taking away seat belts and air bags from people who drive too fast,” he said.
Zibbell agrees, saying these contentions aren’t based in fact.
“When people don’t go into treatment, it’s not because of naloxone,” he said.
Zibbell, in fact, says people with opioid use disorders don’t like naloxone. When they awake from treatment, they feel ill and actually go through withdrawal symptoms because of the way the drug works.
“People don’t want it. It really should be used only as a last resort,” he said.
Cidambi notes that when people are revived and taken to a medical facility is a crucial time to try to get them into treatment programs.
“If there’s no support system, then you are setting them up. Then, they go looking for the drug,” she told Healthline. “We should be focusing more on treatment.”
Volkow is in agreement.
“When you are given naloxone, you feel awful because you go into withdrawal,” she explained. “That person will go out and seek drugs.”
“You have to do everything you can to steer them into treatment,” she added. “That time is a unique opportunity to engage them.”
Alexander agrees the focus should be on reducing the number of opioid prescriptions in the country and convincing people with opioid addictions to get into treatment programs.
“At the end of the day, opioid use disorder is a chronic disease,” he said. “Patients need access to good treatment.”
Kelly said Adapt executives agree that the antidote is only part of the solution.
“Narcan is not the solution to the opioid epidemic. It’s only part of the solution,” he said. “The first priority, though, is to save lives.”
Kelly said antidotes like Narcan can be a “bridge” between someone overdosing and getting into treatment.
Zibbell agrees that a multipronged approach is needed. But first, he notes, you have to save people’s lives.
“The first we need to do is keep people from dying so they can make choices afterward,” he said.
Zibbell also believes the country can focus on antidotes, treatment, and prescriptions at the same time.
“We can do multiple things on this all at once,” he said.