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Is Naloxone an Ethical Tool in our Recovery Toolkit?
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Cecelia Jayme, Director Clinical Services
Hazelden, Part of the Hazelden Betty Ford Foundation
Member of the MARRCH Ethics Committee

Naloxone is a drug that has been around a long time. It was patented in the early 1960’s as an opiate antagonist. In 1971 the US Food and Drug Administration approved it for treating opioid overdoses by intravenous or intramuscular injection (American Chemical Society, 2016). It had miraculous results, the overdose patient, appearing to be at the point of death, would often begin breathing and regain consciousness immediately. Unfortunately, the only people who had access to the injectable naloxone were MDs and EMTs. In other words, by the time help arrived, it would often be too late.

In 2015, The FDA approved a nasal spray version of naloxone. Stephen Ostroff, the acting FDA commissioner at the time, is quoted as saying, “We cannot stand by while Americans are dying. While naloxone will not solve the underlying problems of the opioid epidemic, we are speeding to review new formulations that will ultimately save lives that might otherwise be lost to drug addiction and overdose.” The nasal spray version has made administration of the drug easy, and it is available without a prescription in 46 states, including Minnesota (Skwarecki, 2017).

It is often a family member who discovers the lifeless body of an overdose victim. The helplessness experienced in that moment is profound. In substance abuse treatment, we have long been aware that the identified patient is only part of the whole addictive process. The families, friends, employers and community are all impacted by substance abuse. We are also aware that the chances of overdose on opioids are significantly increased should a patient relapse following a period of abstinence. It would seem that having open and honest conversations with a patient and those who are involved with the patient in order to educate them on how to access, store and administer naloxone would be considered a best practice.

There are those, however, who feel that having these conversations is counterproductive since the whole purpose of treatment is to interrupt the addictive cycle. Some Substance Use Professionals I have spoken with state that the discussion about naloxone in the case of an overdose instills a lack of confidence in the patient, and elicits fear in the loved ones. While I empathize with these perspectives, I disagree with the philosophy of avoiding these difficult conversations for the sake of maintaining a therapeutic alliance. I would actually challenge whether a true therapeutic alliance exists if having difficult conversations will rupture it. My goal is now, and has always been, to be honest and forthright with a client and with the people in significant relationships with the patient where allowed by the patient. The reality is that far too many opioid clients die of their disease before they have a chance to gain the external supports and internal strengths to maintain forward progress in their recovery efforts. Naloxone in the hands of a parent or significant other of an addicted patient does not suggest that there is not confidence in the patient. It does however offer a tool should the worst-case scenario occur.

The World Health Organization (WHO) recommends that naloxone be made available to people likely to witness an overdose as well as training in the management of overdose since most overdoses are witnessed by a friend or family member who may be able to reverse the effects of the opioid overdose while waiting for medical care to arrive (World Health Organization, 2014). This is not intended to be instead of medical attention, it is in order to allow the patient a chance to receive medical attention. The CDC identified 15,466 deaths from heroin overdoses in 2016 while 20,145 deaths were caused by fentanyl or other synthetic opioids (CDC, 2017). The number of deaths continue to rise.

Among the ethics of our profession is the ethical responsibility to empower clients and their families to move forward to self-sufficiency. It is very difficult to achieve that self-sufficiency when living in a realistic fear of finding one’s loved one dead or dying of an opioid overdose with no option other than to call 911 and hope they arrive in time. I would venture to say it would be very much like living on the seacoast with a child who has shellfish allergies and no access to epinephrine. I fully believe that we can support those who love addicted people who are at risk. We can help them to understand that they did not cause the addiction, that they can’t control the addicted person, and no matter how much they care, they cannot cure the addict. I also believe that we can educate and equip them to respond to a crisis in the addiction. We can educate them about Naloxone. We can support them in insisting that the people in their communities that interact with at risk people have education and access to Naloxone.

Is Naloxone an ethical tool in our recovery tool kit? Yes! We work with patients and their families on realistic recovery plans, and within these recovery plans we help them develop relapse prevention and relapse response plans. For a client presenting with an opioid use disorder, having naloxone at the disposal of the people most likely to find them should they relapse and overdose is not only ethical, it is a best practice.

References

  1. American Chemical Society. (2016, May 23). Naloxone. online. Retrieved from https://www.acs.org/content/acs/en/molecule-of-the-week/archive/n/naloxone.html
  2. CDC. (2017, August 8). PROVISIONAL COUNTS OF DRUG OVERDOSE DEATHS, as of 8/6/2017. online. Retrieved from https://www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdf
  3. Skwarecki, B. (2017, Oct. 27). Narcan Is Now Available Over the Counter in 46 States. online. Retrieved from https://vitals.lifehacker.com/narcan-is-now-available-over-the-counter-in-45-states-1819896107
  4. World Health Organization. (2014, November). Management of substance abuse - Information sheet on opioid overdose. online. Retrieved from http://www.who.int/substance_abuse/information-sheet/en/

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