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For rural residents, carrying around a dose of naloxone should be as common as learning first aid, an addiction doctor says.
Dr. Mark Calarco, national medical director for clinical diagnostics at the American Addiction Centers in Brentwood, Tennessee, argues that having naloxone isn’t just for people taking opioids and their family and friends – it’s for everyone, if they want to save lives.
Naloxone is an opioid antagonist that binds to opioid receptors to reverse the effects of opioids. In an overdose, it can quickly work to restore normal breathing.
Naloxone is available in three forms – injection, auto-injection, and nasal spray. The most common form of naloxone is the nasal spray, known as Narcan.
Calarco, who spent a decade in rural health, said the time saved by carrying around Narcan is critical in saving people, especially in rural areas.
“We know that a lot of rural areas in the United States have huge substance use and opioid use disorder issues. It’s a huge problem,” he said. “And so it’s important, if not more important for rural residents to have a dose of Narcan because of the time it takes EMS to get to a rural area. And they maybe even should have more than one. Probably they should have two.”
Rates of drug overdose deaths have been rising across American since 2006, according to the Centers for Disease Control and Prevention (CDC). In rural areas, overdose deaths from natural and semisynthetic opioids, as well as psychostimulants like methamphetamine, is higher than in urban areas.
With the effects of lockdowns and stay-at-home orders stemming from the Covid-19 pandemic increasing feelings of isolation and anxiety, public health officials are seeing more substance misuse across the country. That can lead to overdoses. In fact, more than 40 states across the country have noted increases in overdose deaths averaging 18%. Officials say about two-thirds of these deaths are from opioids.
Calarco said rural residents in recovery are at greater risk for having an opioid relapse because of Covid-19.
“The thing about Covid that’s been so challenging, and has been why we’re seeing more crisis calls, is that it particularly packs a punch for rural areas because of the social isolation,” he said. “People in rural areas are already kind of isolated geographically. And when people in rural areas are in treatment for a substance use disorder, they need face-to-face contact. You need that social interaction for your recovery… so, with Covid, people in rural areas lost that because of the restrictions.”
Previously, U.S. Surgeon General Jerome M. Adams, M.D., has said that naloxone should be “within reach” of “patients taking high doses of opioids for pain, individuals misusing prescription opioids, individuals using illicit opioids such as heroin or fentanyl, health care practitioners, family and friends of people who have an opioid use disorder, and community members who come into contact with people at risk for opioid overdose.”
Calarco said that the definition should be expanded. Just like being able to help someone having a heart attack by learning CPR, having naloxone could save someone’s life.
“The chances are very high that you may be exposed to somebody who has an overdose,” he said. “We know that this is common. And so, to be a good member of society and to help other members of society, even if you don’t know them… if you save somebody’s life, that’s just good karma all around.”
Calarco said rural residents can train themselves on the signs of an overdose through YouTube videos or other resources online, so they know when and how to use the drug. Some symptoms of an overdose include purple lips and fingernails, clammy skin, shallow breathing or not breathing at all, and pinpoint pupils, he said.
Even if someone gives a dose of naloxone to a person who isn’t in the middle of an overdose, the likelihood of harming them is slim.
“There is no danger in giving Narcan needlessly. If a person isn’t overdosing, administering the drug won’t harm them. Not only is it a benign medication, you don’t even have to be directed by a first responder to administer it,” he said.
Calarco said the goal is to buy time.
“After you administer the naloxone, you just roll them on their side because they can vomit,” he said. “But it’s very important that people contact EMS, right away. Some drugs like fentanyl are 1,500 times more potent than morphine and heroin. If you give them a dose of naloxone, you keep them from having brain damage, but the dose may not be sufficient to prevent them from relapsing into respiratory depression again. That dose buys you time, just like CPR does (during a heart attack) while you’re waiting for the health care professionals to arrive. But if you don’t (administer the naloxone) within a very critical window period of the first two to four minutes, it can spell really bad outcomes afterwards.”
Currently, Narcan is available for purchase without a prescription in every state, although state laws about its purchase may vary. According to Emergent Biosolutions, 97% of insurance packages cover the Narcan. Nearly 50 percent of insurance plans provide access to Narcan with no co-pay, and 75 percent of insurance plans have a co-payment of $20 or less, the company said.
However, sometimes, pharmacists and doctors may not know what the law is, Calarco said.
“We’re trying to get the word out to pharmacists and to the general public,” he said. “It’s not always translating down through to the pharmacies and healthcare practitioners.”
Having the medication shouldn’t be restricted to just those who use opioids or their friends and family, Calarco said.
“Whether people want to believe it or not, the (opioid) epidemic is going to keep on rolling,” he said. “This is a way to save lives.”
EDITOR’S NOTE: The federal Centers for Medicare and Medicaid maintains a database of drug company payments to physicians and teaching hospitals. The database indicates that Dr. Mark Calarco has received no payments from the manufacturer of Narcan, Emergent Devices, Inc.