Dr. Phillip Coffin compares naloxone–the drug used to reverse the effects of opioid overdoses–to seat belts.
Seat belts can prevent drivers and passengers from dying in a car crash, but seat belts can’t prevent the crashes themselves.
Naloxone can prevent people who overdose on opioid drugs from dying, but it can’t prevent overdoses in the first place. In fact, if you’ve survived an overdose, your chances of overdosing again in the next year are around 25%, says Coffin, director of substance use research at the San Francisco Department of Health.
And your chances of dying from a subsequent overdose are substantial, suggests a Massachusetts study presented Monday in Washington, D.C., at the American College of Emergency Physicians’ annual meeting.
Opioid overdose deaths nearly doubled in that state between 2012 and 2014 and 2014 and 2016, study coauthor Dr. Scott Weiner said at a press briefing.
“Our group was perplexed by this,” considering that naloxone “is now fairly ubiquitous,” said Weiner, an assistant professor of emergency medicine at Harvard Medical School and director of B-CORE, the Opioid Response and Education program at Brigham and Women’s Hospital in Boston. Evzio, an auto-injection device prefilled with naloxone, and Narcan, a prefilled naloxone nasal spray, make it easy for family members, caregivers or emergency responders to administer the drug.
Weiner and his coauthors examined information from linked statewide datasets for patients who had received naloxone at least once from emergency medical services (EMS) from July 1, 2013, through Dec. 31, 2015, about 400 people a month on average. “It’s quite a bit for our small state,” Weiner said.
The researchers then looked to see who among those patients died during the year after they received naloxone. They found that nearly 16% of the patients were dead within a year after receiving naloxone, including 6.5% who died the same day as getting the overdose treatment. Opioid overdose was the listed cause of death for half of the people who died the same day and a little more than a third who died within a year.
“Naloxone is not a panacea solution for this crisis,” Weiner said.
Indeed, despite the increasing availability of naloxone, U.S. opioid overdose deaths have reached an all-time high.
“Since 2000, more than 300,000 Americans have died of an opioid overdose,” FDA Commissioner Dr. Scott Gottlieb told the House Energy and Commerce Committee on Wednesday at a hearing on the opioid crisis. “Preliminary data for 2016 indicate at least 64,000 drug overdose deaths, the highest ever recorded in the U.S.”
Fentanyl, a growing problem in the United States, is deadlier than most opioids. There has been a “rapid increase since 2013 involving illicitly made fentanyl and other highly potent synthetic opioids,” Gottlieb told the House committee.
One reason is that fentanyl overdose deaths happen within minutes, too quickly for a bystander to rescue victims with naloxone, Coffin told me.
On the other hand, he said, death from a heroin overdose takes about a half hour, and in 80% of heroin overdoses, someone else is there to see it and respond. In 1995, most overdose deaths were due to heroin, but by 2010, prescription opioids had overtaken that illicit drug, Coffin said.
Naloxone is not the problem. “Naloxone is critical. It’s essential,” Coffin said. “It has demonstrated effectiveness in settings where heroin and prescription opioids are the primary driver of mortality.”
But, he said, despite the increasing number of deaths, opioid users and physicians are misinformed about overdoses. “Half of the patients prescribed opioids who had overdosed denied overdosing.” Instead, they say they had a “bad reaction.”
“They’re not being euphemistic,” said Coffin, who once interviewed a patient who had experienced 15 overdoses reversed by naloxone but still denied ever overdosing. “They don’t recognize it as an overdose.”
That’s because they think only junkies who shoot up heroin or suicidal individuals who swallow an entire bottle of Oxycontin pills overdose, he said.
“Doctors don’t know what overdose means either,” Coffin said. “Everyone thinks it means misusing your medication.” In reality, he said, an overdose occurs when you have more opioids in your body than you can tolerate in a given situation. For example, you could take your prescribed dose, but your sleep apnea increases the risk of opioids suppressing your breathing. Or you might wash down your prescribed opioid dose with a few glasses of wine or follow it with a tranquilizer chaser, combinations that could also lead to an overdose.
Historically, not even drug treatment programs have asked patients if they’ve ever overdosed, Coffin said. “It’s not in the questionnaire when you go into a drug treatment program,” he said. “We need to start talking about overdose with anyone who uses opioids.”
In REBOOT, counselors meet one-on-one with overdose survivors for 45 minutes, reviewing how to recognize an overdose and respond to it and how to identify behaviors that increase the risk of an overdose. Counselors also ask whether the survivors are interested in substance use disorder treatment and emphasize the usefulness of morphine or buprenorphine in reducing the risk of an overdose.
Coffin and his collaborators enrolled 63 people from San Francisco’s naloxone distribution program, the Drug Overdose Prevention and Education (DOPE) Project. About two-thirds of study participants had been born men, and their average age was 43. They were opioid dependent, had experienced an overdose in the previous five years and had previously received naloxone. Most were homeless.
They were randomly assigned to participate in REBOOT or receive “treatment as usual,” informational brochures and referrals to treatment, which is typically what people get after recovering from an overdose. Study participants had followup visits 4, 8, 12 and 16 months after their initial session.
Coffin and his coauthors found that REBOOT significantly reduced the occurrence of any opioid overdose and the number of overdoses compared to treatment as usual. They emphasized that theirs was only a small pilot study that needs to be repeated in a larger full trial, which, Coffin said, they are planning with a partner on the East Coast.
“At the moment,” he said, “the minimum I’d say is this study suggests putting the time into talking to people about overdose may be beneficial.”