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Running head: OPIOID OVERDOSE AND FIRST REPONDERS 1

Opioid Overdose and First Responders: How Naloxone Administration Can Save Lives

Eastern Michigan University

Damonica Gomez-Samuel
OPIOID OVERDOSE AND FIRST REPONDERS 2

The alarming rate of preventable deaths per year due to opioid overdose is stocking, and

is now labeled a national opioid epidemic. The American Society of Addiction Medicine

(ASAM) stated that overdose is the leading cause of accidental death in the U.S. claiming more

than 47,000 in 2014. Healthcare, governmental, and community organizations cant agree on

how to slow the trend or stop the deaths caused by overdoses. The need to intersect deaths and

recovery users has caused non-medical first responders like police authorities and firefighters to

be equipped with the antagonizing opioid agent, naloxone. Some researchers protest the

approval of first responders and bystanders administrating naloxone during an overdose. Using

peer reviewed based researched journals, this paper will give attention to the positive and

negative aspects, the reasons for supporting or opposing against nonmedical first responders like:

police, and firefighters administering naloxone. And consider possible consequences of not

giving naloxone, and discuss possible barriers for better patient outcomes when compared to

current systems already in place. Ideally, this position statement will initiate deliberate

conversations among healthcare leaders and politicians to make advances toward regulation and

control over the current crisis that has drastically affected and crossed all social, economic, and

racial classes.
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Over the past decades, overdoses caused by heroin and prescribed opioids have caused

unnecessary and preventable deaths. Deaths due to overdose continue despite substance abuse

rehabilitative inpatient clinics, counseling, and other interventions to stop opioid abuse. The

American Society of Addiction Medicine (ASAM) found that drug overdose is the leading

cause of accidental death in the US. There was 52,404 lethal drug overdoses in 2015 with

20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related

to heroin in 2015. In 2010, West Virginia had the highest drug poisoning death rate of 28.9 per

100,000 people (Beheshti et al 2015). To say that there is an opioid crisis is a complete

understatement of reality. The current events prove that it is a national epidemic. Overdosed

deaths will continue because the addiction cycle is difficult to break and usually starts with

prescribed opioids that progresses into opioid tolerance. Tolerance eventually becomes

dependence, which grows into abuse. As abuse continues it culminates into addiction and death

caused by overdose. For people struggling with addiction, it is difficult to watch them destroy

their lives, witness multiple overdoses, become unconscious, and risk death. Studies show

abstinence and full recovery is impossible for most because overtime neurobehavioral

adaptations Kerensky (2017), occur and become embedded with each opioid use. This

environment has created an unrelenting addiction cycle that is said to be impossible to break.

In response to the current opioid epidemic, The US Department of Health and Human

Services has set three priority areas that address the current opioid epidemic: (1) opioid

prescriber education, (2) community naloxone access, and (3) improved access to medications

for opioid use disorder. Studies show heroin uses usually started with abusing prescription

opioids, hence the need for prescriber education and monitoring cannot be overstated. Opioid
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overdose education and community naloxone distribution (OEND) can actually reduce overdose

death rates Kerensky (2017). There is growing interest in and minimal opposition to overdose

education and naloxone distribution (OEND) programs Muller et al (2015). These programs are

vital in the community and offer overdose response training that includes calling 911, rescue

breathing, administering naloxone, and staying with the victim until recovery or help arrives

Mueller et al (2015). These state sponsored programs aim to prevent or reduce fatalities by

providing naloxone to users or persons addicted to opioids, outside of a medical setting, and

offer training on opioid overdose prevention, recognition, and response Muller et al (2015).

However, overdose education and naloxone distribution (OEND) clinics are only offered in some

states, and more local naloxone distribution programs are needed to meet the demand. Bazazi

(2010) said, naloxone distribution programs remain among the last harm reduction programs to

be implemented widely. Research proved that from 1996 to 2010, OEND programs had trained

and distributed naloxone to over 50,000 persons and reported that over 10,000 overdose

reversals were made during that time Mueller et al (2015). In 2010, a community coalition in

Revere, Massachusetts, requested that the citys reghters be permitted to administer naloxone

through the OEND program. Fire fighters were the first to arrive even before the EMS service.

Revere became the rst re department to join the OEND program and all reghters were

trained on the proper use of naloxone, and all of their vehicles were equipped with IN naloxone

kits. Between 2010 and 2013, Revere reghters administered naloxone 114 times Davis et al

(2014). In addition, in 2017 The Centers for Disease Control and Prevention (CDC) awarded

$28.6 million in additional funding to 44 states and the District of Columbia to support their

responses to the opioid overdose epidemic. The funds will be used to strengthen prevention

efforts and better track opioid-related overdoses (CDC 2017).


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Before 2017 only a fraction of the states offer OEND training, this may imply that drug

users are considered an unpopular population that carry a negative social perception and

overdose deaths affect poor racial minorities who cycle in and out of the criminal justice

system Bazazi (2010). This notion may have influenced and possibly delayed the creating and

making policy changes for drug users who are considered a low social priority. Some opposed

to improved access to naloxone, feel that this population cannot handle the responsibility of

administering naloxone during an overdose Doyon (2014). They highlight that the wide

distribution of naloxone opioid use has actually increased opioid use and that naloxone only

offers abusers a false sense of security Doyon (2014). The same author highlighted that only

10 60 % of cases were being reported to 911 by bystanders. It is argued that this hesitation may

be due to concerns of police involvement, or outstanding warrants, confiscation of naloxone,

drug seizures, fear of eviction, and threat of arrest or incarceration Doyon (2014). Some argue

that when they witness an overdose, they delay calling 911 for fear of arrest of heroin

possession, a pre-existing warrant, or because of fear of jeopardizing their housing Muller et al

(2015). Skeptics argued that when naloxone is used, overdose survivors are unlikely to seek or

engage wholeheartedly in addiction treatment (Kerensky 2017). They argue that first responder

naloxone administration enables opiate users to reverse an overdose without being admitted to a

medical setting and that it delays entry into a drug treatment program Bazazi et al (2010). In

addition, it allows people to continue using opiates without facing some of the negative

consequences of opiate misuse. Bazazi et al (2010). Many agree that having naloxone might

reduce the likelihood that emergency services would be called, but according to Bazazi et al

(2010) no data demonstrate this. In fact, a study done on one prevention program in New
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York City found that 74% of participants called for help after administering naloxone.

Available naloxone kits would be beneficial for this group because they are acting as first

responders.

When an overdose occurs and 911 is called, police and firefighters usually arrive before

the EMS. These first responders must be equipped with naloxone in order to save lives. In 2010

the Office of National Drug Control Policy stated that naloxone should be in the patrol cars of

every law enforcement across the nation Davis et al (2014). States like Michigan permit police

to carry and administer naloxone. However, in a few police authorities dont have the option to

administer naloxone and save lives. According to Wootson (2017) Sheriff Richard Jones of

Butler County, Ohio, refuses to let his police officers carry Narcan (naloxone). Even the spray

form is rejected. He stated We don't do the shots for bee stings, we don't inject diabetic people

with insulin. When does it stop? Then he went on to say I'm not the one that decides if people

live or die. They decide that when they stick that needle in their arm. In addition, Jones's claims,

that naloxone recipients wake up agitated and ready to fight Wootson (2017). Although Sheriff

Jones view is extreme many critics silently agree with him. They dont understand that opioid

addiction is like a disease that most dont recover from. Sheriff Jones said Narcan is the wrong

approach for a war on opioids that we're not winning, and said he favored stronger prevention

efforts to prevent people from first using the drug (Wootson 2017). Naloxone is viewed as a

quick fix that offers immediate help but does not solve the problems associated with addiction.

But as patient advocates we have to help people in times of need and ensure that first responders

need to have it in their possession.


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During an opioid crisis overdose, naloxone must be given before overdose symptoms

cause death. Giglio (2015). This timely first dose should be given within the first few minutes

by anyone available including non-medical first responders like police and fire fighters. Death

typically occurs within 1 to 3 hours after an overdose and is usually caused by respiratory failure

Giglio (2015). Naloxone is a potent opioid antagonist that is FDA approved for emergency

treatment of opioid overdose when respiratory and/or central nervous system depression is

present. Injectable naloxone dose concentration is 0.4 mg/1 ml Kerensky (2017). Since 1971

naloxone has been used to reverse opioid overdose Mueller et al (2010). A study of adverse side

effects of IM naloxone was withdrawal related and included: gastrointestinal discomfort,

physical aggressiveness, tachycardia, shivering, sweating, tremors, confusion, and restlessness

Mueller et al (2015). Challengers to naloxone contend that the implementation of overdose

prevention programs focusing on education and awareness are safer alternatives that reduce

opioid use than naloxone (Beheshti et al 2015). Nevertheless, naloxone administration is needed

during an overdose and together with overdose education programs and support the odds of

recovery are increased.

There is concern about the relatively short half-life of naloxone when compared to

that of some opioids, because it could lead to further respiratory depression Doyon (2014).

The same author also recommended that naloxone be prescribed in two doses, and given within

the first few after the first. Other objectors feel that the activity of naloxone is considered unsafe

because it causes a complete reversal of narcotic effect that could result in acute withdrawal

syndrome which may include tremulousness, nausea, vomiting, and other more severe

symptoms as respiratory distress, tachycardia and possible cardiac arrest Beheshti et al (2015). In

addition, the same authors said that not only should naloxone be carefully administered but
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patients should be continuously monitored after receiving doses because the duration and action

of some opioids take longer to leave the system compared to the short half-life of naloxone is

only 30 to 81 minutes Beheshti et al (2015). Acute withdrawal syndrome is described as being

an extremely intense surge and craving for more opioids. Some critic feel that his side effect of

naloxone has led to secondary overdosing resulting in death. In the HBO documentary film by

Peltz (2017) Warning: This Drug Can Kill You a young man named Brenden Cole 23 years

old, was found unconscious due to an overdose of heroin and was given naloxone, then taken and

sent home from the hospital. He died that same day from the second heroin overdose. His mother

said that the EMS gave naloxone but it did not work the second time. First responders to need to

know that naloxone can cause intense craving for more opioids after receiving naloxone. These

and other very unpleasant symptoms can be managed with overdose education and naloxone

distribution (OEND) training, first responders have improved confidence and feel equipped to

administer naloxone safely and effectively Muller et al (2015). Because of this, critics question

the ability of nonmedical first responders during a crisis, and objectors say examples like

Brendens is proof that only medical professionals in an acute care setting should give naloxone.

As a registered nurse I agree that naloxone should be available to the public and used by

nonmedical first responders. However, most nurses may only use naloxone on an inpatient

setting and on rare occasions. The challenge for most healthcare professionals is to understand

and realize that possible overdose and death is an everyday reality for people addicted to opioids.

They need naloxone when they overdose and first responders like police authorities and fire

fighters along with EMS should administer correctly when needed. Research has proven that

even trained bystanders administration of naloxone scored high for: safe administration,

overdose recognition, and overdose response verses those untrained. These results prove that
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with proper teaching and hands on training good technique can be achieved when the participates

are willing Giglio (2015).

First responder naloxone administration compared with the goals of Healthy People 2020

Strengths verses challenges and weaknesses compared to Healthy People 2020


Strengths- naloxone is available in different forms, nasal naloxone can be administered
safely by nonmedical first responders and is currently being used around the country
Challenges- availability of naloxone to nonmedical first responders, and funding
Weaknesses- post overdose and naloxone dose monitoring, although rare, possible side
effects of naloxone, recovery and one on one counseling

Heathly People 2020: Substance Abuse


Policy and Prevention- SA-9: Increase the proportion of persons who are referred
for follow up care for drug problems after diagnosis, or treatment for one of these
conditions in a hospital emergency department (ED)

Benefits, advantages verses disadvantages compared to Healthy People 2020

Benefit- antagonist of opioids, reversal of symptoms caused by overdose, cost effective


Advantages- nonmedical first responders can be taught proper administration, kits are
portable and usually have multiple doses in kits
Disadvantages- naloxone is a quick fix and does not reduce or stop continued drug
abuse and does not stop or control addiction

Heathly People 2020: Substance Abuse


Epidemiology and Surveillance - SA-13: Reduce past-month use of illicit
substances
Screening and Treatment - SA-8.1: Increase the proportion of persons who need
illicit drug treatment and received specialty treatment for abuse or dependence in the
past year
Baseline ((2008): 16.0 per 100,000 population
2020 Target: 17.6 per 100,000 population
Desired Direction: Increase desired

Screening and Treatment - SA-7: Increase the number of admissions to substance


abuse treatment for injection drug use
Baseline (2006): 255,374
2020 Target: 280,911
Desired Direction: Increase desired
OPIOID OVERDOSE AND FIRST REPONDERS 10

Highlights verses drawbacks and losses compared to Heathy People 2020

Highlights- naloxone has been used to save lives and has proven to have few side
effects
Drawbacks- withdrawal: with an abrupt discontinuation of an overdose caused by a
tolerated high ends with intense cravings for more of the drugs; withdrawal period
varies and is unpredictable
Losses- bystanders may not call 911 after administering naloxone, users may suffer
more severe symptoms that could cause death

Heathly People 2020: Substance Abuse


Epidemiology and Surveillance - SA-12: Reduce drug-induced deaths
Baseline (2007): 12.6 per 100,000 population drug-induced deaths
2020 Target: 11.3 per 100,000 population
Decrease direction desired by 2020

Conclusion

Although naloxone has proven to be a valuable tool in reversing overdose deaths it is not

the answer to the overall problems associated with addiction. There are drastic changes and an

increased need for education and training of people addicted to opioids. However, equipping rst

responders with naloxone will not only save lives but will offer hope to the recipient with the

possible outcome of better health free from opioid abuse and addiction. In addition, methadone is

currently used to help curve withdrawal from opioid and heroin cravings. Kerensky (2017)

added that treatment with a daily long-acting opioid agonist, like methadone or buprenorphine,

is the most promising way to work towards engaging him or her in treatment.

The importance for first responders and nurses to know how to care for and monitor

patients who received naloxone was proven by this discussion. Evidence shows that within the

first few hours after naloxone withdrawal symptoms are at its highest and continued monitoring

is required for users to recover and reach stability after an overdose. In addition to monitoring an
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adequate discharge plan that includes following up with recovery and abstinence counseling with

possible inpatient services from a state sponsored clinic may be needed. Due to the complexity of

recovery, it usually depends on the patients participation and efforts to control their own

behaviors and feelings regarding opioid abuse and addiction. Overdose education and naloxone

distribution community programs must continue their efforts in educating users on the use of

naloxone and the teaching bystander administration of naloxone. Objections to access to

naloxone may persist because of the concerns related to lack of education, administration of

naloxone, failure to call 911, failure to recognize signs of overdose, there will continue to be

objectors to wide spread distribution of naloxone. Here in Michigan, a law was passed in

September 2017 that allows naloxone to be sold as an over the counter drug at places like

Walgreens, and CVS, and no prescription needed. Indeed, legislation is supportive of non-

medical responders administering naloxone, but it must be available to them, to save lives. And

in 2014 the CDC announced an award of one million dollars to the state of West Virginia to

improve the drug-monitoring program for prescription drugs Beheshti et al (2015). My hope is

that the healthcare organizations and community organizations team up and encourage the

development of increased mandatory state and federal laws that demands all first responders

medical and nonmedical to carry and administer naloxone or be fined.


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