Dr. Loh: Over-the-counter naloxone is an opportunity to save a life

In the last 23 years, there have been progressively more annual deaths from drug overdoses, mostly from opioids, due to unconscionable marketing by some pharmaceutical companies, production of long-acting oxycodone and unscrupulous prescribers.

In our country, we have seen almost one million deaths. More than 80,000 died in 2021 alone. The vast majority of these have been accidental, especially since illicit drugs have been spiked with fentanyl, an extremely potent opioid that can cause respiratory arrest at ridiculously low doses. People who use these drugs for not approved indications often are not aware that their recreational drug of choice has been laced with narcotics and that cessation of the respiratory drive will be the result.

Punitive societal strategies focused on end-users has filled our jails and rehabilitation programs, without hugely impacting the supply chain since law enforcement is constantly playing whack-a-mole. Shut down one illegal supplier and others pop up. It’s a tough job that makes one think that Sisyphus had it easy. Reducing demand would help solve this, but effective strategies have been frustrating to devise and implement. And people keep dying.

Stricter regulation of prescriptions, plus severe punitive measures against the abusing pharmaceutical companies and the prescribing providers, has mitigated the rate of rise of deaths, but far too many victims remain.

At the Food and Drug Administration Anesthetic and Analgesic Drug Products Advisory Committee Meeting on Feb. 15, all 19 voting delegates unanimously agreed on a strategy to save lives. They agreed to make a previously prescription-only medication called naloxone available over the counter, or OTC. Naloxone, otherwise known by its trade name Narcan, has been around for decades. I remember using it in emergency rooms 50 years ago.

This is how it works. Opioids, derived from opium, include naturally occurring morphine, but also include the semisynthetic and synthetic opioids such as heroin, methadone, codeine, oxycodone, hydrocodone, tramadol, and fentanyl and others. These agents stimulate opioid receptors and are very effective at controlling pain but can be abused because they also produce euphoria, as well as delirium. Compounding this problem is that is they can produce dependence. And genetics can play a role in risk in opioid-use disorder.

Breathing is an automatic activity, that is, you don’t actively think about your breathing. How much you breathe, assuming no mechanical problem, is usually driven by the carbon dioxide and oxygen levels in your blood. Your brain has sensors that monitor those levels, and when the carbon dioxide levels creeps up, or failing that, if your oxygen level starts to fall, the brain causes you to breathe more. Those brain sensors are functionally turned off by opioids, so you actually have no incentive to breathe … so you don’t … so you die. An incidental finding with opioid overdoses is pinpoint pupils, which in a nonbreathing patient is a real clue that this is an opioid overdose.

Naloxone blocks the opioid receptor from the opioid, thus reversing the respiratory depression that causes most opioid deaths. As with all medications, there are serious adverse effects possible, but you first have to be alive to suffer them, and without the naloxone, that won’t be a problem.

The FDA Advisory Committee approved an OTC naloxone nasal spray by Emergent Solutions and is identical to the prescription version. The full FDA will make the final decision in March, but I expect it to go along with the advisory group. That the spray will likely be available in convenience stores, supermarkets, big box stores, and even vending machines will make it much more likely for it be available should the need arise.

It’s estimated that half of all overdoses have bystanders present. And if you are in or around an area where there is a risk of encountering someone at risk for an opioid overdose, that is, everywhere, it may be prudent to know where a naloxone nasal spray is available.

To that point, this is a nasal spray. No needles, so you have no chance of sticking yourself. Also, no harm if you give it to someone who didn’t need it. There are early reports of other drugs being mixed in with opioids, such as the animal muscle relaxant xylazine, which will not be blocked by naloxone. But if there is an opioid in the mix, odds of survival will be improved by the naloxone.

It is unclear what the pricing will be, but hopefully grants will allow bulk purchases and distribution. There will be clear-use instructions on the single-spray device. You just might save someone’s life.

Irving Kent Loh, M.D., is a preventive cardiologist and the director of the Ventura Heart Institute in Thousand Oaks. Email him at drloh@venturaheart.com.

This article originally appeared on Ventura County Star: Dr. Loh: Over-the-counter naloxone is an opportunity to save a life