This country has a serious public health problem related to the use of prescription medication. Statistics show an almost 300% increase in the number of opioid prescriptions from 1991 to 2010. Although many of these medications are being used as prescribed, 52 million people, or 20% of the total population aged 12 years and older, admit to at least a one-time use of a medication for a nonmedical reason, and 7 million admit to abusing them regularly. The results are that prescription painkillers are being abused at a rate second only to marijuana; injury deaths from motor vehicle or traffic accidents are now in second place, having been replaced by prescription poisoning deaths; and prescription drug overdose deaths are greater in number than combined cocaine- and heroin-related deaths (National Center for Injury Control and Prevention, 2011; National Institute on Drug Abuse [NIDA], 2001; Trust for America's Health, 2013).
When the Centers for Disease Control realized that deaths caused by drug overdoses had been rising for 2 decades, they decided that prescription drug abuse was an epidemic that would continue to grow unless addressed using a collaborative effort of policy, programming, and community and agency responses. Because of a lack of research, these approaches were developed from best advice, not best practice, but they have still been effective. Using a four-pronged plan of education, tracking and monitoring, proper medication disposal, and enforcement, the response was rapid. In 2011 and 2012, the number of people who were currently abusing dropped by 12% (Executive Office of the President, 2011; National Center for Injury, 2014; Trust for America's Health, 2013).
At the same time that the numbers of individuals abusing prescription drugs have been decreasing, the Substance Abuse and Mental Health Services Administration's (SAMHSA, 2013a) National Survey on Drug Use and Health is reporting that the number of individuals aged 12 years and older who were abusing heroin doubled between 2007 and 2012. Media reports are attributing the rise in heroin abuse to the decline in the abuse of prescription painkillers. Support for that theory comes from a recent study by Cicero, Ellis, and Surratt (2012). Of the 2,500 people surveyed during the 3-year study, 66% reported switching from prescription opioids to heroin. The reasons given were the ease of obtaining and using heroin and the significant difference in cost between an 80-mg OxyContin tablet at $80 and a small bag of heroin for $5. With this change, drug overdose deaths because of heroin have also doubled. Some reports give the daily rate for all combined drug-overdose-associated deaths at 100 a day (NIDA, 2001). The epidemic of use is now an epidemic of death.
Since 2010, the Centers for Disease Control, NIDA, SAMHSA, and a variety of nonprofit community organizations, many of which funded by the Robert Wood Johnson Foundation, have been working together to address the increase in overdose deaths. The SAMHSA's (2013b) Opioid Overdose Toolkit outlines five strategic approaches to prevent future overdose deaths:
1. Encourage providers, persons at high risk, family members, and others to learn how to prevent and manage opioid overdose.
2. Ensure access to treatment for individuals who are misusing or addicted to opioids or who have other substance use disorders.
3. Ensure ready access to naloxone.
4. Encourage the public to call 911.
5. Encourage prescribers to use state Prescription Drug Monitoring Programs (SAMHSA, 2013b, pp. 5-6).
When it is administered, naloxone competes for the opiate receptor sites in the brain. As it displaces the opiates at those sites, it reverses the respiratory depression that is the usual cause of an overdose death and prevents the overdose. If administered quickly, all opioid-overdose deaths are preventable (Hardesty, 2014). Naloxone is only effective when used in response to an opioid drug overdose, although there may be some advantage to using it in the case of a combination of drugs, one of which is an opioid. Because it is not psychoactive, there is no potential for abuse. For at least 40 years, emergency medical service personnel have been stocking and using injectable naloxone to resuscitate individuals who might otherwise have died without it (SAMHSA, 2013b). The injectable form of naloxone has the approval of the Food and Drug Administration (FDA) and at $6 a dose or $15 for a kit; the drug is inexpensive. However, despite this long history of successful use, there has been, and continues to be, a great deal of opposition to its use and potential legal consequences for individuals reporting or treating an overdose.
The Obama Administration supports the strategy of ensuring that naloxone is available to all first responders and that there are laws in place to protect them if they use it (Hardesty, 2014). The local law enforcement agencies, emergency medical service personnel, and other first responders who are permitted to use it are encouraged to be equipped with naloxone and trained in its use. In the areas where it is still prohibited, they need to support the efforts for changes in the laws governing its use. Through the work of a number of organizations, as well as the U.S. Conference of Mayors, the American Medical Association, and the American Public Health Association, 17 states and the District of Columbia have effected amendments to "Good Samaritan" laws that will provide the overdose victim and the first responder protection against prosecution and increase access to naloxone. The laws fall into two categories. The first supports wider prescription and use of naloxone by removing the barrier to individuals obtaining and using the drug to reverse an overdose. Protection is also given to the prescriber who acted in good faith when they prescribed it. The second category protects individuals from negative legal consequences when summoning help in the event of an overdose (Davis, 2014; Hardesty, 2014; SAMHSA, 2013a).
It is estimated that these changes have resulted in the reversal of over 10,000 overdoses since 2001. Baca and Grant (2005) conducted a review of the literature within the dates of January 1999 and June 2004. They found that data for these years are primarily anecdotal; however, peer distribution supported promising results for a more formal approach to distribution. Bazazi, Zaller, Fu, and Rich (2010) found that opiate overdoses were a persistent public health problem accounting for as many as 10,000 deaths annually. They noted that objections to the distribution of naloxone continue although adverse reactions are rare, and there is increasing evidence that supports that naloxone is relatively easy to administer, safe and inexpensive to use, and saves lives. Although formal use is limited to just a few U.S. cities, in the United Kingdom, Italy, Germany, and Australia, distribution programs are making naloxone available to opiate users and their friends and families.
In October 2010, the Harm Reduction Coalition identified 50 programs known to distribute naloxone for surveying community-based programs. An online format was used. The questions included the year the program started, how many individuals they trained on prevention and naloxone administration, the number of reported overdose reversals, and if numbers were documented or estimated. Although not currently FDA approved, aerosol naloxone is available. The survey asked what formulations the programs distributed, if they were having difficulty obtaining naloxone, and what their overall experience has been like. Of the 50 programs initially contacted, 48 responded. Programs began distributing in 1996 and were located in 15 states and in the District of Columbia. The initial 48 programs reflected a much larger rate of distribution through a total of 188 local programs. The state health departments of Massachusetts, New Mexico, and New York reported for multiple local programs. Wisconsin had a nongovernmental state-wide operation with 16 programs. Using 2008 data, the survey demonstrated that the higher rates of overdose deaths occurred in the sates without local naloxone programs (Wheeler, Davidson, & Jones, 2012).
The future looks promising. Research is available to address the major objections to naloxone distribution. Instead of encouraging increased drug, communities with distribution programs have decreased self-reports of use. The benefit of an overdose-related hospital admission motivating an individual to enter a drug treatment program is negated by the fact that the overdosing individual may never reach the hospital without the use of naloxone. Statistics from one program demonstrated that 74% of individuals went on to call for additional help. Although an opiate overdose is viewed as a serious medical problem that will require the intervention of trained medical professionals, there are numerous studies that basic training can give lay persons and opiate drug users sufficient skills to recognize and respond to an overdose (Bazazi et al., 2010).
Further research is needed to support the efficacy of take-home naloxone to empower drug users and increase the availability of naloxone through increased prescribing, expanded distribution in communities, and relabeling of naloxone. Meanwhile, public policy is supporting increased access. SAMHSA has published the Opioid Overdose Prevention Toolkit available at http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA13-4742 and has given states permission to use block grant funds to provide overdose prevention education and to purchase and distribute naloxone. At this time, only injectable naloxone is funded. The aerosol formulation not currently FDA approved is in clinical trials that are showing positive results. In time, this may give additional options. Additional assistance with education, training, and resources is available through two organizations, the Harm Reduction Coalition (http://harmreduction.org) and the University of Washington Alcohol and Drug Institute (http://adai.washington.edu/ and http://stopoverdose.org/). Although it may be important to decrease or stop drug use, it is absolutely necessary that opiate users have the opportunity to live long enough that they can pursue treatment when they are ready.
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