Photo by Nancy Pietroski
“We don’t have those kinds of people in our park (ski resort, swim club, dive ship, bike trail, etc.)”
To those that say this, the emphatic reply is: “Yes, you might.” The statistics are deadly and sobering: drug overdose is the leading cause of accidental death in the US; from 1999-2016, approximately 9,000 children and adolescents died from opioid poisoning, and in 2021, the totals for all opioid deaths topped 100,000. Opioid overdose can occur in patients who are prescribed an opioid medication, people who misuse or abuse opioids, or victims of accidental exposure, the latter including purchasers of illegal prescription meds like Xanax or Percocet tainted with fentanyl.
Naloxone: The opioid reversal agent
To combat opioid overdoses, naloxone has been available as a reversal agent since 1971, primarily for use by EMS providers, health care providers, and outreach workers. The US Department of Health and Human Services recommends co-prescribing naloxone (and educating patients and their families about its use), to those at risk of opioid overdose including: those receiving opioids at a dosage of 50 morphine milligram equivalents (MME) per day or greater, having other comorbidities such as COPD or obstructive sleep apnea, or are taking illicit benzodiazepines or other drugs like heroin or fentanyl. For an accidental overdose in a wilderness medicine setting, where opioids may be administered for pain in acute traumatic injury, providers should be proficient in managing the patient’s airway and respiratory status. In addition, the Wilderness Medical Society (WMS) recommends in their 2014 guidelines on pain treatment in remote environments that naloxone be carried as an adjunct. Administration of naloxone presents very little risk, even if the patient has not taken opioids and is experiencing hypoglycemia, myocardial infarction (MI), etc.
In February 2016, following Federal Drug Administration (FDA) approval, Narcan Nasal Spray was launched, providing a convenient and needlestick-risk-free alternative to ampules/vials, prefilled syringes, and autoinjectors. The atomizer is available by prescription, both from harm reduction groups and under statewide standing orders from a pharmacist without a prescription (laws vary by state)—the latter are often run in partnership with community organizations. To encourage prompt recognition of opioid overdose and administration of naloxone by these groups and family members/friends, many states have established Good Samaritan laws to protect those administering the agent. The site Naloxone Overdose Prevention Laws also provides a very extensive and detailed dataset on state laws including: civil, criminal, or professional disciplinary immunity to healthcare providers that prescribe/administer naloxone, civil or criminal immunity for lay responders, and pharmacy naloxone dispensing.
Do you really need naloxone in outdoor settings?
So how often do you think you would come across the need to administer naloxone in a wilderness or other outdoor setting? People in the outdoors are healthy and shouldn’t be using illegal (or illegal doses of) drugs, right? But wouldn’t you pack it in your medical kit, if you’re a trained healthcare provider, park and recreation professional, or trained in outdoor first aid or something similar? A very interesting article posted by the National Recreation and Park Association, “The Naloxone Debate — To Carry or Not to Carry” reviews some of the cons—of course we know the pros.
- Safety and liability. As mentioned above, naloxone itself poses very few risks, and liability-wise, laws protecting those administering naloxone are growing rapidly. However, opioid withdrawal symptoms precipitated by naloxone administration can include physical violence, possibly physically endangering those administering the drug and in the vicinity of the patient.
- Stigma and bias around substance use. Formerly referred to as substance abuse, less biased terminology now being used is “people with substance use disorder”.To educate those who say “It won’t happen here,” substance use disorder and addiction must be treated as a disease, and as healthcare clinicians in concert with community outreach and other organizations, we must educate ourselves and others about this disease and try to lessen the stigma.
- Public perception. We can ask ourselves, what will the community think if they know we are trained to carry and administer naloxone? Isn’t that admitting there might be a problem (that we don’t really want to acknowledge)? The problem is not going away, so it does no good to hide our heads in the sand. As healthcare clinicians, we can participate in initiatives to educate the places where we practice that are digging their heels in about training their practitioners because they don’t think that they have a problem.
So, should you carry naloxone, whether you’re working or recreating?...
…This may change everything: Narcan Nasal Spray Approved for OTC Use
On February 15, 2023, at the urging of clinicians, strong advocacy groups, and the Biden administration, two federal advisory committees recommended unanimously (19-0) to the FDA that naloxone be made OTC. The federal panels concluded that naloxone does not require medical training to use, although studies submitted on Narcan nasal spray demonstrated some user errors (spraying atomizer into the air instead of the nostrils).
And on March 29, 2023 (much quicker than expected), it was approved. Narcan Nasal Spray 4mg should be available in pharmacies (along with cough and cold preps and extra strength dry skin cream) in supermarkets, Big Box stores, vending machines, convenience stores, and the widespread availability will hopefully alleviate the stigma around securing the drug. Per the FDA, the manufacturer will determine the availability and price of the product. Other formulations and dosages of naloxone will remain available by prescription, but an up to 2mg autoinjector may be in the works for future OTC use. If you have not been trained on administration of the drug, there are many great training resources out there.
Your decision to carry naloxone, if you’re not doing it already for your job, is a personal one, but it’s a good idea. It could happen wherever you are, and you may likely save a life.
Naloxone Training Videos
Excellent training videos are available on www.narcan.com and https://getnaloxonenow.org/#home.