Last week I covered a meeting at the FDA to determine whether the opioid overdose remedy, naloxone (Narcan), should be made available over the counter. The drug is non-addictive and nontoxic, and new data presented at the meeting suggest that it can cut overdose death rates by 50%.
With nearly 15,000 people dying of opioid overdose every year—making up the majority of overdoses, which now kill more people than car accidents—you might imagine that an FDA meeting to potentially expand availability of a drug that could save half these lives would be big news. But I seemed to be the only reporter in attendance. At least, my reporting (and that of the people who linked to it) are the only coverage that comes up on Google.
And that speaks to the bias the media has in dealing with addiction, which involves intensive focus on problems like overdose and on “solutions” like cracking down on doctors, pharmacies and users, but scant interest in reporting on measures that save addict’s lives.
For example, here’s a local news story highlighting a county’s decision to copy a comprehensive national anti-overdose program. It focuses on changes in prescribing practices and access to addiction treatment—but doesn’t mention the distribution of naloxone, which gave the model program its name: Project Lazarus, because naloxone’s ability to reverse overdoses often seems as miraculous as bringing back the dead.
The New York Times recently spotlighted efforts to reduce prescribing to deal with opioid abuse—but overlooked the only overdose-fighting solution that actually has published evidence of effectiveness. An AP investigation of prescribing rates also neglected naloxone.
More than two dozen members of the public testified at the FDA meeting—mainly family members of overdose victims and advocates who have worked distributing the drug and seen its power to help. The families’ main question was: why didn’t we hear about this before our children died?
Fortunately, the naloxone debate has brought an important new voice into this debate—that of parents, who honor the value of their children’s lives, with or without recovery.
As Marilee Murphy Odendahl, who lost her son Ian to overdose three days after his 28th birthday, put it, “Why this hasn’t been touted on every media outlet and rooftop I will never understand.”
Megan Ralston of the Drug Policy Alliance described receiving calls and emails from family members who had only discovered the existence of the overdose antidote after losing a loved one. “I have had more gut-wrenching conversations than you can imagine,” she testified. “You truly can’t imagine how massive the need for naloxone is. I know firsthand because I answer these calls. It’s horrible to experience that much pain and grief and the majority of them aren’t just dealing with the trauma of losing a loved one.”
Instead, what families discover is that few people care whether their loved one lives or dies once they’re addicted to drugs. Indeed, many of the meeting’s attendees became infuriated at what they saw as the expert panelists’ needlessly academic discussions of the ethics of informed consent, the barriers to over-the-counter access and the possible side effects of the drug.
The good news was that only one of more than two dozen speakers opposed greater naloxone availability—and he represented the American Society of Anesthesiologists, which fears that lay people will not be able to handle using the drug safely. (It is administered by injection or nasal spray; it work almost instantaneously.) Another doctor was the only opponent the FDA panel of five aimed at debating the OTC question. His objection was that while naloxone clearly works for heroin overdose, those who OD on longer-acting opioids like methadone may fall back into overdose and die later if 911 isn’t called.
But these objections are not supported by the data. Some 50,000 doses of naloxone have been handed out by nearly 200 community-based naloxone distribution programs, for a total of 10,000 successful overdose reversals since 1996. According to those who work in these programs, the only failures of the drug have been when it is given after someone is already dead—or if the overdose didn’t actually involve opioids.
Moreover, research presented at the meeting comparing 19 Massachusetts cities and towns, which had previously had at least five overdose deaths per year, clearly favored naloxone. The towns with naloxone programs which had reached more than 150 people per year had a 50% reduction in deaths, while those that saw less than that had a 27% drop, compared to those without naloxone access. The drug has been available over the counter in Italy and Sweden for years without causing problems. (The “Keep Calm and Carry Naloxone” T-shirt in the photo on the billboard is designed by British harm-reduction activist Nigel Brunsdon. You can order one here.)
But in the US, the prescription requirement is a major barrier to access. Programs that want to distribute naloxone currently need a doctor to write prescriptions, which greatly increases their costs (although some states allow “standing orders” to minimize this burden). It also means that if you’d simply like to have it in your first-aid kit, you need to find one of these programs or contact a doctor (if you live in New York City, a call to 311 will give you the nearest naloxone program location). Easy OTC availability, of course, would make it easy to have this lifesaving drug nearby.
The only other speaker who voiced concern about making naloxone nonprescription was Bertha Madras, Harvard psychology professor and former deputy drug czar under President George W. Bush, who had previously been seen as the most outspoken critic of naloxone distribution. However, she claimed that she’d been misrepresented as a naloxone opponent—she does support wider distribution, she says, but she wants it closely coupled with referral to treatment.
When she said that, I flashed back over my 20-plus years covering the debate over needle exchange. It seems that whenever there’s a new intervention that can keep drug users alive, the only way people want them to have access to it is if they agree to a future life of sobriety in return. Although Madras did say that “life comes first,” most of her presentation was about getting people hooked up with treatment.
And while that’s obviously not a bad idea—and is currently done by existing programs—it represents a bizarre double standard that isn’t seen in any other aspect of medicine. If we had a cure for AIDS, we wouldn’t care if it doesn’t also cure cancer. If a heart attack victim succumbed to that disease because he ate too many cheeseburgers, we don’t require instant placement in “diet treatment” as a price of admission for making defibrillators accessible to nonmedical people. We recognize the fundamentable value of saving lives.
Fortunately, the naloxone debate has brought an important new voice into this debate—that of parents, who honor the value of their children’s lives, with or without recovery. Said Odendahl of her son Ian, who suffered from mental illness as well as addiction, “He was much more than the sum of his illnesses. He was incredibly intelligent, kind and talented. He was a good son and my greatest joy.”
Until we truly value the lives of drug users—unconditionally—we’re not going to get effective addiction treatment or drug policy. The FDA meeting did show a clear consensus favoring expanding availability of naloxone—but also significant financial and regulatory obstacles to over-the-counter access.
Without ACT UP–style pressure from these families and from current and former drug users, however, the likelihood of reform is low, despite the fact that the FDA seems open to trying to help. The needle-exchange fight seems to have made it safe for families to support saving users rather than cracking down on them—in the past, families of people who have died of addiction-related causes have generally been in the “get tougher” camp. Perhaps together families and people with addiction can spur change.
A little support from the media wouldn’t hurt, either.