Rather Than Panic, Our First Response to Fentanyl and Carfentanil Should Be More Naloxone, in Higher Doses

Nov 29 2016

Rather Than Panic, Our First Response to Fentanyl and Carfentanil Should Be More Naloxone, in Higher Doses

November 29th, 2016

Fentanyl, carfentanil and “pink” (U-47700) are among the potent synthetic opioids that are, to different extents, increasingly available on the street. They’re all very powerful, which is another way of saying that they are effective in much smaller doses than heroin, say.

Dangerously, given that most drug-related deaths result from drug combinations, heroin is often sold cut with these drugs, above all fentanyl (often, though by no means always, without the buyer’s knowledge). And their presence has been implicated—often accurately, sometimes not—in many deaths.

Most media sources have responded as you’d expect: with headlines giving these substances labels like “elephant tranquilizer” and proclaiming how many thousands of times stronger than morphine they are. They usually fail to point out that both sales of risky, unknown combinations of drugs and the incentive for illicit vendors to sell more concentrated forms of drugs are direct results of drug prohibition.

Rather than panic, we should spread practical information. Media reports sometimes suggest that naloxone, the opioid overdose reversal drug, fails to work when these substances are involved. However, naloxone is still effective—it’s just that higher doses (and wider distribution) are required.

Dr. Shawn Ryan, an assistant professor and physician of emergency medicine at University of Cincinnati Medical Center, has a timely piece on The Hill today in which he advocates recommending higher naloxone dosages as well as wider availability. He writes:

… overdoses caused by [fentanyl, carfentanil and other powerful synthetic opioids] can be reversed with naloxone … but they require stronger medication doses in a shorter window of time to combat their potency, rapid onset and potential fatality. This means we have to get more naloxone administered as soon as overdose symptoms become apparent, and as a result, the current initial, recommended dose of naloxone has been widely challenged as ineffective against the current and evolving opioid epidemic. Specifically, it is common practice today to immediately provide at least two doses of this lower naloxone dose for it to work effectively–all at a time when every second matters in order to save a life.

He continues:

In fact, the U.S. Food and Drug Administration (FDA) recently held a joint advisory meeting where a majority of the experts voted in favor of increasing how much naloxone is given initially … in the community setting–meaning non-medical areas like someone’s home, i.e. the place where a majority of opioid-related overdoses are occurring.

Accordingly, it’s essential that the available products and devices provide consistent and adequate dosages of naloxone and must be readily, rapidly and safely administered … This is where I believe we can make a difference now by providing a stronger recommended dose for all naloxone devices and products intended for community use…

Dr. Ryan goes on to point out that even at higher doses, naloxone is safe:

With any shift in medical treatment comes its critics. Some [FDA] advisory committee members and participants voiced concern over potential acute withdrawal symptoms associated with higher doses of naloxone. In my experience, these effects are minimal, not life-threatening and, essentially, temporary. Death and serious brain injury however, are not.

Wise words. And while advocacy has seen naloxone access and liability protection laws proliferate across numerous states in recent years, we have to ask why on earth they’re not yet universal.