Recently, I was at a concert with some friends, I noticed the floor was slick, and warned my best friend, “Be careful, the floor is really slippery, don’t fall.” Within five minutes I reinforced the sentiment that my parents should have named me “Grace,” a joke they have made since I was a small child. I slipped, fell, and ended up fracturing my fibula and required surgical repair. This resulted in having to reschedule my planned trip to Thailand. So, being relatively immobile, in a fair amount of pain, and having pain medication and addiction being frequent topics of recent conversation, I figured this would be a good opportunity to explore opioid use and the controversial topic of naloxone/Narcan.
Over the last few years there has been a pretty heated debate on whether Narcan should be more readily available for people suffering from opioid addiction and/or their friends/family members. So what’s the problem, and what is naloxone?
Naloxone is an opioid antagonist, meaning it is something that counteracts the action of opioids. Opioids are substances like heroin, oxycodone, hydrocodone, etc. that bind to specific receptors in our brains. A benefit of opioids is the binding of opioids to these sites results in pain relief, however danger comes because this can result in a sense of euphoria which can trigger a very intense reward system in our brains thus potentially leading to addiction/abuse/misuse.
Basically naloxone acts as opioid “police” or “bouncers.” Imagine opioids as underage kids at a wild party, the job of naloxone is to round them all up and boot them out. Naloxone is often used for rapid opioid reversal in an emergency situation (kind of like an antidote). Since an opioid overdose can cause respiratory depression and coma it can be deadly, naloxone can reverse the action of opioids and prevent these lethal outcomes.
So what’s the controversy? There has been a push to make this medication readily available for people with substance use disorders and/or friends/family members to have on hand so that it may be administered in case of an overdose. Some argue that making this medication readily available will only encourage people to start or continue using opioids because the risk of overdose would be significantly reduced. Now, everyone is certainly entitled to his/her own opinions and beliefs, however to me this seems very similar to arguments that we shouldn’t have sex education, make contraception available, or administer the HPV vaccination to children because “it will only encourage them to engage in these behaviors.” In my belief, the more education someone has on a matter the better informed they are and thus make more educated/informed decisions and multiple studies support this.
This gets a little tricky in regards to substance use because the decision making/reward system parts of our brain are exactly what gets affected by substance use. Most frequently overdoses occur in a few situations: 1. a person has been using a substance, tolerance has developed, as a result of continued use, higher doses of the substance are required to get the desired “high” a person is seeking, or 2. a person has been using a substance, he/she sustained some period of sobriety and relapse, using the same amount of substance in question, however since there has been time without use of the substance some of that tolerance has gone away (meaning it won’t take as much to get the same high), the body gets overwhelmed and overdose results. Now this doesn’t mean it’s impossible to overdose on the first use of a substance, or that there aren’t some people who may try a substance because there is some kind of perceived safety net, however in my professional experience this is not the majority of cases.
So what should you know about Naloxone?
It is an opioid antagonist a.k.a. it is the opioid police. Imagine the chaos of people fleeing a party and getting put into a police car when the cops show up.
It is unpleasant, uncomfortable chaos. When naloxone comes on board, it basically displaces all the opioids from where they have bound which is UNCOMFORTABLE. One reason opioid use is so hard to kick is the withdrawal. Naloxone essentially makes a person go into instant withdrawal, which is NOT FUN.
There is no “high” with naloxone. There is no intrinsic reward that comes from naloxone use. If anything, say someone hypothetically was experimenting with opioids knowing he/she had this perceived safety net, the sheer discomfort of this instant withdrawal would in itself likely be a deterrent from future use.
One of the most important things I hope to leave people with is a better understanding of substance use. Generally speaking, people do not start using/abusing/misusing substances when things in his/her life are going fantastically. The majority of times substance use is a maladaptive coping mechanism used to numb some kind of intolerable emotional pain. What I frequently remind family/friends of is THIS IS NOT AN EXCUSE, rather an explanation of behaviors.
So why do some people become addicted and others don’t? This is a complicated question with no easy answer. However there are physiological changes that happen in our brain when we use substances. It may start as “Hey this feels good, and helps me get away from the **** going on in my life right now” which we can call ‘impulsive behavior’ a specific part of the brain is activated in this process. However when it shifts to compulsive behavior ‘I need this to get me through the day and you are going to be in massive suffering/you are going to die if you don’t get [substance, A,B,C,D, etc.] an entirely different system in our brain is activated.
Ok, so what flips the switch from impulsive to compulsive? A bunch of different things. However one of the most important seems to be social supports. There have been animal studies that have animals both exposed to addictive substances. One with a very uncomfortable environment with limited supports, the other with a significantly more supportive environment. While the subject in the supportive environment may try the addictive substance, the same kind of dependence doesn’t occur. This is not to say this is the only factor, but it is a key one.
There was a stand-up bit I saw YEARS ago where the comic poked fun saying “Alcoholism is the only disease you can get yelled at for having.” Every once in a while I need to let this sentiment sink in and resonant with me, and something I will tell you is that it makes me angry. It makes me angry at what a poor job we do of educating others on substance use, and treating it as what it is, a psychiatric/physiological condition that should be treated with the same understanding, compassion, and concern that any other kind of medical condition is instead of as a ‘character defect.’
It may be easy for people to scoff at this and continue to lack compassion, but what I would say is if you are able to exert enough energy to have contempt or distain for people suffering from these conditions and say “Well why don’t you just go get help?” Why don’t you just get a job?” I challenge you to earnestly speak to someone or the family member of someone who has been struggling with a substance use disorder.
Does the woman now addicted to heroin who was eight years old when she was shot up with heroin for the first time and forced into prostitution by her dad deserve public ridicule or disdain? What about the (wo)man who spent years of his/her life sending and receiving gunfire in war zones who comes home and ends up finding his/her only escape pain medication prescribed to treat injuries he/she sustained? What about the doctor or the lawyer who comes home after days on end of shouldering the emotional burden of each and every one of his/her patients/clients and can find no solace outside of a whiskey bottle? Likely we don’t see these people the same way we do the indigent person downtown carrying all of his/her worldly belongings in a shopping cart. However it’s relatively rare for someone passing these judgements (out of distain, discomfort, fear, or whatever) to actually speak to these people like the actual living, breathing human beings they are. If we look at the actual science and neurochemistry that is involved in addiction there is absolutely no question this is an actual disease, not a character defect, and we need to start treating it as such.
My opinion is that I have seen more than enough people struggle with addiction in both my professional and personal life. Narcan saves lives. It is something that is INCREDIBLY uncomfortable to be administered during an overdose, people do not get a high off of it, people don’t feel good after using it. Withdrawal is something so uncomfortable and so powerful that it is a perpetuating factor in addiction… going into instant withdrawal is not desirable. Remember, people go to EXTREME lengths to avoid symptoms of withdrawal.
My final question or thought would be, if a medication is available to save the life of a person with a potentially life threatening condition why would we not make it available? If it was your child/sibling/significant other/friend/etc. who was struggling with an addictive disorder and had the possibility of dying of an overdose, would you not want something available to save his/her life?
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f you or someone you know is experiencing a mental health/substance use condition contact the national mental health and substance abuse hotline
SAMHSA’s National Helpline – 1-800-662-HELP (4357)