The death rates from opioid overdose in the United States have gained attention from every corner of the country. On average, 115 Americans die of opioid overdose every day. This represents a 5-fold increase in opioid-related deaths from 1999 to 2016.1 In many states, these numbers are even larger. The first wave began with increased prescribing, the second wave involved heroin, and the third wave involved synthetic opioids, usually illicitly manufactured fentanyl, appearing in heroin, counterfeit pills, and even cocaine.1 Clearly, this is an epidemic, recently recognized as a public health emergency. Political and medical personnel are working to develop solutions, addressing both upstream and downstream drivers of this epidemic. The rapid growth in opioid overdose deaths continues to reflect escalating use of street drugs such as heroin, fentanyl, and fentanyl derivatives but is also the result of a 300% expansion of retail opioid prescribing beginning in the early 1990s and peaking in 2012.2 It is a problem that spun out of control from many directions.
The problems are multifaceted, and the solutions will not be easy. However, as with most epidemics, attention is focused on prevention, survival, and many crisis points that can no longer be ignored. Many solutions are in progress—including new health policies and federal funding allocations. At every level, local and national education programs are expanding to prepare health care providers and the public to change how opioids are produced, distributed, administered, and regulated. A vision currently exists where opioids will become cautiously guarded options for pain management.
To this end, there are dramatic shifts in clinical practice as we reeducate providers and prescribers. A new understanding of pain and its management, including alternatives to opioids for both acute and chronic pains, is underway. Public awareness campaigns and expanded patient education at the point of care and at the pharmacy counter will bring more information to the public. Medical industry, in conjunction with government regulatory forces, will address production and distribution quotas, as well as marketing practices to reduce what has been identified as overprescribing and inaccurate representation of these dangerous drugs. As a society, we will work to reduce the stigma and recognize addiction as a preventable and treatable illness, and for some, a chronic disease. As providers, there is much work to do and we all own a piece of it.
Surviving an overdose may be the first step in treatment or at least an opportunity to live another day with hope for treatment. A recent editorial reminds us that the greatest struggle is not only getting people into treatment, it also is keeping them alive long enough to get help. Being alive, they say, is itself a path to treatment.3
Successful intervention is achievable at many points of addiction, even as someone is at the precipice of death from an accidental or unintentional overdose. Naloxone (Narcan) is an effective reversal agent. Its application extends beyond the already widespread use in hospitals and is now safe and effective in the community. Naloxone works by binding to opioid receptors in the brain in place of opioid drugs. Overdoses result from an opioid's agonist effects at the mu-opioid receptor (MOR), located on brainstem neurons that control breathing. The MOR antagonist naloxone (Narcan) can reverse an overdose, but only if it is administered shortly after the overdose occurs.1
Narcan is not a new drug; it may have been one of the first drugs administered by many hospital-based providers. It has long been used as a strategic resuscitation drug that can be given intravenously or aerosoled into the endotracheal tube. Its speed and effectiveness are impressive. Within minutes, it prevents opioids from binding to the MOR receptor in the brain, creating a temporary reversal of the opioid effects.
In 2015, Narcan was introduced in a user-friendly intranasal spray, through a partnership with the National Institute on Drug Abuse and medical industry. The Food and Drug Administration–approved nasal spray results in blood naloxone levels equivalent to those achieved with parenteral administration.1 More recently, a new formulation is available in a new 2-dose package. The small 2-in square plastic device is ready to use upon opening the easy-peel package. The device is similar to many over-the-counter nasal sprays. Administration is as simple as 1 squirt, using 2 fingers and a thumb, into 1 nostril.
THE SURGEON GENERAL'S CALL TO ACTION
In April 2018, the US Surgeon General, Dr Jerome Adams, released an advisory to encourage the public to keep naloxone on hand.4 Although Narcan is already carried by first responders, research shows that when naloxone and overdose education are available to community members, overdose deaths decrease in those communities.2
Dr Adams is committed to increasing the availability and targeted distribution of naloxone. His advisory report states that this is a critical component to reduce opioid-related overdose deaths. The report continues to explain that when access to Narcan and community training are combined with the availability of effective treatment, it moves us toward ending the opioid epidemic. Table 1 includes the Surgeon General's April 2018 advisory statement.
ACCESS To NARCAN
In most states, Narcan is available at the local pharmacy without a prescription. Standing orders exist to expedite public access. Some charges may exist at retail drug stores, but many drug treatment centers provide Narcan at no cost. Most community groups, local health departments, and needle exchange programs distribute low-cost or free naloxone kits, which come with gloves, facemasks, and instructions.
Many education programs are emerging to train professionals and lay bystanders to recognize overdose and administer Narcan. Pharmacists are providing instructions with every handoff of a Narcan package. Informational posters for quick use are posted in many communities. Most users require no formal training but do benefit from some instruction about how to use the nasal spray and information about accessing emergency assistance and protecting the victim during recovery.
Although naloxone (Narcan) has saved many lives, overdoses frequently occur when no one else is around. Using alone significantly increases the risks of dying from on overdose. Tragically, when someone does arrive in time, he/she may not have Narcan, or even if Narcan is available, he/she may not know how to administer it or is unsure of the steps to take to safely administer it. In addition, responders fear that their own safety may be compromised as overdose events have been fueled by the increased use of potent synthetic opioids as fentanyl and Carfentanil. These drugs may be up to 100 to 1000 times more potent than heroin or morphine.
Adding Narcan training to basic life support measures is a necessary step to prevent opioid deaths. Many basic life support programs have added Narcan training. In Boston, Massachusetts, a state that saw 1909 opioid-related deaths in 2017 and another 657 deaths in the first 6 months of 2018,5 a local health care insurance provider plans to provide Narcan kits and education to all employees. Each employee in the program will receive kits containing 2 doses of the opioid overdose reversal drug, Narcan. The kits will also have a surgical mask, gloves, and instructions for administering Narcan. The insurance provider plans to work with employers to learn how they could best use the kits. Municipalities will likely wish to keep them stocked at libraries, parks, pools, and other public areas. Those employees will also receive training on reversing opioid overdoses.6
Naloxone has already prevented hundreds of deaths. In other cities, such as Baltimore, providers believe that naloxone should be part of everyone's medicine cabinet and everyone's first aid kit—a fact reiterated by the 2018 Surgeon General's advisory.4 Public health officials in Baltimore reinforce the concept, noting that if we do not save lives today, there is no chance for a better tomorrow.6 At Baltimore's dont die.org home page, Dr Leana S. Wen, MD, Health Commissioner for Baltimore City, describes why and how to use Narcan in a 4 minute 26 second video available at http://dontdie.org.
To address this epidemic that kills about 25 000 Americans annually, Baltimore was an early adopter—developing one of the first online training programs to train community members, families, and addicts, as well as health professionals, to administer bystander Narcan.7 Many programs exist, including many tools now a posted on government and community websites. Table 2 lists a few examples.
BYSTANDER NARCAN TRAINING
Many communities are taking action. Narcan has been credited with reversing nearly 1124 overdoses from October 2016 to May 2017.8 Boston Public Health Commission offers education and training to opioid users, their families, and community partners that work with people at risk of overdosing. Providers may also participate at no charge. Participants learn about the importance of calling 9-1-1 in the event of an overdose, how to perform rescue breathing and administer nasal Narcan, and treatment options for opioid users. The 1-hour online course requires that participants (1) learn about overdose prevention, (2) demonstrate response to an overdose, and (3) demonstrate Narcan administration.8 Full overdose prevention training is offered in an online format, designed to be completed at the participant's desired pace. Interactive-formats allow downloadable resources and printouts. Engaging videos (7-8 minutes in length) are available in English and Spanish.
Public service and social media programs also provide information and education to extend awareness and Narcan training.9 The Surgeon General's advisory appeared on Twitter, and many updates continue. Table 3 presents a quote from the advisory statement that appeared on April 5, 2018, and includes a link to this work on the government twitter account.
WHAT YOU CAN DO
Know that there are models of care at the health system level emerging to address this issue. Join these efforts and become part of effective change. One remarkable program is currently in progress at Brigham Health in Boston. This model may help other institutions develop a comprehensive Opioid Stewardship Program, a new program currently underway at the Brigham. The group views the role of a stewardship program to be 3-fold. Dr Scott Weiner and his group describe this approach in a recent Joint Commission publication.11
The first intervention is to do whatever is possible to keep opioid-naive patients from receiving opioids for the first time if not necessary. The meaning of this is not to avoid adequate and compassionate pain control; rather, the intention is to encourage non-opioid medications as a first-line treatment of pain, recognizing that opioids are high-risk medications. The second aim is to encourage safe use and monitoring of opioids when indicated, paying close attention to guidelines from the local health system, society, and governing bodies (for example, the CDC). Finally, there needs to be comprehensive and compassionate care for patients with OUD (Opioid use disorder), including creation of resources to treat patients with this disease. For this third aim, the Project SHOUT (Support for Hospital Opioid Use Treatment) webinar series is a helpful resource for establishing an OUD program for inpatients.11
This report shared many lessons learned and reminds us that this is still a work in progress. One recommendation from this early report is to include nursing at the early stages. This is advice is well appreciated, as we are seeing that each discipline has a unique lens and much to offer.
Recently, Dr Christine Vourakis, editor of Addictions Nursing, led a special topic issue on the opioid crisis. Seven original papers and 5 columns offer a nursing perspective from childhood screening to hospital-based efforts and research on treatment options. The issue includes a continuing education article highlighting a systematic review on Naloxone effectiveness.12 The issue is a comprehensive, focused approach that will provide nurses and other disciplines with new knowledge, skilled advice, and evidence-based tools to help build or advance opioid treatment programs.
Be prepared to respond to an overdose emergency as you would to other medical emergencies. As first responders, nurses and other medically trained personnel are encouraged to carry Narcan. Narcan comes in a sealed container; each package contains 2 doses (4 mg/0.1mL internasal spray).10 Activate Narcan training at your school, work place, and home. Join a Narcan challenge by asking your local pharmacy and community centers if they are able to distribute Narcan, and disseminate this information throughout your community. Keep Narcan in your home and travel first aid kits and explain to your family why this addition is needed.
Advise patients, family, and friends to make sure they have Narcan on hand if opioids are prescribed for the first time. Continue to keep Narcan on hand if opioids remain in the home. Identify safe disposal sites and techniques to dispose of unused opioids in your home, office, or vehicle.
Perhaps most importantly, work toward reducing the stigma; change your words, actions, and care to reflect compassion and hope for patients with OUD. This alone may help us shift the trajectory of this crisis as it will lead us to new solutions. And, finally, continue to follow the science and a growing body of evidence13 that will guide us out of this epidemic!
Remember, we all own a piece of this, and change is possible.