“In 2017 alone, 168 people died of drug overdose in Lancaster County, Pennsylvania, 167 of them were not my 22-year old son. I need know no other statistic.” – Doug Cwienk
In January 2017, our son was lying on the floor in our family room, literally dying. He was saved by the quick work of Bart Township Fire Company QRS and three shots of Narcan (generic name; Naloxone). Those two things gave us another 6 months with the terrific young man that our son was when he was attending his meetings and doing his step work. Narcan is very effective at saving lives but it is only useful for opioid overdoses (Nate had snorted heroin that evening), not other drugs. The effectiveness of Narcan is the reason that the Commonwealth of Pennsylvania has established a “standing prescription” so that anyone in Pennsylvania can go into a pharmacy and purchase Narcan without a prescription. I would like to dig into a little deeper discussion of Narcan and medication-assisted treatment (MAT) used to combat substance use disorders. So, please join me in this post, “Narcan and Friends”.
Note: I will use the term opioid throughout this post because it is a more general term. Opiates are derived from opium, ultimately from poppy plants. Opioids includes opiates, synthetic compounds that were developed to function like opiates and mixtures of the two.
How Does Narcan Work?
We discussed in earlier posts that opioid misuse causes a massive flood of dopamine in the brain. For this dopamine production to occur, the opioid molecule must first bind to an opiate receptor which causes other responses such as a pain relieving and sedative effect (that is what opioids were developed for). When you overdose on an opioid, you have too much sedative effect causing you lose consciousness and your respiration to be suppressed or stopped entirely. That is how an opioid overdose kills you, it slowly shuts your breathing down and then your heart stops because it is not getting the oxygen that it needs.
In pharmaceutical terms, Narcan is a competitive antagonist for opioids. This means that Narcan pushes the opioid molecule off of the receptor and the Narcan then occupies the receptor, keeping the opioid molecule from reattaching. What this means in practical terms is that a person in opioid overdose, given Narcan is taken from their extreme high to withdrawal very quickly because the receptors no longer have opioids attached to them. Knowing that withdrawal is extremely uncomfortable, the instantaneous ride from high to withdrawal must be horrible…but the alternative (death) is much worse.
Obviously, we do not want the Narcan to stay on the receptors forever because these receptors serve other functions, such as your brain’s own pain regulation systems. Narcan is designed to be metabolized in less than an hour, so that it is no longer in your body. Unfortunately, this means that if you overdosed with enough opioids, some are still running around in your brain. When the Narcan is broken down by your body the opioids that are still running around in your brain reattach to the receptors. This is very dangerous because it can cause an individual to go back into overdose. That is the reason why someone revived with Narcan needs to go to the hospital for a few hours of monitoring and re-administration of Narcan if necessary.
The Effectiveness of Narcan
Narcan is well designed for its intended purpose and it does its job very well. Some of the stronger opioid compounds, such as fentanyl and carfentanil are resistant to Narcan requiring more Narcan to reverse the overdose. I recently read a statement by the Lancaster County district attorney stating that we are on track to have fewer overdose deaths in the county in 2018 then we had in 2017. More people surviving is obviously good but it doesn’t mean that the opioid crisis is now shrinking. In fact, there have been more overdoses in 2018 than 2017 but more people are being saved by Narcan.
Narcan cannot be abused, it blocks the high of opioids. So, if you have a loved one that may be abusing opioids or you spend time around people that may be using opioids it would be wise for you to get Narcan and keep it with you. As stated above, if you live in Pennsylvania you can get Narcan without a prescription.
The fastest way to get Narcan to work is by intravenous injection, which is what the EMTs will do if they are saving someone. For regular people like you and me, the Narcan that we can obtain is a nasal spray. It is easy to administer and there are many places that will give you training in how to administer Narcan if you wish. In the Lancaster area, one group that provides this training is Project Lazarus. You can find a group in your area by searching on the internet for “overdose reversal training”.
What Narcan Does Not Do
Narcan does not let you down easy, it saves your life. By very rapidly stopping the effect of the opioid, it stops the suppression of your respiration but it throws you into withdrawal. As stated in the “Warm Hand-Offs” post the person revived with Narcan is often very agitated and cannot focus because their brain is screaming for the substance that it “knows” they need to survive. Their brain is trying to save their life using every trick that it can but it is wrong about what is needed. For more discussion of this, please refer back to the science of addiction posts that started this blog.
Narcan does not prevent relapse, in fact, many individuals have been revived more than once. How can you return to the substance that just tried to kill you? This makes no sense to a person that is not suffering from addiction. But, let me offer this analogy:
Suppose you are lost in the desert for a week or more and you are literally dying of thirst. You find a small pool of water and drink from it. The water is not pure. You become very sick and almost die. You survive and continue on but you are still close to death from lack of water. If you find another pool of water, would you drink from it, not knowing if it is pure or not? Of course, you would, you will die without water.
This is how a person with substance use disorder’s mind is working but it mistakenly thinks that the drug of choice is as necessary for survival as food or water. They will use again if they do not get and stay in recovery. They may even use in secret to hide that they have relapsed. That is what happened with Nate. He used in secret so that no one would know he had relapsed and he died alone, without anyone there to give him Narcan.
Narcan does not help a person with substance use disorder get or stay in recovery, that can be done with medically-assisted treatment which we will discuss in the follow-up post to this post. Do you have thoughts or experiences to share? Please comment, let’s work together.
NOTE: I have given more thought to using the term “person with substance use disorder” or “person suffering from addiction” rather than addict. It occurred to me that what is missing with the word addict is the word person. The term addict de-humanizes. It is like the use of Jap for Japanese people during WW2 or Huns for German people during WW1 or savages for native persons. It is easier to mistreat people, to look down on people, to allow people to suffer if we stop thinking of them as people.
I hope that you will join me next week for a discussion of “Narcan and Friends – Part 2”.