A recent story out of Middletown Ohio has gained national attention due to a unique proposal by a city council member that proposes a “3 strike” policy for opioid overdoses where the third time an individual overdoses, the ambulance would not respond and provide care (The story can be found here: http://www.wlwt.com/article/middletown-considers-3-strike-policy-on-responding-to-overdoses/10215284). This story is one of many regarding whether opioid overdoses should receive Narcan. I have encountered many people, both healthcare providers and the public who have made statements such as “we should just let them die it was their choice” or “why can’t we just say no and stop enabling them” (I find both statements to be appalling).
The reality of overdoses…
Many people are quick to jump to prejudicial opinions about victims who overdose on opioids. The classic stereotypical image of an addict or a “junkie” is plastered all over television and movies. The reality of this is that many of these addicts are normal people who ended up in a bad position. Some of these overdose victims did not “make a choice” but instead became addicted following a legitimate prescription and use for opioids. They were eventually “cut off” after becoming addicted with no support from the healthcare system.
What about the ethics of not responding to an overdose or giving Narcan?
The basis for medical ethics consists of four basic concepts including respect for the autonomy of the patient, beneficence (benefit to the patient), non-maleficence (doing no harm), and justice. The concept of justice suggests that all persons in similar situations are allocated the same resources and given the same care. Not all opioid overdoses are heroin overdoses. Many overdose victims are patients who unintentionally overdose from a legitimate opioid prescription. From an ethical standpoint, all overdose patients should be treated equally. Also, in terms of beneficence, the treatment provides benefit to the patient, and not providing treatment would result in further harm.
Let’s look at some facts on Narcan…
Narcan IS NOT Free
I have recently seen numerous posts on social media stating that we should not be giving Narcan to addicts for free if patients with allergies must pay for epinephrine pens or patients with cancer must pay for chemotherapy. Let’s get something straight here… Narcan IS NOT free. As stated above a 2mg dose of Narcan (a standard dose) costs approximately $54. I can also assure you that the Narcan people are receiving is not free. Someone is paying for this, whether it be a government entity or an insurance company.
Let’s look at an example of how Narcan is paid for. If an addict overdoses on heroin and 911 is called the patient will likely be given Narcan by someone in the EMS system (e.g., EMT or paramedic). The EMS service will then transport the patient to a local emergency department and bill the patient for the care provided. If the patient is on Medicaid, reimbursement for an ambulance bill may be as low as $317.30 for an advanced life support ambulance staffed with a paramedic (using the CT Medicaid fee schedule as of August 2015). The patient will likely contribute nothing to this bill and the ambulance service will be reimbursed by Medicaid, a government, therefore tax funded system. This same billing and reimbursement scenario would occur if the patient was having an allergic reaction, having chest pain, having respiratory distress, or they broke their arm and needed pain control. All of these patients will receive the care they need from EMS and the patients are not just being handed a “free” dose of Narcan while we are leaving patients dying in the street of anaphylaxis because they can’t pay.
The argument that Narcan shouldn’t be free to addicts if epinephrine is not for people who have allergies is just absurd, neither are free as you can see.
Are we giving too much Narcan?
One thing I do believe is that we may be giving too much Narcan. The following is anecdotal but I as well as my colleagues have observed this on numerous occasions. Paramedics tend to give small doses of Narcan to get the patient breathing again and surprising to many, a number of overdose patients do not require Narcan because their respiratory drive is not depressed. Many patients who become euphoric are unconscious but breathe normally after using an opioid are mistaken as “overdoses” when in fact they achieved their desired effect and took a “dose”.
With non-healthcare providers such as police officers, firefighters, and the general public using Narcan we have seen a lot of patients receiving Narcan that frankly don’t need it. So I do agree that we are giving too much and Narcan is arguably overused.
(Note: For the patients who do need it who require large doses due to the strength of the drug they overdosed on, I think the doses given to reverse respiratory depression are typically appropriate and not excessive.)
Yes, addiction is a disease.
I have also seen this argument recently on social media; addiction is a choice not a disease. The individual may have made a choice to take a pill or inject a drug for the first time, but the subsequent addiction to the drug is a disease. That choice to take the drug may have been the result of a legitimate need for an opioid and a legitimate prescription from a well meaning healthcare professional.
The term disease can be loosely defined as a disorder of human function that results in specific signs or symptoms. In the case of addiction a physical dependency to the substance is developed, in this case opioids (the same applies to alcohol, sugar, caffeine, etc.). That physical dependence results in an alteration of the brain’s reward system and the neurotransmitters involved. Patients with addictions can have physical modifications of the nucleus accumbens core, an area of the brain with dopamine receptors that is associated with reward. This physical dependence produces signs and symptoms, consistent with the definition of disease.
As with many other diseases comes other comorbidities. In the case of opioid addiction patients are often at higher risk of HIV, hepatitis C, endocarditis, and many other health complications.
Narcan is only the tip of the iceberg.
In the grand scheme of the opioid epidemic, the debate about Narcan is only the tip of the iceberg. All over social media and in news outlets people who are misinformed will continue to argue about whether we should provide a lifesaving medication to an opioid overdose.
In terms of the cost to the system, the $53.99 spent on a dose of Narcan is nothing compared to the medical bills associated with an HIV diagnosis that requires expensive medications for life and leads to other comorbid medical problems that are expensive to manage. Instead of talking about safe injection sites and clean needle programs, we continue to debate the cost of Narcan.
As we continue to argue about the availability of Narcan and who should have access to it, we forget that there are many addicts who seek treatment who are denied because of their insurance or the lack of available resources. Instead of finding solutions to expand access to addiction treatment, we continue to debate who should get Narcan.
We continue to worry about whether Narcan is enabling addicts and whether addiction is a disease. Instead, we could be evaluating the healthcare system and developing safer non-opioid treatments for pain and plans for patients on long term opioids that prevent addiction.
It’s time to stop talking about Narcan and it’s time we start looking at solving the opioid epidemic.
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