Recently, a new higher dose of naloxone (Klaxxado) was approved for use by the FDA. Naloxone is a life-saving drug that can reverse the effects of an opioid overdose and has proven effective since it has been in use. Yet as fentanyl has become a growing problem in the opioid epidemic, there is a worry that the existing formulation of naloxone (commonly known by the brand name, Narcan) may not be strong enough to reverse an overdose, given that fentanyl is much stronger than heroin. In theory, the need for a higher dose naloxone product makes some sense; it is logical to think that higher doses of naloxone would be necessary for reversing an overdose of a more potent substance. However, that line of thought may lead to misaligned priorities.
Instead of making naloxone more readily available to those who urgently need it in any form, the focus has turned to making a newer and more expensive version.
One important question that does not get enough attention is this: has anyone in the community of drug users and those who work to support them asked for a new, stronger product or mentioned it as a priority? The National Harm Reduction Coalition has a specific statement on their website stating that naloxone in its current forms works for fentanyl, including both a nasal spray and an injectable formulation. Their priority – as it should be – is around accessibility, not dosage strength. Making naloxone free and/or cheap and available without a prescription (ideally over-the-counter) is key to preventing loss of life. Many states now have standing orders that naloxone can be purchased from a pharmacy by anyone without a prescription. This is a great step by legislators, but products can still be expensive and some people may be deterred by the perceived stigma of having to ask for the medication at the pharmacy. And there are other underutilized strategies that many in the recovery community are also advocating for, including increased naloxone trainings and standardizing access to the nasal spray formulation nationwide – especially for those unable or unwilling to use syringes.
Continuing to market higher and higher doses of naloxone seems to suggest that “more is always better.”
Although administering naloxone to someone who has not been using opioids will not cause harm, using excessive doses of naloxone can lead to unnecessarily severe withdrawal symptoms.
We don’t generally give massive doses of other drugs “just in case,” and keeping someone alive does not necessarily require a complete removal of the effects of the opioid. Severe withdrawal symptoms can be unpleasant and traumatic for both those experiencing them and those observing them. But those pushing for this new dose are suggesting that this isn’t something to worry about.
Insisting that severe withdrawal is a non-substantial side-effect just feeds into the stigma that people who use drugs are bad and need to be punished since it’s “their fault” they ODed.
Even popular media is realizing this tradeoff might not make sense – including The Atlantic.
It is true that some studies have indicated that larger doses of naloxone are being administered in recent years than in years past. However, it is hard to say WHY more naloxone was administered – was it truly needed, or was it given out of an abundance of caution or inexperience with using the medication? Other studies suggest no difference in the naloxone dose is needed for fentanyl compared to other opioids. While there are cases where multiple doses of naloxone may need to be used, suggesting that current forms of naloxone are ineffective for reversal of a fentanyl overdose are not just incorrect, but dangerous. Public health messaging works best when the advice is clear and simple, and pushing people away from what works will cost lives.
...suggesting that current forms of naloxone are ineffective for reversal of a fentanyl overdose are not just incorrect, but dangerous.
None of this is to say there is not a place for higher dose naloxone, or that exploring new ideas for overdose prevention is wrong. However, we shouldn’t lose sight of what has already been shown to work. Is the value greater for the pharmaceutical company or the person experiencing an overdose? Humans like to search for silver bullet solutions, but the truth is, we already have a great option, we just need to continue to remove the barriers to access so naloxone is available when and where it is needed.
Instead of muddying the waters with tools that add little value in terms of lives saved (and may cause harm), we should continue to focus efforts on making it as easy as possible to access the life saving drugs we already have.