Dying alone: the sad irrelevance of naloxone in the context of solitary opiate use.

Abstract

The provision of naloxone is an important component of harm reduction for opiate dependency. Naloxone reverses opiate-related overdoses, does not have any addictive properties and can be administered using a syringe (intramuscularly) or intranasally 1. Indeed, the US Department of Health and Human Services has listed the distribution of naloxone as part of the five-point strategy for addressing the opioid epidemic 2. However, the key to naloxone administration is that there must be another individual present to administer the drug in the context of an overdose. Meanwhile, however, opiate-related overdoses have increased throughout the United States, with close to 30 000 individuals dying in 2017 due, to synthetic opioids, 15 958 from heroin and 14 958 due to natural and semi-synthetic opioids, with 49 068 total dying from opioids compared to 42 249 in 2016 and 33 091 in 2015 3, 4. Although naloxone distribution has increased during these years, there is still much work to be done. Along these lines, there has been interest in more clearly understanding ‘gaps in the naloxone cascade’ 5. In other words, researchers and experts in the substance abuse field recognize that awareness and access to naloxone is not sufficient to stem the tide of opiate deaths. Previous research indicates that, unlike cocaine, use of opiates stimulates a more pleasurable response when taken at home or in a quiet environment 6, suggesting that a large proportion of heroin users may be taking the drug alone. Narcan, the primary brand of naloxone, states that opioid overdose emergencies ‘most often happen accidently and at home’ 7. Similarly, an epidemiological study that evaluated the social context of heroin-related overdose and death in San Francisco from 1997 to 2000 found that in 68% of deaths, the user was alone 8. Other socio-cultural contexts may have different contexts of use, however, with a study from Russia finding that most users reported previous heroin overdoses in the context of having friends/other people present (76%) 9. Meanwhile, there are virtually no data on the context of opiate associated deaths post-2000 in the United States. What was the physical environment where the death occurred? Was the user alone? Were emergency services called? Given the high volume of deaths that are associated with opiate overdose in the United States and attempts at harm reduction to reduce this trend (e.g. including efforts to open the first public use safe injection site opening in San Francisco in the United States 10, there needs to be a clearer understanding of the social and environmental context of opiate-associated deaths beyond the types of drugs used. Furthermore, toxicology studies of heroin-associated deaths have found that, in many cases, survival was most probably longer than 30 minutes, based on the absence of 6-monacetyl morphine (6MAM), a metabolite of heroin in the blood 11. The prolonged time to death indicates the possibility of intervention and the importance of having others present so that someone can intervene if needed. Although some harm reduction strategies specifically target the need to not use alone, such as the message given in Baltimore by BMore Power: ‘Go Slow. Never Use Alone. Carry Naloxone’ (www.20secondssaves.org), other harm reduction messages mention the need to carry Narcan without emphasizing that using alone can result in death. For example, the Dope project based in San Francisco and New York City has educational materials for pill users that educates about fentanyl and advises users to carry Narcan, but mentions nothing about using alone 12. Lastly, in the context of providing further medical rationalization for the opening of safer injection sites in the United States, the medical and public health harm reduction language needs to consciously emphasize the dangers of solitary use patterns. We need to address research gaps to better understand the social and environmental context in which opiate deaths occur, as well as to prioritize the harm reduction message that opiate users must never use alone. None.