Since the beginning of the new century, the number of opioid overdose deaths has increased by more than 400%, but there’s a medication on the market that promises to reduce the number of fatal overdoses: Narcan.
Today, this life-saving drug is credited for saving thousands of lives across the US. Learn what it is and how it works.
In the past, drug overdose was believed to be something that happened to social deviants and took place in dark alleys. As overdose cases have spiked in multiple states recently, overdose prevention has become a hot topic among scientists who are looking for a tool for harm reduction.
The search led to naloxone, better known for its brand name Narcan, a drug that made resuscitation, rescue, and “reversal” after an overdose possible. Since its approval for opioid overdose in the United States in 1971, naloxone has shifted law, policy, clinical medicine, and science toward harm reduction.
Today, it’s not unusual to see law enforcement officers carrying Narcan. With the Good Samaritan Act, police officers on patrol have the right to carry Narcan and Automated External Defibrillators (AED) with them. They can now save the life of a person who is overdosing before the medical team arrives. This is crucial as police officers are often the first ones to arrive on the scene, and naloxone can only be effective if it’s administered four to six minutes after someone overdoses.
Narcan is not effective in reversing the effects of an overdose of benzodiazepines, barbiturates, GHB, clonidine, and ketamine. It also cannot prevent an overdose due to stimulants such as cocaine and amphetamines.
The opioid epidemic in the US began in 2010 as a result of a large number of opioid prescriptions being given to treat severe pain. Pain management in the US is a serious issue. It’s estimated that millions of adults in the US live with chronic pain. In 2016 alone, around 50 million people suffered from chronic pain, and 20 million suffered from high impact chronic pain.
Some pain conditions are related to an increased risk of attempted suicide. In the US, suicide attempts have increased by 30% from 1999 to 2016.
The most common opioids that are abused include:
In 2017, the number of deaths due to opioid overdose was more than 47,000 per year. In the same year, around 1.7 million people in the US were battling a substance use disorder related to prescription opioid pain relievers, and 652,000 suffered from addiction to heroin. According to 2018 data, 128 people in the United States die every day after overdosing on opioids.1
The Centers for Disease Control and Prevention estimates that prescription opioid misuse poses an economic burden. It costs the US government roughly $78.5 billion every year, and the costs include healthcare, lost productivity, and substance use disorder treatment.
Opioid receptors are found on nerve cells all around the body. When opioids attach to receptors, they change the activity of the cell. In the brain, they lead to feelings of sleepiness and comfort, and in the brainstem, they cause relaxed breathing and reduced cough. In the spinal cord, opioids slow down pain signals, and in the gastrointestinal tract, they can cause constipation.
Narcan is an opioid antagonist. It blocks opioid receptors from being activated. It attaches so firmly to the receptors that it knocks other opioids off.
When administered right away, Narcan can work in minutes to reverse the effects of an overdose. It works for 30 to 90 minutes before the opioids return to the receptors.
The nasal form of Narcan is given to someone who’s lying on their back. Narcan can also come in the form of a device that’s injected directly into the thigh. In some cases, more than one dose is required.
Once the drug is administered, the person’s breathing must be monitored. If the person stops breathing, CPR should be given to them until the medical team arrives.
According to the National Institute on Drug Abuse, from 1996 to 2014, around 26,500 lives were saved from an opioid overdose due to Narcan.
Narcan is generally safe, but it has a few potential side effects. As it knocks opioids off their receptors, it can promote some symptoms of withdrawal.
Here are some of the critical side effects that may appear while taking Narcan:
Nausea / Vomiting
Buprenorphine-naloxone is a combination medicine that’s used to treat opiate addiction. It was approved by the US Food and Drug Administration (FDA) in 2002 as an office-based maintenance treatment for opioid dependence. It has been shown to decrease the number of hospital admissions, morbidity, and mortality.2 The drug combination is also administered in inpatient and outpatient care, where the goal is to find the lowest dose to eliminate opioid use, reduce withdrawal symptoms, and improve treatment retention.
Pentazocine Naloxone is a drug combination prescribed to treat severe pain. Pentazocine is an opioid pain reliever that acts on the central nervous system (CNS) to relieve pain. When Pentazocine is used for an extended period, it can cause mental and physical dependence.
Naloxone is added to the mix to prevent misuse of the opioid. It acts on the CNS to block the effects of opioids, especially the “high” feeling that makes people want to abuse them.
An opioid overdose requires a fast diagnosis. In some cases, it can be challenging to distinguish between a high and an overdose. To save a life, it’s essential to know the signs of when a person is experiencing an intense high versus when they’re experiencing an overdose.
When someone is experiencing an intense high from a substance like heroin, they will display the following signs:
Falling asleep or losing consciousness
Intense scratching due to itchy skin
Slurred speech or inability to talk
Slow and shallow breathing
Choking or gurgling sounds
Blue/purple fingernails or lips
Slow heartbeat or low blood pressure
If the person is awake, it’s recommended to walk them around, keep them awake, and monitor their breathing. It’s also important not to leave them alone.
Opioid overdose is dangerous, mainly due to its effect in the brainstem that leads to relaxed breathing. Breathing can relax so much that it can stop, resulting in death. When a person is administered Narcan, their breathing can be restored.
Moreover, mixing opioids with alcohol and sedatives increases the risk of respiratory depression and death. The combination of opioids, sedatives, and alcohol is often present in fatal opioid overdoses.
Overdose deaths contribute to between a third and a half of all drug-related deaths. In most cases, overdose deaths are attributed to opioids.
With continued use, opioid receptors become less responsive. The body develops a tolerance to the drug, and in order to produce the same effects, more of the substance must be taken. This makes opioid overdose more likely.
The rate of fatal opioid overdose in those who abuse opioids is roughly 0.65% per year. Non-fatal overdoses happen more often than fatal overdoses. It’s estimated that around 45% of people who use drugs experience a non-fatal overdose.4
As the opioid epidemic is occurring on a large scale, the number of opioid overdoses can be reduced by individual actions. When a person survives, it’s because someone was there to respond. In fact, around 70% of people who use drugs witness a drug overdose during their lifetime.
There’s a specific group of people who are at a higher risk of experiencing an opioid overdose. The group includes people who:
Have developed an opioid dependence
Use prescription opioids and take higher doses than recommended
Use opioids in combination with other substances, like alcohol and sedatives
Take opioids and have medical conditions like depression, liver or lung disease, and HIV
There’s also a group of people who are more likely to witness an opioid overdose. This group includes people who:
Are abusing opioids
Are friends and family of someone with an opiate use disorder
Are in contact with people who overdose, including health-care workers, police officers, emergency service workers, peer education and outreach workers
Death from an opioid overdose can be prevented if Narcan and basic life support are provided shortly after the overdose. However, for Narcan to be effective, the medicine must be given to the person four to six minutes after they overdose.
If a family member or a friend has access to Narcan, it’s possible to save their loved one’s life by administering the drug themselves. Narcan can reverse the effects of a fatal overdose and keep the person alive until the medical care team arrives.
Many programs have proven that equipping people who are most likely to witness an opioid overdose with Narcan can help prevent the worst-case scenario.
From 1996 to 2010, 188 programs located in 15 states and the District of Columbia gave take-home naloxone to people who were taking opioids. The survey, completed in 2010, found that these programs trained and provided naloxone to around 50,000 people and received reports of more than 10,000 overdose reversals.4
Consequently, many countries began adopting this approach. Many jurisdictions in the US have been providing healthcare and community workers with Narcan in an attempt to reduce the number of opioid overdoses. There are 46 states, plus the District of Columbia, that have statutes that allow naloxone distribution to third parties or first responders via direct prescription or standing order.
To reduce the number of deaths resulting from an opioid overdose, it’s helpful to learn how to prevent and manage an opioid overdose.
Five steps are recommended to first responders to reduce the number of deaths resulting from opioid overdoses, including:5
Assessing the signs
Calling for help
The first step in saving a life is assessing the signs. When a person overdoses, they can show some or all of the following signs:
Contracted and small pupils
Falling asleep or dozing
Loss of consciousness
Slow and shallow breathing
Blue/purple fingernails or lips
Choking or gurgling sounds
If an opioid overdose is confirmed, the next step is to provide stimulation.
A person can be stimulated by calling their name. If they don’t respond, grind knuckles into the sternum or rub knuckles on the person’s upper lip.
If the person responds, it’s critical to make sure they remain responsive and breathing. Continue monitoring their breathing until the medical team arrives.
If the person doesn’t respond, it’s crucial to call 911.
Calling for medical help is essential. Someone with medical expertise must tend to the person as soon as possible.
If you are having difficulties distinguishing between a high and an overdose, it’s best to treat the case as an overdose and call 911 immediately.
Dial 911 and say, “Someone is unresponsive and not breathing.” The 911 operator will ask for a specific address and description of the location.
The next step would be to follow the dispatcher’s instructions, which might include beginning CPR.
While waiting for the medical team to arrive, it is essential to try to keep the person awake and breathing. As opioids cause shallow breathing, it’s vital to check whether they’re breathing regularly. Never leave the person alone and wait until the emergency team arrives on the scene. You will not get in trouble for reporting an overdose.
Narcan should be given to any person who’s showing signs of an opioid overdose.
In some cases, more than one dose might be needed. For example, people who have taken more potent opioids might not respond with only one dose of Narcan. As fentanyl has a higher potency compared to heroin, multiple doses may be required to reverse the effects of an overdose.
If the person who’s overdosing doesn’t respond 2 to 3 minutes after they’ve been given a dose, it’s advised to administer a second dose of Narcan.
The effects of Narcan depend on the number of doses, route of administration, and overdose symptoms.
The FDA has approved Narcan in a nasal form. The product delivers a therapeutic dose of Narcan in the case of an overdose. The spray comes prefilled and requires no assembly. It’s sprayed into one nostril while the patient lays on their back.
In its injectable form, Narcan generally comes supplied as a kit with a minimum of two doses and two syringes. First responders can receive training on how to administer Narcan using a syringe from the provider of the kit.
The FDA has also approved a naloxone auto-injector as a means for preventing an opioid overdose. The auto-injector can deliver a dose of Narcan through clothing, and it’s injected in the outer thigh. The device provides verbal instructions describing how to deliver the medication once it’s turned on.
After administering Narcan to the person experiencing an overdose, it’s important to explain to them what is happening. Withdrawal triggered by Narcan can lead to unpleasant feelings and confusion or agitation. It’s helpful to provide reassurance and say words of comfort.
If the person has slow and shallow breathing or is not breathing at all, it is vital to offer ventilatory support. Two methods can be very effective in providing ventilatory support: rescue breathing and chest compressions.
To offer rescue breathing, it’s critical to follow these steps:
Make sure that the person's airway is clear
Tilt their head back, and pinch the nose closed
Place your mouth over the person's mouth to make a seal
Give two slow breaths
Watch to see whether the person's chest will rise
Give one slow breath every 5 seconds until the person resumes breathing
To give chest compressions:
Place the person on their back
Press hard and fast on the center of their chest
Keep your arms extended
A person who has overdosed and received Narcan must be closely monitored for at least 4 hours from when the last dose was administered. People who have overdosed on a more potent opioid such as fentanyl should be monitored for a longer period.
As the effects of Narcan last a very short time, overdose symptoms may return. For that reason, it’s crucial to call 911 so that the person receives proper medical treatment as soon as possible.
In most cases, people respond to Narcan within 2 to 3 minutes after administration and breathing should return to normal.
If the person doesn’t respond to the medication, it’s possible that the overdose is not due to opioids but some other substance.
Law enforcement officers have often been the first emergency responders to arrive at the scene of an overdose, but they weren’t typically equipped with a drug like Narcan.
In recent years, that has dramatically changed. As of 2015, law enforcement departments in 28 states are allowed to, or required to, carry naloxone when responding to an overdose. However, in some states, there has been considerable opposition to equipping law enforcement officers with the drug.
Several jurisdictions cite fear of being found legally liable for their on-the-job actions as the main reason why law enforcement officials refuse to equip officers with the medication.
One study examined the legal risk associated with law enforcement officials (LEO) administering naloxone. It concluded that the liability risks related to naloxone administration are the same or lower than those of other activities in which LEOs commonly engage.6
Regarding authorization, Narcan is a prescription medication and can only be administered by a person who holds a valid prescription order. LEO responders do so under what is called a protocol or standing order.
In the case of immunity, the study searched the Westlaw legal database to check whether an out-of-hospital administration of Narcan by LEOs has been the grounds for a lawsuit. Not a single case of a lawsuit was discovered. In nearly all cases, the legal risk to any person who acts in an attempt to save another person’s life is very low. The risk is further reduced if that person is a LEO performing their professional duties.
It would be beneficial for the government and law enforcement officials to think of ways to most effectively bring these Narcan interventions to a nationwide scale as part of a comprehensive and cross-sectoral effort to put an end to the opioid epidemic.
Many states consider Narcan to be a drug that can save lives when administered during an overdose, but one 2018 study suggests that Narcan may be responsible for the continuous increase of opioid abuse. It argues that it does so through:7
Providing a "safety net" and thus encouraging riskier drug use
Saving the lives of people actively using drugs who survive to continue using drugs
According to the study, the broad access of Narcan has led to more emergency room visits and theft related to opioid use with no decrease in opioid-related mortality. The largest increase in opioid-related mortality has been registered in the Midwest, with a 14% increase. The study further suggests that the availability of Narcan has also resulted in more people abusing fentanyl.
However, many people consider the study to lack reliable evidence to claim that the medication caused harm.
The prevention of an opioid overdose is only possible through the timely administration of a drug like Narcan. The more time that passes, the higher the risk of respiratory depression. Because damage to the brain and other organs increases, the longer the victim remains hypoxic, saving the person who is overdosing depends on how quickly their normal respiration is restored.
Narcan has been administered by paramedics for years, although the first people to arrive at an emergency scene are often law enforcement officials (LEOs) and emergency medical technicians (EMTs).
It’s also estimated that across the US, EMTs outnumber paramedics 3 to 1, while there are ten times more LEOs than paramedics.
With this information in mind, it’s only reasonable that EMTs and LEOs should be equipped with Narcan. When emergency personnel such as EMTs and LEOs have the legal right to carry the medication, the amount of time between the onset of respiratory depression and the administration of Narcan can be reduced.
Using more than one drug at a time is known as polydrug use, and it’s the cause of most fatal overdoses. Even though combining drugs can intensify the effects, it can also increase negative consequences. Polydrug use can often lead to:
Liver damage and failure
People who are abusing drugs may not understand the risks of mixing different substances. Even combining two prescription drugs can be fatal. Taking more than one prescription drug to self-medicate can lead to a deadly overdose. Adding alcohol to the mix further increases the chances of a lethal outcome.
A popular combination is “speedball,” which is a mix of cocaine and heroin. Heroin, which is a depressant, and cocaine, a stimulant, can be a deadly combination. When these drugs are taken together, its common for the person to falsely believe the are less intoxicated than they are, leading to taking large amounts of the drug combination. Taking too much heroin can also lead to respiratory failure when cocaine’s effects wear off.
Other overdoses happen when people mix prescription opioids or heroin and alcohol with benzodiazepines.
Taking two stimulants at the same time can also be fatal. For example, taking cocaine and ecstasy at the same time can increase heart rate, increasing the risk of heart attack or stroke.
To prevent an overdose due to taking a mix of drugs, a person should:
Only take one drug at a time
Make sure to take fewer amounts of each drug if more than one drug is being taken
Avoid mixing heroin/prescription pills with alcohol
Not take more than one drug when alone. It's safest to have a friend nearby who knows what drugs have been taken and the amount
When a substance has been abused for an extended period, a high tolerance to that substance will develop. People can develop tolerance to both prescription drugs and illicit drugs. High tolerance means that the body will require higher doses of the drug to experience the same effects.
It’s also possible for a person to have a low tolerance to a substance. Low tolerance indicates that a person’s body can only process a small amount of a drug.
Tolerance builds up over time as the substance is used for a long time and in high doses. A person’s level of tolerance also depends on many other factors, such as:
High tolerance can be dangerous. When a high tolerance is developed to a drug, there is a greater risk of overdose as the amount of a drug typically taken increases.
Low tolerance can also be life-threatening. A person’s tolerance can decrease if they take a break from using a drug. When that person starts using that drug again and takes a high dose, they may accidentally overdose.
To prevent overdosing due to low or high tolerance, a person should:
Take fewer amounts of a drug if they haven't used it, even if they took a break only for a few days
Make sure to go slow if they're taking a drug after a long period of abstinence
Take smaller amounts if they're sick
Do a tester shot before taking a dose
Opt for snorting a drug instead of injecting it
Some drugs are purer than others. A drug that has more than a 90% purity, for example, gives a faster, more intense, and longer-lasting high.
Overdoses often happen when a substance within a drug is purer than the person using it anticipates. Even if the person has developed a tolerance for a substance in its diluted form, when they consume that substance in a purer form, the outcome can be death.
The same applies to prescription drugs. Although the contents and the dosage of prescription drugs are apparent, it’s uncertain how strong one type of pill is compared to other similar kinds of pills.
Opioids, due to their potency, have low rates of purity. A lethal dose of fentanyl, for example, is no larger than a quarter of a milligram, so a person can’t use the drug in its pure form without overdosing.
To avoid overdosing, a person should:
Test the potency of the drug before taking a full dose
Buy drugs from a dealer that they know is selling high-quality substances
Know the potency and the purity of the drugs they're taking
Take precautions when they switch from taking one type of the opioid pill to another
People who are taking drugs are often advised not to do so in isolation. Not taking drugs alone is critical in harm reduction. People who use drugs alone, without a friend who knows what they’re taking and can be monitoring them, are at a much higher risk of fatally overdosing.
To try to stay safe, a person should:
Have a syringe or nasal Narcan ready in case they overdose while alone
Leave their door unlocked
Call a friend to check on them
Set up an overdose plan with their friends and family
The risk of an overdose can also depend on the age and the physical health of a person. For example, drug abuse among the elderly is considered to be highly dangerous. People older than 65 have a decreased ability to metabolize drugs and have a higher brain sensitivity to drugs.
Moreover, people of an older age can have other health issues such as cardiovascular diseases or diabetes. Young people who suffer from these illnesses are also at a higher risk of overdose. Liver disease in individuals poses a significant threat to overdosing. A liver that functions poorly is not able to process drugs or alcohol effectively.
People who have been using drugs for a long time are also more prone to overdosing. Although they might have developed tolerance to a drug, their long-term use may have accumulated many illnesses such as viral hepatitis, HIV, or infections.
Another factor that may affect the risk of an overdose is a compromised immune system. If a person’s body is weakened due to an infection, they’re at a high risk of an overdose.
The risk factors for an opioid overdose include:
History of substance use disorders
High prescribed dosage
Multiple prescriptions including benzodiazepines
Mental health conditions
If there is the presence of decreased physical health or are older, here are some tips for prevention:
In cases of liver damage, they should avoid using pharmaceuticals with a lot of acetaminophen in them, such as Vicodin. They're more difficult for the liver to break down.
A person shouldn't take large amounts of a drug if they lost weight or are feeling sick, as this can decrease tolerance.
Stay hydrated and eat regularly.
Visit the doctor and let them conduct detailed tests of physical health. Knowing the presence of an illness such as blood pressure or heart disease can help prevent an overdose.
A drug can be used in many different ways. It can be swallowed as a pill or sprayed into the nose as a nasal spray. It can be shot into the vein as an intravenous injection or into the muscle as an intramuscular injection. It’s not uncommon for a drug to be inserted into the rectum or injected just under the skin.
People using drugs often crush the contents of a tablet or pill and snort its contents.
If a person takes a large amount of a drug, it can lead to an overdose, regardless of the method of administration.
However, some methods of administration deliver the drug more quickly to the brain and are more likely to create a rush. These methods include smoking and injection.
When a person inhales the smoke, it goes directly to the lungs and is then rapidly absorbed into the bloodstream. That’s why smoking is one of the fastest ways for someone to experience a high.
Injecting a drug into the vein or muscle is another popular method. When a drug is injected into the body, its full effects are felt almost immediately, typically within 3 to 5 seconds.
There are some tips to keep in mind if a person wants to prevent a fatal overdose:
Some methods of administration, such as smoking and injection, are more dangerous than others.
Opt for snorting in cases when using alone or there is a decreased tolerance to a drug.
When switching the method of administration, it's important to remember that the body may not be able to handle the same amount.
The timely administration of Narcan can help prevent an opioid overdose. It does so by blocking opioid receptors from being activated. Narcan comes in several forms, including intranasal, injectable, and auto-injector.
When an opioid overdose happens, more than one dose of Narcan may be required, especially if large amounts of opioids have been taken. The medication is an appropriate response for overdoses of all types of opioids, including fentanyl.
However, it’s not effective in treating overdoses of stimulants, like benzodiazepines, barbiturates, clonidine, GHB, and ketamine.
Forty-six states and the District of Columbia have equipped first responders with Narcan in an attempt to fight the opioid epidemic. Equipping law enforcement officials and emergency medical technicians with Narcan is a crucial strategy for dealing with the misuse of prescription opioids and preventing opioid overdoses and deaths.
However, Narcan is not a treatment for addiction. Recovery from opioid use disorders is possible with support from an addiction treatment center.