If We Are Going to Survive the Fentanyl Crisis, More People Need Naloxone Training.
Viewpoint articles are written by members of the SPH community from a wide diversity of perspectives. The views expressed are solely those of the author and are not intended to represent the views of Boston University or the School of Public Health. We aspire to a culture where all can express views in a context of civility and respect. Our guidance on the values that guide our commitment can be found at Revisiting the Principles of Free and Inclusive Academic Speech.
A couple of weeks into my summer internship in one of the poorest neighborhoods in Canada—Vancouver’s notorious downtown eastside (DTES)—a young man was walking through an alley where someone was smoking crack. As he passed, the person keeled over in an obvious opioid overdose. Someone else in this situation might have frozen, not knowing what to do; someone else might have decided the individual deserved what they got and kept walking. This young man ran into the street looking for a Narcan kit. He found me, and we ran back to intervene.
Some months earlier, I had walked into my local pharmacy here in Boston and asked for naloxone, which was given to me without a prescription. It also came without instructions. If I had been in that same situation even a week before I was, I wouldn’t have known what to do.
Fortunately, I had received a Narcan, or naloxone, kit and very thorough training the week before this incident in the DTES, so I knew what to do. We called 911, started rescue breaths, and administered naloxone, and the person survived.
Before having that training, maybe I would have acted anyway, but the situation also might have turned out differently.
This is why Narcan training needs to be expanded and as widely available as the drug itself.
Although the DTES has been called Vancouver’s friendliest neighborhood, it is an area rife with poverty, homelessness, and public drug use. It is also home to the first supervised injection facility (SIF) in North America. While overdose deaths within the DTES decreased after the SIF’s inception, the fentanyl crisis we are experiencing in Massachusetts and across the continent is hitting British Columbia with the same ferocity. In the first half of 2017, there were 209 suspected overdose deaths in Vancouver. In response, the Ministry of Health allowed the opening of several SIF-like sites.
For various reasons, however, not everybody uses these sites every time they use, so people still OD in alleyways, in their rooms, and on the street. I cannot imagine there is anyone in the neighborhood who hasn’t seen an overdose or lost a sibling, parent, friend, or someone else to an overdose. Every week I heard reports of OD deaths in alleys, of people found in their rooms several days after ODing, even of a major activist who died of a suspected “hotshot.”
To increase awareness and people’s chances, Narcan kits are widely available in the neighborhood. Service providers and community members alike sport these kits, which are not available without at least a 5-to-10-minute, on-the-spot training, as those in the US should be.
Naloxone works by binding to the opioid receptors in the brain, essentially “kicking out” opiates from binding to them. Most of the side effects are the effects of dope sickness or withdrawal, which can happen when the naloxone is administered, and serious side effects are rare. Even so, an understanding of how naloxone works, and of overdoses in general, is important to have before you use it.
You should know, first of all, how to recognize an overdose. Opioid overdoses prevent oxygen flow, so signs include shallow or raspy breaths, slow breathing, or no breathing at all; pale skin and cyanosis, particularly around the lips; and unresponsiveness or fainting. The person may also become rigid in a hunched-over position, something I have seen is more common with fentanyl.
You should know to try to revive a person. I find “Hey, I’m going to Narcan you!” will effectively get some people right up. Sometimes it takes a firm sternal rub or a pinch to the shoulder.
You should know that oxygen is at least as important as naloxone in an OD response. If you see an overdose and don’t have naloxone, give rescue breaths and call 911. Early signs of an overdose can be controlled with just oxygen, and even in more extreme situations, oxygen alone may be enough. Additionally, the lack of oxygen to the brain during an overdose can cause serious brain damage.
You should know how to administer naloxone. It takes surprisingly little effort to stick a needle in someone’s skin, so jabbing a skinny person at a 90-degree angle is likely to put the needle into their bone. Large muscles are the best places to stick the needle—biceps, thighs, even the stomach—and it should go in at an angle, something closer to 45 degrees than 90 degrees.
You should know it takes at least three to five minutes for Narcan to start working, and that you should continue rescue breaths throughout this period. Only after that time should you try another dose. If only one dose is needed, multiple doses won’t do anything except cause dope sickness.
You should know naloxone only works for 30 to 90 minutes, so the person could OD again after that period.
You should know that if you intervene on an overdose and the person dies anyway, it is not your fault.
Maybe you will go your whole life without seeing someone OD. But this fentanyl crisis isn’t just happening in neighborhoods like the downtown eastside or Boston’s own so-called “methadone mile.” It is happening at college parties, behind the closed doors of Chestnut Hill residences, in public restrooms. You can probably get naloxone in your neighborhood pharmacy, but training needs to be as readily available so that anyone can be ready for an overdose.
Caity Bernards is an MPH candidate and member of the Life on Albany Committee with a passion for harm reduction.