Fixing fentanyl with naloxone alone won't work
UBC academics worry officials pushing too hard on solution that doesn't address root cause of the problem
The city of Vancouver is experiencing a drug crisis — in 2016, 215 people died from an overdose within the city boundaries.
Whether local to the area or seeking refuge in Vancouver to escape colder climates of other Canadian cities, some of the most vulnerable people in our society have been made even more vulnerable by a dangerous new trend that involves cutting a highly potent cheaper drug into known others.
This trend is about to get worse with the new arrival of carfentanil, fentanyl's more lethal cousin.
These unpredictable and dangerous new additions to illicit drugs such as heroin have transformed what was formerly an RCMP problem into a public health problem.
Everyone from paramedics to teachers to funeral home directors have been warned they need to protect themselves from any exposure to dangerous drug residues.
Users and non-users alike have been encouraged to gain access to naloxone kits that can reverse an overdose.
Though the magnitude of this crisis grows every day, the associated ethical and societal challenges have yet to be examined fully.
No accountability for naloxone kits
We observe, for example, that people in our communities may obtain a naloxone kit at the local pharmacy, at a cost manageable by most — but without apparent accountability.
Who is keeping track of the kit selling, buying, and using?
Who are the community members now possessing and responsible for a potent drug?
Are they individuals suffering from addiction who now may carry both drug and antidote, and whose executive functioning and decision-making abilities may sometimes be impaired by drug use?
How many times have they purchased a kit? Are they parents, school principals and nurses with adolescents who may be at risk? University professors, or our students? Should our parks have naloxone kits hanging on posts, like plastic bags for dog clean up?
As noted in an editorial last December, naloxone is not risk-free: injections of the drug can lead to intense withdrawal symptoms and, without appropriate follow-up, individuals who just received a dose of naloxone may be compelled to use soon after to relieve these symptoms, perpetuating the cycle.
Reduces drug users' contact with services
The important benefits of widespread access to naloxone kits must be balanced with the cost of promoting a solution that does not address the root cause of the problem.
Further, in keeping with the vision for harm reduction in substance abuse, providing widespread access to naloxone kits may decrease the need to contact emergency medical services, and reduce the exposure that users might otherwise have to care services for curbing or coping with withdrawal symptoms and, perhaps most importantly, services that may lead to a decrease in drug use.
It is imperative that we understand the broader context of naloxone administration, therefore, and ensure the loss of opportunities to access health and social services are minimized.
Other key factors in the naloxone equation are the ethical and legal implications of prescribing, selling or giving away naloxone when it is most likely not going to be administered by the person for whom it is intended.
When in possession of such a kit, what is the framework for responsible use?
What are the liability implications for the person who administers naloxone, on the one hand, and possibility for trauma after misguided or failed use on the other?
- B.C. program handed out 220% more naloxone kits in 2016 than last 3 years combined
- Vancouver approves spending $2.2M to address overdose crisis
- Vancouver's Mobile Medical Unit sees more than 600 patients in first month
As we move forward with widespread distribution of naloxone kits, Good Samaritan laws must be revisited to ensure the protection of individuals who are doing their part to mitigate the outcomes of this epidemic.
Public shouldering responsibility
While these important concerns must be explored, the evidence to date suggests that in the equation of risk versus benefit, the actions that Vancouver's leadership have taken for making naloxone available as a life saving procedure have been vital.
Unless a proactive prevention strategy is implemented as vigorously as the current reactive one, however, little traction over the challenges that this crisis of mental health and addiction represents will really be made.
The strategy must involve the pairing of naloxone kit distribution with careful monitoring of the impact of the intervention, deep consideration of a public that is now shouldering unprecedented responsibility, and novel approaches to harm reduction that will tackle the cause, and not the outcome, of the opening of a Pandora's box.
Judy Illes is Professor of Neurology and Canada Research Chair in Neuroethics, and Julie M. Robillard is Assistant Professor of Neurology, in the National Core for Neuroethics and the Djavad Mowafaghian Centre for Brain Health at UBC.