Medical students confront the opioid crisis, extol the rescue medicine naloxone.
Every 19 minutes, someone in America dies from an opioid overdose. But a simple lifesaving act – giving a shot of the antidote naloxone – can quickly revive many drug users from the brink of death.
Now a group of Harvard medical students wants everyone to know about the naloxone rescue.
“White Coats for Recovery,” as the group calls itself, is tapping social media to show people how to buy and use naloxone, commonly known as Narcan®. The antidote blocks the path of opioids such as heroin or narcotic painkillers, and can restore breathing back to normal during an overdose – if administered in time.
Naloxone is credited with reversing more than 26,000 opioid overdoses between 1996 and June 2014, according to the Centers for Disease Control and Prevention (CDC).
“We recognized an opportunity to make a small, concrete contribution to the much broader fight against the opioid crisis,” says Siva Sundaram, a student at Harvard Medical School and member of the HMS Center for Primary Care Student Leadership Committee, which launched the social media campaign.
Naloxone was long available only to hospitals and advanced emergency personnel. But new laws in at least 25 states expand naloxone access to police officers and first responders, as well as laypersons who might experience or witness an opioid overdose. While regulations vary by state, today naloxone is dispensed over-the-counter by many pharmacies, health clinics and addiction treatment centers.
“Providing naloxone kits to laypersons reduces overdose deaths, is safe and is cost-effective,” the CDC notes in its report, “Opioid Overdose Prevention Programs Providing Naloxone to Laypersons — United States, 2014.”
An overwhelming 82.8 percent of reported overdose reversals in 2014 were done by active opioid users who carried naloxone; another 9.6 percent of reversals were administered by loved ones who witnessed an overdose, the CDC reports.
To test the availability of naloxone at local pharmacies, Sundaram and his classmates are working with a pilot study at Boston Medical Center. The students try to buy the antidote without a prescription and post photos of their purchases on the White Coats for Recovery Facebook site.
“Our experiences have definitely varied,” Sundaram says. “In some cases, the pharmacist was familiar with the process of providing the drug under the statewide standing order (which allows people to purchase naloxone without a separate prescription) and provided appropriate counseling on how to administer it,” he says. “In other cases, the pharmacist was confused about the procedure and refused to bill the student’s insurance without seeing a separate prescription. Sometimes, there simply hasn’t been any naloxone in stock.”
Ultimately, White Coats for Recovery hopes to stem the explosion of drug overdose deaths and inspire future doctors to provide compassionate, effective care for people with addiction, Sundaram says.
Drug overdoses claimed the lives of 47,055 Americans in 2014 – the equivalent of about 129 Americans each day – according to the CDC. That’s more than any previous year on record, and drug overdoses now surpass car accidents as the leading cause of injury death among people 25-64.
Opioids such as prescription painkillers and heroin accounted for 61 percent of the overdose deaths in 2014, the CDC says. And the toll increasingly impacts American society: 41 percent of adults say they personally know someone who abused prescription opioids in the past five years – and one in five say that abuse led to a fatal overdose, according to a STAT-Harvard national poll conducted in March, 2016.
Many Americans blame the opioid crisis on unsafe prescribing practices by the medical profession. Providers wrote nearly 207 million opioid prescriptions in 2013 – up 172 percent from 1991 – according to the National Institute on Drug Abuse.
More than one in three adults believe doctors who inappropriately prescribe painkillers are to blame for the epidemic, according to the poll by STAT-Harvard.
“Through excessive and careless prescription of opioid painkillers, the medical establishment has helped create this crisis. Yet we, as current and future physicians, dentists, and other healthcare professionals, can be part of the solution as well,” notes White Coats for Recovery on its Facebook page.
Sundaram and his peers want skills-based training in effective addiction screening, diagnosis, treatment and prevention. This spring, they organized their own trainings on how to use life-saving naloxone.
“There have always been individual students interested in addiction medicine, and in most medical schools, there definitely are opportunities for good training in addiction medicine (elective courses, specialists to shadow, etc.) – but students have to seek them out,” he says.
Similar concerns were expressed in a letter to the Deans of Massachusetts medical schools by an advocacy group, The Student Coalition on Addiction, which represents all four of the state’s medical schools:
“. . . Although substance use disorders are common and pervasive, we are concerned that medical students may lack adequate training in and exposure to addiction medicine . . . It is crucial that future medical professionals be trained in evidence-based strategies to care for those who are already affected by addiction. Improvements in safe prescribing practices alone will come too late for the 185,000 individuals in Massachusetts already struggling with addiction, and the more than 1,000 people in the state who died from opioid overdoses in 2014.”
Lack of addiction training is a universal problem in medical schools, according to Kelly J. Clark, President Elect of the American Society of Addiction Medicine.
“Physicians are not adequately trained to diagnose and treat addiction,” says Clark. “As a psychiatrist, I had four years of medical school and four years of psychiatric residency training. My total formal training in addiction was in residency – two months of the four years!”
To reduce the surge of addiction, Clark advocates greater access to medication-assisted treatment such as buprenorphine (brand name Suboxone), which has been shown to be effective in reducing opioid cravings and overdose deaths. She also supports legislation that would increase the number of patients that a physician can treat with buprenorphine (currently limited to 100 patients per doctor).
“As a nation, we need to very quickly understand that addiction is a chronic brain disease,” Clark says. “Like all chronic illnesses, it requires being addressed from a biological, psychological, social, and spiritual approach that allows each individual to best manage their condition over time and live the fullest possible life.”
Understanding addiction as a chronic brain disease will help shed the stigma that keeps people from getting help, Sundaram notes. Even among doctors, that stigma exists, he says.
“Some physicians share the same inaccurate and unhelpful belief that so many Americans do: that addiction is primarily a moral failing,” Sundaram says. “But even among those who think of addiction as a medical illness, I believe there is a widespread sense of hopelessness and ineffectiveness. Many physicians see patients struggling with addiction as the ones who just won’t get better, who won’t or can’t help themselves enough to be helped.”
The Obama administration is asking medical schools to adopt the CDC’s first-ever physician guidelines to curb opioid prescribing. The protocols advise doctors to first try alternatives for treating chronic pain – such as ibuprofen, aspirin or exercise therapy – and to limit opioids to three days, rarely more than seven (the guidelines do not apply to cancer or surgical patients or end-of-life care).
Reforming opioid prescribing is an important step, Sundaram says, but not enough to stop the epidemic of drug abuse. Providing long-term, evidence-based care for people battling addiction is critical, he says.
“Addiction is a treatable illness. It may not have the cure rates we like to see, but just like with diabetes, there are treatments that can help people live better lives,” he says. “We just need to train physicians in the wide range of evidence-based interventions they CAN implement: from Motivational Interviewing to prescribing medications like Suboxone to simply screening patients for substance use disorders.”
More emphasis and funding for addiction treatment – instead of incarceration for drug offenses – is a key component of the Comprehensive Addiction and Recovery Act (CARA), passed by Congress on May 13, 2016. The legislation also strengthens prescription drug monitoring programs and expands access to naloxone to reverse opioid overdoses.
Clark, the incoming president of the American Society of Addiction Medicine, praises the student campaign to put naloxone in the hands of more people.
“It’s wonderful to see both a lack of stigma toward people with substance use disorders as well a passion for public health among doctors in training,” she says.
ADDICTION HELP HOTLINES:
1-800-NCA-CALL (800-622-2255) 24-hour helpline sponsored by the National Council on Alcoholism and Drug Dependence.
1-800-662-HELP (4357) 24-hour National Drug and Alcohol Abuse Hotline offering information and referral services to people seeking treatment and other assistance; sponsored by the Center for Substance Abuse Treatment (CSAT)
1-888-957-3422 24-hour hotline providing free, confidential referrals to treatment programs and rehab clinics nationwide. Sponsored by DrugRehab.org; counselors available 24/7.