Pubdate: Thu, 29 Dec 2016
Source: Knoxville News-Sentinel (TN)
Copyright: 2016 The Knoxville News-Sentinel Co.


Tennessee looks at making naloxone, an easy-to-administer drug that can
reverse the effects of opioid drug overdoses, widely available without a
prescription. But will over-reliance on the medication be a long-term side

[photo] Thomas Clemons instructs people visiting a Baltimore needle
exchange van on how to use naloxone to reverse heroin overdoses. More and
more states, including Tennessee, are looking at the easy-to-administer
drug as a way to stem increasing opioid overdose deaths.(Photo: Amy

Around 30 times a week, Rural/Metro paramedics in Knox County administer
naloxone to people overdosing on opioids.

The ambulances have carried the drug for around 20 years now. It works by
blocking the effects of opioid drugs on the respiratory and central
nervous system. In minutes, it can restore normal breathing, potentially
saving the life of someone dying of an overdose.

There's always been a place for it in the paramedic's bag of tools -- but
over the past three to four years, Rural/Metro personnel have seen the
need to use it rise steadily, said Chris McLain, clinical manager for the
ambulance service. Over the last six months, he said, Rural/Metro's first
responders have been using it 100-120 times a month.

And they're no longer the only ones carrying the drug. Since Knoxville
Police Department began carrying naloxone in September 2015, officers have
used it 27 times on people overdosing on opioid pills like oxycodone and
street drugs like heroin.

A little more than halfway through 2016, Knoxville Fire Department has
already used it 46 times -- compared to 54 times in all of 2015, said
Capt. D.J. Corcoran. And 2015 more than doubled the number of times -- 19
- -- KFD used the drug in 2014.

At the same time, it's becoming more common for private citizens to have
naloxone on hand. Some pain clinics are requiring patients fill naloxone
prescriptions along with their prescriptions for opioid drugs. Friends and
family members of addicts are beginning to request -- and fill --
prescriptions for the drug to keep on hand, legal in Tennessee since 2014
and encouraged last year by Tennessee Department of Health Commissioner
Dr. John Dreyzehner.

'Ask for it, prescribe it, keep it around,' Dreyzehner said. 'Relatively
speaking, it is more effective at saving lives than CPR or an AED,' the
automated external defibrillator that can shock the heart back into

But, like an AED, naloxone requires training to use correctly, McLain
said. And like CPR, it's a temporary fix -- something to do while waiting
for paramedics to arrive, he said.

'I think it's kind of a misconception to say (naloxone) 'saves' somebody,'
point-blank, McLain said. Though effective, it's not fail-safe, he said.
Some patients -- especially chronic users -- need more than one dose. Some
patients also need to be ventilated, or they go into cardiac arrest.

And some patients get naloxone over and over again, and it can become less

'We do have 'repeat customers,' ' McLain said. 'Sometimes you have
communities and groups of people who just can't get off the (opioid)

Public health officials are increasingly looking at naloxone -- brand name
Narcan -- as an antidote to Tennessee's increasing overdose death rate. In
2014, the last year for which state numbers are available, a
record-setting 1,263 Tennesseans died of drug overdoses -- at least one in
all but four counties in the state, including 133 in Knox County. The
state expects to release 2015 numbers in a week or two.

Between Jan. 1 and June 15 of this year, 118 suspected overdose deaths
happened in Knox County, said Sean McDermott, assistant district attorney
general, though it's possible not all were Knox County residents. Exactly
how many of them were opioid drug overdoses, he can't say -- the numbers
aren't broken down by types of drugs, he said.

Last month, U.S. Surgeon General Dr. Vivek Murthy, on a visit to
Knoxville, announced increasing access to naloxone was one of his three
primary areas of focus in the fight against the opioid epidemic. At a June
30 forum in Abingdon, Va., hosted by U.S. Secretary of Agriculture Tom
Vilsack, Virginia Governor Terry McAuliffe touted that state's initiative
to make naloxone available statewide to anyone without a prescription -- a
policy Tennessee may soon have also.

This year, the Legislature passed Public Chapter 596 allowing 'any willing
pharmacist,' collaborating with the state's chief medical officer, to
dispense naloxone over the counter 'using their best clinic judgment, good
faith and reasonable care.' The collaborative practice agreement that
would result in pharmacies having a standing order for the drug has been
written and now will be reviewed by various state boards. At the same
time, health departments -- including Knox County's -- have been working
with pharmacies to make the easy-to-administer drug more available.

Last fall, pharmacy chain CVS announced Tennessee was among states where
its pharmacists would dispense naloxone without a prescription. They could
do so using a standing order already compliant with state law, Mike
DeAngelis, director of public relations for CVS in Rhode Island, told the

But though DeAngelis said then the company would 'reinforce' its change in
policy to its 135 stores in Tennessee, calls to Knoxville CVS stores last
week found some will prescribe naloxone without a prescription, while
others won't.

Other Knoxville pharmacies varied on whether they would prescribe or even
stock the drug, which can range widely in price. For those not filing the
drug to insurance -- for which a prescription would be required, even at
CVS -- cost could be a barrier.

Brandon Lock, head pharmacist for local chain Belew Drug's Broadway
Shopping Center store, said his pharmacy keeps in stock both Narcan and
generic naloxone, in two forms: injected through a needle into the muscle,
and sprayed into the nostril through a syringe. (Paramedics also sometimes
give the drug intravenously.)

Narcan with the kit that allows it to be injected averages about $4,000
for those paying cash rather than filing insurance, Lock said. By
contrast, the Narcan nasal syringe kit averages about $159, and the
generic naloxone nasal kit -- which most people opt for -- costs about
$75, he said.

Lock said demand for the drug has increased.

The Federal Drug Administration didn't approve the nasal spray form of the
drug until November 2015, though some agencies were using it before then.
When the more affordable version of naloxone became widely available, that
opened the door for many agencies to carry it, said Jessica Belitz,
community outreach coordinator for the nonprofit Blount Memorial
Foundation and staff coordinator for the Blount County Substance Abuse
Prevention Action Team.

'We were interested in supplying it to our first responders, but at the
time law enforcement felt it needed to be FDA-approved,' Belitz said.

In February, the team provided the nasal spray kits to three law
enforcement agencies and two fire departments in Blount County, Belitz
said. It's been used at least a dozen times so far, she said.

In addition, the coalition provided the kits to middle and high schools in
all three school systems in Blount County, she said, though she's not
aware that they've yet been used in a school.

Belitz said both first responders and schools were eager to have the drug
on hand, especially since Tennessee -- like Virginia -- has passed laws
protecting people who administer naloxone 'to a person reasonably believed
to be experiencing an overdose' from being sued or criminally prosecuted.

'One of the No. 1 complaints I hear is access,' Belitz said. 'Family
members who may be living with someone or close to someone who's addicted
call me, and they want to access this medication. aE& But even with a
prescription, it's still a challenge for some to be able to get ahold of

McLain, of Rural/Metro, urges anyone who might give the drug to become
educated on its proper use -- and its limitations. He worries people may
grow overly reliant on the drug, thinking they can continue using opioids
and 'self-medicate,' rather than seeking medical help.

He warned that people given naloxone suffer withdrawal as the drug blocks
the opioid drugs already in the body, which can make them combative. Some
initially respond to naloxone but then 'rebound,' especially if they're
chronic users or there are large amounts of opioid drugs in their system.

Call 911 first, he said, then administer naloxone.

Dreyzehner said the drug can 'prevent a mistake from being deadly or give
more people a second chance at recovery instead of death.'

And people should think of it as a second chance -- not a long-term
solution, McLain said.

'If you have a headache, you can take some Tylenol, but we still need to
know what's causing the headache,' he said. 'Prevention is the key, and
getting into some kind of treatment plan to get people off the (opioid)
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