Pubdate: Sat, 10 Mar 2018
Source: Globe and Mail (Canada)
Copyright: 2018 The Globe and Mail Company
Author: Margaret Wente
Page: O11


The life-saving drug may actually increase opioid abuse. Here's

My friendly local pharmacy has started selling naloxone kits to the
general public. They think everyone should have one. The idea is that
you never know when you're going to have someone overdose in your home.

As the opioid crisis spreads like a curse across North America,
naloxone - a lifesaving drug that neutralizes the effects of an opioid
overdose - is not confined to first responders anymore. Schools in
Toronto are stocking up in it. Librarians across the United States
have been trained to administer it to overdosing visitors. Everywhere,
the message is: make sure you have some on hand, just in case.

So what is the effect of naloxone on reducing drug-related deaths?
Jennifer Doleac decided to find out. As an economist at the University
of Virginia, she studies the consequences (and the unintended
consequences) of public policy. She and her fellow researcher, Anita
Mukherjee at the University of Wisconsin, thought that the widespread
rollout of naloxone across the U.S. provided a natural experiment in
drug policy and moral hazard.

The concept of moral hazard is simple. If you reduce the risk of any
given behaviour, then people might do more of it. The classic example
was the introduction of seat belts in cars. It turned out that seat
belts saved lives - but not as many as you might think, because they
also encouraged some people to drive faster and more carelessly.

Most of us are rational actors - even drug addicts. As drug users
realize they're far less likely to die from an overdose, some start
using more powerful drugs, in higher doses. Some switch to fentanyl
(which is far deadlier than heroin). Some "use" more often. "You
wouldn't think that people caught in the depths of addiction would
respond to incentives," Prof. Doleac says. "But they do."

There's plenty of anecdotal evidence for what's happened since
naloxone became common. In their paper, the professors cite media
reports that describe naloxone parties, where people use heroin and
prescription painkillers knowing that they have easy access to
naloxone in case they overdose. First responders say they're fed up
with saving the same people over and over again. Recently The New York
Times chronicled the depressing story of Patrick Griffin, a long-time
addict with a heroin and fentanyl habit, who once managed to overdose
no fewer than four times in six hours. Each time, emergency medical
workers revived him. Despite his family's pleading and his frequent
near-death experiences, Mr. Griffin stubbornly refuses to go into
treatment. One town councillor in Ohio got so annoyed with repeat
offenders that he proposed cutting them off after the first two overdoses.

Naloxone has caused a variety of other unintended consequences, the
researchers say. Drug-related theft is up. So are emergency-room
visits. There's even evidence that in one region of the U.S. - the
Midwest - naloxone use actually increased overall drug mortality.

Prof. Doleac expected that their results would be controversial. What
she did not expect was the enraged reaction from people in the
public-health world. The moment their paper was published this week,
the twittersphere exploded. She was deluged with abuse, even death

"The public-health community should acknowledge the behavioural
effects we find here," she says. "But they really don't like the idea
that there might be trade-offs." Why the resistance? As fierce
advocates for more harm-reduction strategies, such as access to
naloxone, they're afraid that admitting to any potential downside
would weaken their arguments for more resources and strengthen the
resistance against them.

Economists have seen this all before. After the development of
treatments that turned HIV from a death sentence into a manageable
condition, risky sexual behaviour among gay men exploded. One study,
cited by the researchers, found that treating HIV-positive men more
than doubled their number of sexual partners, and led to a sharp
increase in HIV incidence. Then as now, publichealth activists didn't
want to deal with the evidence.

To be clear, nobody - certainly not Prof. Doleac - thinks we should
withhold lifesaving treatment from drug users. But we shouldn't ignore
the evidence either. Naloxone is no magic bullet. The overwhelming
lesson of the opioid crisis is how intractable it is. There are no
quick wins and no easy fixes. Another example: when the formulation of
OxyContin was changed to make it more tamper-resistant, opioid-related
deaths did not decline, as expected. People just switched to heroin.

"We need to experiment with a variety of approaches," Prof. Doleac
concludes. "And we should be humble."
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