Recently, there has been intense ethical debate surrounding expanded access to the life saving opioid overdose reversing drug naloxone (Brand name: Narcan). There are generally two stances which people take, one group believes that Narcan should be widely available due to its lifesaving properties, while the other group disagrees, stating that increased Narcan availability would serve to promote excessive opioid use. This blog post intends to describe how Narcan works to reverse an opioid overdose, and dive into the ethics of harm reduction.

Opioids have analgesic and euphoric effects. They are commonly used for recreation and/or pain management. There are multiple types of opioids which act as opioid agonists, meaning that they bind to and activate opioid receptors in the brain.

1. Endogenous opioids – these are opioids which are naturally present in our bodies, including enkephalins and endorphins. They play a role in diminishing pain, food metabolism, cardiovascular regulation and driving euphoric responses (as mentioned in review by Zagon & McLaughlin, 2017).
2. Natural opiates – these are natural opioids which come from the poppy flower. This group includes opium and analgesics derived from it including morphine and codeine (as mentioned in review by Ballantyne & LaForge, 2007; Center for Disease Control [CDC], 2021). Fun fact: Poppies were associated with the Greek god Morpheus, the god of sleep and dreaming, and his father Hypnos, due to their analgesic properties (Stanton, 2022).
3. Synthetic opioids – Opioids made in a lab. This includes fentanyl, a full mu-opioid receptor agonist, which allows it to bind to opioid receptors with more efficacy than natural opioids can. Fentanyl is estimated to be 50-100 times more potent than morphine (Luba et al., 2022). Synthetic opioids also include methadone, which can be prescribed to treat opioid use disorder (CDC, 2021).
4. Semi-synthetic opioids – These opioids are commonly prescribed in pain management. They are a mix between natural and synthetic opioids. This group includes oxycodone, hydrocodone, hydromorphone and oxymorphone (CDC, 2021)

An opioid overdose can happen when someone takes opioids at an excessive amount (CDC, 2021). Symptoms can include the following (Montgomery County Department of Public Safety, 2020): 

• pinpoint pupils
• cyanosis (for a lighter skinned person, skin has a blue tint; for a darker skinned person, skin might have a grayish tint)
• decreased breathing volume and respirations
• nausea and vomiting
• decreased level of consciousness
• unconsciousness, gasping/choking sounds
• heavy snoring

An opioid overdose can be deadly, as the person may become hypoxic (taking in too little oxygen).

Recall that opioids are opioid agonists. But Narcan is a competitive opioid antagonist, with a high affinity for mu opioid receptors (Jordan & Morrisonponce, 2022). This means that the naloxone can beat the opioids to opioid receptors, bind to them, and thereby kick out or block the opioids from filling that receptor and continuing to enact effects [see image below], effectively reversing the deadly effects of the opioid overdose (CDC, 2021). When Narcan is administered, it can induce withdrawal symptoms in about 2-3 minutes depending on the amount and potency of opioids the patient took (Montgomery County Department of Public Safety, 2020). For information regarding what to do in a drug overdose visit: https://www.verywellhealth.com/how-to-use-narcan-nasal-spray-7373509.

Recently, the state of Maine has allowed greater access to Narcan, by allowing Narcan to be obtained over the counter (https://getmainenaloxone.org/have-it-on-hander/). According to the Maine Data Drug Hum, over 8,907 people were saved from opioid overdoses in 2021 (https://getmainenaloxone.org/). This form of harm reduction has saved people’s lives, yet there are still people who ethically disagree with its usage. Is there validity to the common opposing arguments?

Investigating Common Arguments About Narcan

Do “Narcan parties” exist?
A “Narcan party” is an alleged opioid party where users come together to purposefully overdose, knowing that they have Narcan on hand which can revive them (Farah, 2017). One online non-empirical article, “The Latest Dangerous Drug Trend Doesn’t Actually Exist” by Troy Farah debunks the myth of the “Narcan party”. Farah writes that although politicians, laymen, and a handful of first responders have reported hearing of the existence of “Narcan parties”, upon further questioning, no one was able to provide concrete evidence of their existence (Farah, 2017). Narcan rapidly induces uncomfortable withdrawal symptoms, so it seems that the likelihood that someone would purposefully overdose, come close to death, then suffer withdrawal symptoms is low. However, to my knowledge, no empirical studies within the field of psychology or sociology have explored this topic yet.

Does Narcan availability affect perceived heroin risk?

The question of whether expanded access to Narcan reduces risk perceptions about opioid use was addressed by Kelly and Vuolo (2020). They used US census data from 884,800 respondents from 2004-2016 to look for correlations between the respondent’s perceived risk and their state’s implemented naloxone access laws. They found that there was no evidence of decreased heroin risk perceptions due to naloxone access laws (Kelly & Vuolo, 2020). This question of if Narcan affects risk perception, alludes to the theory of “risk compensation” (Farah, 2017). Phrased in another way, it’s like asking, does the existence of seatbelts encourage reckless driving? Perhaps. Perhaps not. But that does not mean that the number of seatbelts should be restricted for only good drivers. Logically, we acknowledge that the reward is greater than the risk. So, we continue to manufacture seatbelts (Farah, 2017). Psychological conditions, including addiction, are as worthy of treatment as any other medical condition.

Does Narcan administration affect rates of further care?

This argument rests on the assumption that if a layperson administered Narcan to a person who has overdosed, that they would not call for higher medical care. This is a valid concern, however, calling for medical assistance is part of training to administer Narcan (Bazazi et al., 2010). This protocol of calling for higher care after administration is similar to training in administration of an EpiPen. One overdose prevention program in New York found that 74% of participants called for help after administering naloxone (Bazazi et al., 2010; Piper et al., 2008). This number is significantly higher than the proportion of drug users in NYC who have reported calling an ambulance during witnessed overdose events without necessarily having Narcan education (67.7%) (Piper et al., 2008; Tracy et al., 2005). Now that Narcan is becoming more widely available, it is important that efforts be made to educate the public about the steps of proper Narcan administration which includes calling for a higher level of care, so that the person can receive further support. 

Narcan is not intended to stop opioid abuse, it’s intended to reverse an opioid overdose– in anyone who may have used excessive opioids, not just people diagnosed with a severe substance use disorder, or people who have overdosed on synthetic opioids. See chart below for a breakdown of the variety of opioids which have induced overdose deaths in the US in 2020 (data from Kaiser Family Foundation [KFF], 2020). The person may or may not continue to use opioids after this withdrawal. What is more important is that Narcan can give that person a chance at living and deciding what they want for their future. Opioid deaths are continuing to rise in part due to the increase in illicit synthetic opioids, making access to and proper administration of Narcan incredibly relevant (Jordan & Morrisonponce, 2022). It is important to continue to fight for harm reduction, and have open conversations with people from various viewpoints in order to dispel the stigma and save the lives of people experiencing opioid overdose.

Works Cited

Ballantyne, J. C., & LaForge, S. K. (2007). Opioid dependence and addiction during opioid treatment of chronic pain. Pain, 129(3), 235–255. https://doi.org/10.1016/j.pain.2007.03.028

Bazazi, A. R., Zaller, N. D., Fu, J. J., & Rich, J. D. (2010). Preventing Opiate Overdose Deaths: Examining Objections to Take-Home Naloxone. Journal of Health Care for the Poor and Underserved, 21(4), 1108–1113. https://doi.org/10.1353/hpu.2010.0935

Center for Disease Control. (2021, January 26) Commonly Used Terms. Retrieved from https://www.cdc.gov/opioids/basics/terms.html. 

Farah, T. (2017, July 31). The Latest Dangerous Drug Trend Doesn’t Actually Exist. The Outline. Retrieved from https://theoutline.com/post/1964/narcan-parties-heroin-overdoses?zd=3&zi=inblzavm. 

Jordan, M. R., & Morrisonponce, D. (2022). Naloxone. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK441910/. 

Kelly, B. C., & Vuolo, M. (2022). Do naloxone access laws affect perceived risk of heroin use? Evidence from national US data. Addiction, 117(3), 666–676. https://doi.org/10.1111/add.15682

KFF (2020). Opioid Overdose Deaths by Type of Opioid. Retrieved from https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-type-of-opioid/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. 

Luba, R., Jones, J., Choi, C. J., & Comer, S. (2023). Fentanyl withdrawal: Understanding symptom severity and exploring the role of body mass index on withdrawal symptoms and clearance. Addiction, 118(4), 719–726. https://doi.org/10.1111/add.16100. 

Montgomery County Department of Public Safety; Division of EMS. (2020). First Responder Naloxone Program (pp. 1–16). Retrieved from https://www.montcopa.org/DocumentCenter/View/29411/2020-9-1-Naloxone-Training. 

Naloxone in Maine saves lives. (2022). Get Maine Naloxone. Retrieved from https://getmainenaloxone.org/. 

Piper, T. M., Stancliff, S., Rudenstine, S., Sherman, S., Nandi, V., Clear, A., & Galea, S. (2008). Evaluation of a Naloxone Distribution and Administration Program in New York City. Substance Use & Misuse, 43(7), 858–870. https://doi.org/10.1080/10826080701801261

Stanton, K. M. (2022, November 4). Poppy Flower Meaning and Symbolism: Honor & Remembrance. UniGuide. Retrieved from https://www.uniguide.com/poppy-flower-meaning-symbolism. 

Tracy, M., Piper, T. M., Ompad, D., Bucciarelli, A., Coffin, P. O., Vlahov, D., & Galea, S. (2005). Circumstances of witnessed drug overdose in New York City: implications for intervention. Drug and Alcohol Dependence, 79(2), 181–190. https://doi.org/10.1016/j.drugalcdep.2005.01.010

Zagon, I. S., & McLaughlin, P. J. (2017). Endogenous Opioids in the Etiology and Treatment of Multiple Sclerosis. In Multiple Sclerosis: Perspectives in Treatment and Pathogenesis (pp. 125–138). Codon Publications. https://doi.org/10.15586/codon.multiplesclerosis.2017.ch8