Vital Strategies Q and A with Erin Russell about findings from the Compassionate Overdose Response Summit
Naloxone distribution is an important harm reduction strategy for preventing overdose death. Thanks to the tireless work of harm reduction advocates, it has become a widely recognizable tool in the overdose prevention landscape. This lifesaving medication works within minutes to reverse opioid overdose.
However, not all naloxone products are the same. Some pharmaceutical companies are aggressively promoting higher dose and long-acting naloxone products to government and institutional purchasers. Given the volatility and variability of the illicit drug supply, questions have circulated about whether and how these products could affect overdose response.
In March 2024, Health Management Associates held an expert summit, co-sponsored by Vital Strategies, to discuss the importance of compassionate overdose response and the need for a standard protocol. HMA subsequently issued a report on the proceedings and the International Journal of Drug Policy published the summit’s consensus call to action.
The summit brought together 450 leading medical, public health, and harm reduction experts, including people who use drugs, to share knowledge and best practices for responding to an overdose. Summit speakers presented on experiences from four states, offering empirical evidence that an increase in naloxone dose is not necessary to reverse overdose, even when responding to overdoses involving potent substances like fentanyl.
Vital Strategies interviewed Erin Russell, Principal at Health Management Associates and summit organizer, about the harms associated with higher dose and long-acting naloxone and the importance of investing in evidence-based public health responses to the overdose crisis.
What is the role that naloxone plays in overdose prevention?
Naloxone administration is one part of a continuum from identifying an overdose to post-overdose care and support. Naloxone is a miracle drug that simply knocks opioids off receptors in the body, temporarily cancelling out its effects. An opioid overdose is characterized by very slow and shallow breathing, because opioids depress the respiratory system. If someone is overdosing, naloxone saves their life by stopping the opioids’ effects. However, that is more complicated if other substances are in the person’s system. Someone may need support breathing until they can do so on their own.
What are the risks associated with higher dose and longer acting naloxone products?
High-dose and long-acting overdose reversal products are those that provide > 4 mg in one intranasal dose, or > 0.4 mg of naloxone in one intramuscular dose. Data presented at the summit showed that people are more likely to experience withdrawal symptoms, such as vomiting, after a higher dose of naloxone.
Naloxone is incredibly effective, and a standard dose of 4 mg is enough to reverse most overdoses. When administered, naloxone will do its job to efficiently remove opioids from the body’s receptors. More naloxone does not allow it to work any faster, because we have only so many opioid receptors in the body. Furthermore, higher dose and long-acting products tend to make withdrawal more severe, leading to vomiting, nausea, flu-like symptoms and anxiety. Physician experts presented research at the summit comparing a standard dose product with a higher dose 8 mg product that found no difference in survival, but more than double the risk of withdrawal.
How we engage with a person immediately after an overdose matters; it is a time to offer compassionate support. If we’re employing products that are far above the needed dose, and that make people suffer more after an overdose, then we’re not only abandoning human compassion but also losing a valuable opportunity to engage with that person for follow-up care.
High-dose and long-acting products are an unnecessary distraction from the strategies that have always worked. And since people who use drugs have not been consulted in the development, design, or approval of these products, the short- and long-term impact of the withdrawal caused by these products has been dangerously minimized.
What were some of the most important (or surprising) takeaways from the summit?
One interesting takeaway had to do with the history of overdose prevention education. Eliza Wheeler from Remedy Alliance/For the People presented a flow chart, now decades old, that showed harm reduction responders how to monitor breathing, indicating when to escalate the response. We have been honing these techniques for many years in close collaboration with people who use drugs, which is what makes them so effective.
These techniques include monitoring oxygen levels with a pulse-oximeter and using assisted oxygen devices to support breathing when levels dip to a concerning level. While individuals can apply these techniques in their community, they are extremely effective in a supervised consumption or “overdose prevention center” setting.
Opioid settlement funds going to states and localities are creating new opportunities for investment in saving lives, and leaders across the country are making decisions now on how to spend those funds. How can states and localities spend opioid settlement funds in a way that supports evidence-based practices?
Opioid settlement funds can be used to purchase standard-dose naloxone products that have been in use and are already known to be effective, like 0.4 mg intramuscular injectable and 3 mg or 4 mg nasal spray for community distribution. Continuing to make these standard lower dose products available free of charge in communities will facilitate more compassionate overdose reversal.
For other strategies, I would point people to the Principles for the Use of Funds from the Opioid Litigation, developed by a coalition of organizations led by Johns Hopkins’ Bloomberg School of Public Health. To find out how to get involved in your state’s settlement planning process, check out the Community Guides developed by Vital Strategies and Opioid Settlement Tracker.
The report on the event is here, and you can watch the recording of the event here.