Letting First Responders Use Higher Doses of Narcan to Fight Opiate Overdoses

Lilo H. Stainton | December 15, 2017 | Health Care
Bipartisan move to give paramedics, firefighters more flexibility in type and dosage of opioid antidotes

narcan naloxone
New Jersey is considering updates to a law designed to protect emergency responders who administer life-saving opioid antidotes in order to address a growing and painful truth: preventing overdoses with today’s more powerful drugs requires increasingly robust strategies.

The Senate health committee unanimously approved a bipartisan bill Thursday that would give paramedics, firefighters, and other first responders more flexibility in the type and number of doses they can use when administering naloxone, which can reverse an opioid overdose. The measure, which cleared the Assembly in March, awaits final passage in the full Senate.

The vote followed graphic testimony from emergency responders who said that current Garden State regulations do not enable an individual to administer multiple doses of naloxone without approval from a medical director. They said a single dose is sometimes not enough to save a patient overcome by the more powerful, and increasingly common, blends of heroin and the cheaper, synthetic opiate fentanyl.

“The game has changed. These are not the opioids of the 20th century,” warned Steve Spurr, a firefighter who heads the EMS committee for the New Jersey Firefighters Mutual Benefit Association.

John Armato, a committeeman and longtime firefighter in Buena Vista Township — who will be sworn in as a state Assemblyman in January — recalled a recent incident in which responders struggled in pouring rain to revive a drug user lying in the street outside his home, while the man’s family surrounded them screaming for his life. The first 2mg dose failed to rouse him, and it took several long minutes until a state trooper arrived and was able to administer a second naloxone dose.

Naloxone combats overdoses

“Fentanyl makes the drug Narcan (a leading brand of naloxone) work so much harder,” explained Armato, who approached Assemblyman Vincent Mazzeo (D-Atlantic) and worked with him to sponsor the proposed change. “This bill will go far in saving lives,” Armato said.

Naloxone is becoming an increasingly common weapon in combating overdose deaths, which killed more than 2,100 New Jersey residents last year; according to a task force report, 800 of those deaths involved fentanyl. Under Gov. Chris Christie, the state has ramped up programs to support the use of these products — formulated as shots and now a nasal spray; it has helped to distribute the antidote to first responders, starting in 2014, and has hosted training for citizens to ensure they can use it safely.

In addition, citizens can purchase naloxone at drugstores around the state. While it was already on sale at hundreds of chain stores, like CVS, Christie signed a law in June that makes it easier for independent pharmacies to sell it. Overall, the treatment has been administered more than 12,000 times in New Jersey in the past three years.

The Overdose Prevention Act, which Christie approved in 2013, was also designed to increase public access to naloxone and to protect those who prescribe and administer the antidote from criminal or civil penalties, or disciplinary action.

Under protocols issued by the state Department of Health — which apply to emergency medical technicians, but not firefighters, and were updated this fall — responders can administer one 2mg dose via a muscle shot or nasal spray, or opt for a new 4mg nasal spray. But they must wait several minutes to assess the patient’s response, to be sure they are not dealing with seizures or other complications, and get permission from a medical director to provide a second dose.

Many patients need a second dose of antidote

After minor amendments in the Senate, the proposed reform, led by Mazzeo and Assembly health committee chairman Herb Conaway (D-Burlington), a physician, would enable responders to use any naloxone brand and administer up to three shots or nasal spray doses without consulting outside professionals. The amended version would also give the DOH 45 days to update emergency medical services statewide.

Tommy Begres, a firefighter in Michigan and clinical director at Adapt Pharma, which makes Narcan, called the bill a “common sense” approach to solving what has become a widespread problem nationwide, now that nearly one-third of all opioids are laced with fentanyl. While research shows one in four overdose patients may need a second dose of the 2mg antidote, Begres said that has only happened with 6 percent of the patients who receive the 4mg version.

Sen. Colin Bell (D-Atlantic), a lead sponsor of the measure (S-3083) with Sen. Steven Oroho (R-Sussex), said that even with state permission to use a full 4mg of naloxone, one dose is not always enough. “Fentanyl is so potent, it may require several doses of naloxone to bring someone out of a fentanyl overdose,” he said.

“First responders who encounter overdose victims should only need to worry about saving lives and not about potential liability,” Bell said, adding, “I am proud to sponsor this legislation in memory of Senator Whelan’s tireless struggle for the most vulnerable and for those he has represented. Senator Whelan wanted to provide first responders with the necessary resources to save lives, and that is what this bill does.”

Despite the lifesaving nature of these drugs, escalating prices have become a concern and Sen. Joe Vitale (D-Middlesex), the health committee chairman, drilled Begres on the cost of these products.

Price of antidote: $37.50 to $4,700

Berges said Adapt charges the public $125 for two doses of the 4mg spray when purchased at a drug store; insurance generally covers naloxone, often without any co-pay. Emergency responders and other public officials can get the same two-pack of 4mg spray for $37.50, he said. But Adapt’s competition, Evzio Pharmaceuticals, charges $4,700 for a pair of 2mg injections, he added.

Ensuring that responders are armed with naloxone is critically important, Sen. Fred Madden (D-Burlington), agreed, noting that some 140 people have died this year in his district because of overdoses. Naloxone alone isn’t treatment, he warned, but a chance to escape death. “We’re saving lives, but we’re not curing anything with this. In some cases, we’re just passing it on to the next episode,” he said.