Many communities have established programs to save individuals with naloxone postoverdose. This saves lives initially but does little to prevent future overdoses, which will likely happen in most people rescued with naloxone. These people are at highest risk of overdosing again, and they are rarely able to connect with and start adequate treatment. They get up, thank their rescuer, and walk away to resume use because no one has addressed the disorder. This is similar to treating a broken arm in an alcoholic who fell on the ice while drunk. Casting the arm does nothing to prevent it from happening again because the root of the problem is not being addressed.
Why not stop overdoses before they occur? About one in twenty opioid overdoses on any given day is fatal, and the average person who overdoses goes on to have ten to twenty overdose events. These near deaths serve as a dozen or more missed opportunities for shepherding someone into treatment with methadone, buprenorphine, or injectable naltrexone, the three FDA-approved medications proven effective in reducing overdoses. When opioid overdose victims are offered treatment with buprenorphine in the emergency room and they accept it, they initially do better than people only given a phone number to call.
Naloxone is necessary, but I am afraid that on its own it is merely a Band-Aid. Focusing efforts on it may distract policy makers from seeking needed solutions. Naloxone works best as part of a comprehensive treatment system, where overdoses can be reversed but, more importantly, prevented. If only naloxone advocates could mobilize their enthusiasm and resources to expand their mission to increase information and access to maintenance treatments with methadone, buprenorphine, or naltrexone—a more complex but ultimately lifesaving task.
With the rapid expansion of fentanyl-like drugs and other powerful opioids, the call for evidence-based treatment is now more urgent than ever. In just three short years, between 2013 and 2016, US deaths from fentanyl rose by 540 percent. When people overdose on fentanyl, naloxone only makes a tiny impact. Heroin leaves a longer timeframe, depending on how much is consumed, during which the antidote can be administered successfully. With fentanyl, breathing stops in a matter of minutes, and rescuers have little time to deliver the antidote. The only hope in protecting individuals from death by fentanyl is to have easy access to OUD medications. The unique situation we find ourselves in calls for a new paradigm—long-term medical treatment as an overdose-reduction strategy.
Treating Waves Three and Four of the Epidemic
The opioid epidemic is currently in its third wave: It started with the explosion of prescription painkiller use between 2000 and 2010. It moved on to heroin. Since 2013, we have seen a dramatic rise in fentanyl use. Current treatment approaches using medications were developed and designed for the first and second phases of the epidemic. We do not know whether these treatments will be adequate to help individuals addicted to fentanyl or whether we can prevent fentanyl overdose deaths. Fentanyl-like substances appear to be different enough from heroin or painkillers that patients using them regularly may need a different treatment approach. Currently, there are no studies to help guide treatment, yet fentanyl is particularly deadly, and additional research is urgently needed if this trend continues.
A fourth wave of the epidemic may be on the rise, one that is already being seen in other countries and in some parts of the United States. An increasing number of people are using opioids in combination with stimulants and establishing a mixed opioid/stimulant addiction. In increasing numbers, opioid users are adding cocaine and methamphetamine to the mix. Treating such individuals will require yet a different strategy. Methadone, buprenorphine, and naltrexone work well for OUD, but other drugs are not fazed by the medications. Less is known about medications that can help reduce cravings for and use of stimulants.
I would not be surprised if within another thirty years we have a test to tell who is at high risk of developing addiction. We will have vaccines to protect people at the highest risk and to prevent relapse in people who achieve initial abstinence. We will have many more medications to safely treat addictions to all substances, including long-acting medicines, an injection that only has to be taken once or twice per year, or perhaps an implant lasting a lifetime. We will have tests to tell which medication to use for any given patient. We will use physical treatments—magnetic, electric, or light stimulation—to diminish functioning in very select areas of the brain to decrease or eliminate craving and improve decision-making in afflicted individuals.
But for now, the urgency to treat existing OUD patients with the effective medication we have on hand is at an all-time high. If we catch opioid users before they turn to fentanyl-like opioids or stimulants, we can profoundly reduce the impact of the next waves—which we are less prepared to tackle than we are opioids as a single addiction. When the fourth wave crests, the nation will be drowning in an even bigger sea of overdoses.