Mass. first responders to carry larger Narcan doses

Emergency personnel may now carry doses up to four milligrams of naloxone nasal spray

By Christian M. Wade
The Eagle-Tribune

BOSTON — Police officers, firefighters and other first-responders in Massachusetts will be allowed to carry more potent doses of the life-saving overdose antidote naloxone under new state guidelines.

The changes, approved by the state Office of Emergency Medical Services, authorize emergency personnel to carry doses up to 4 milligrams of naloxone nasal spray, sold under the brand name Narcan. Under previous policy, they were limited to 2 milligram doses.

Naloxone can reverse overdoses from heroin and other opioids, but first-responders say stronger or multiple doses are often needed to revive patients who have used substances laced with fentanyl, because of its higher potency.

"Sometimes they have to administer Narcan four or five times because the drugs are so powerful," said Lt. Edward Guy, a spokesman for the Andover Police Department.

Massachusetts is one of a handful of states that limited naloxone dosages — a cap that has prevented police and fire departments from accepting some donations of Narcan from pharmaceutical companies.

In July, the Police Assisted Addiction Recovery Initiative — founded by former Gloucester Police Chief Leonard Campanello and businessman John Rosenthal — received a donation of 10,000 doses of Narcan from its manufacturer, Adapt Pharma.

The nonprofit group had to divert the 4 milligram doses, which were too high, to fire and police departments in other states.

"With stronger and more dangerous drugs like fentanyl claiming more and more lives each day, stronger, more potent doses of Narcan allow first-responders to save more lives," Rosenthal said in a statement.

"We cannot save a dead person. Every life saved with Narcan is an opportunity for a person suffering from the disease of addiction to reclaim their life," he said.

The state's decision to increase the allowed dosages of nasal spray follows a recommendation by a U.S. Food and Drug Administration advisory committee to increase the minimum amount for an injectable dose of naloxone, which is now 0.4 milligrams.

Narcan counteracts the effects of heroin, OxyContin and other painkillers by blocking certain receptors in the brain.

But recent studies have suggested that higher doses may increase the chances of acute opioid withdrawal syndrome, which can make patients aggressive and even violent. Because of that, some first-responders may be reluctant to administer repeat or future doses, according to the FDA.

Other studies have recommended treating children and young adults — who may accidentally overdose after coming in contact with heroin or other opioids in their homes — with a higher dose because they tend to metabolize naloxone more quickly than adults.

Barbara Herbert, a physician and president of the Massachusetts chapter of the American Society of Addiction Medicine, supports the state's decision to increase the maximum Narcan dosage.

She said lower doses aren't as effective with fentanyl overdoses.

"It's a good idea, as long as we track what happens," she said. "If we find that it makes people more uncomfortable or difficult for our first responders, then we'll have to pull back. But there haven't been any reports of that happening yet, even anecdotally."

The state's medical community has debated naloxone doses over the years, Herbert said. During a heroin epidemic in the 1990s, some emergency rooms lowered the injected dosage to 0.2 milligrams to lessen withdraw symptoms.

"But we're dealing with stronger heroin, often laced with fentanyl, so we need to respond with a stronger medicine," she said.

Sander Schultz, Gloucester's emergency medical services coordinator, said the city's fire department responds to several calls for accidental overdoses each month, and first-responders often administer more than one 2 milligram dose of naloxone to revive patients.

For patients with strong addictions, a strong naloxone dose can also intensify withdrawal symptoms.

"So that person whose life you just saved will be in a lot of discomfort," Schultz said. "They're going to vomit and become agitated."

Like most states, Massachusetts has experienced a surge of fatal, opioid-related overdoses. Health officials said preliminary estimates show more than 984 deaths from opioid overdoses in the first six months of 2016 -- a number expected to rise as more data become available.

Last year, overdoses claimed an estimated 1,659 lives statewide, including 223 in Essex County.

The state has been stockpiling naloxone for cities and towns amid concerns about skyrocketing prices of the drug.

Attorney General Maura Healey reached a deal last August with naloxone manufacturer Amphastar Pharmaceuticals that provided $325,000 for a bulk-purchasing program to acquire and distribute the medicine at reduced prices, averaging about $20 per dose.

Besides law enforcement, naloxone is made available to the public by pharmacies as an injectable product and nasal spray. School districts across the state have also stocked up on the overdose-reversing drug. Those doses range from 0.4 milligrams for injections to 4 milligrams for the nasal spray.

What's unclear is whether the state's decision to increase naloxone dosages will drive up costs for cities and towns.

"Even if the cost doubles, it will still be less than what police departments were paying a few years ago," said Mark Leahy, executive director of the Massachusetts Association of Police Chiefs. "Overall, this will be far a more efficient way to administer Narcan."

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