NARCAN: A LINE IN THE SAND TO STOP AMERICA’S OPIOID TSUNAMI
The evidence is clear. The only factor moderating runaway opioid deaths is naloxone campaigns with increasing, repeated saves – while failed treatments, learned false confidence, persistent misprescribing, and uncontrolled surging high-risk opioid use push Narcan’s limits and the stakes
by Clark Miller
Published April 16, 2023
All bets are off. Always have been.
The factors driving America’s intractable thanatotic descent are deep and psychological, embedded in cultural manifestations of fear, aggression, ultimately trauma.
Escape from fear and pain of emptiness and vulnerability drives the needle and the misprescriber’s pen, acts of weakness and cowardice, the fist and the belt, the lies that ensure publication and status, the lies that reward.
Down through time and death.
Economies of fear and its escape are volatile and opportunistic, cold and hot. Today’s black tar is tomorrow’s fentanyl is next week’s tranq dope. Today’s soothing, protective lie – that opioids treat pain, that SSRIs treat depression, psychedelics are the next cure – is tomorrow’s outrage, next week’s virtue signal.
As predictably as cheap, easily lab-produced, hyper-potent fentanyl replaced heroin, it will be replaced by the new, more potent synthetic or drug combination that fuels the profits that buy security where there is no security, provides escape from pain where there is none. Just as the next lie that soothes, that stays a step ahead of the intolerable truth, that flees from courage and change, paves a descent.
Narcan is for America’s lethal opioid crisis what the AED – automatic external defibrillator – is for heart disease. Every use to save a life points to an incidence of heart disease. If emergency use of resources in campaigns to urgently expand distribution, training, and public use of the AED were required, that would point to a worsening epidemic of heart disease, a failure to address and treat heart disease, not to gains against heart disease.
And under that analogy, media and entertainment campaigns to portray manufacturers and promoters of high-risk foods, or the distributors of unhealthy foods – or of the distracting devices and content that keep Americans overweight and sedentary – as the villains responsible for an epidemic of heart disease would represent the highly comforting use of lies, distortions, of defenses, to escape the pain of responsibility for choices, provide escape from and avoidance of the only way forward toward moderation of an epidemic of heart disease.
Those defense mechanisms that are triumphs of American ingenuity and creativity, marshaled in media and institutional disinformation campaigns to protect the real forces perpetuating opioid and other substance compulsive use and epidemics, keep their target audience in learned helplessness, keep the suppliers and prescribers in careers and material gain, safe and secure. For now.
For America’s opioid crisis, itself the product of profitable, numbing relief that creates more pain, the analogy breaks down, apocalyptically – because the human heart is not adapting day-to-day, not changing its behavior unendingly in ways that predictably will defeat the life-saving revival biomechanics of the AED.
On the streets of pain and lost hope and in the labs meeting demands, it’s entirely different. The opioid abuser at risk of death by overdose is a moving target by choice and by circumstance, by the vagaries of an illicit drug supply. By the deep psychological needs and distortions including learned helplessness and the lie of his having a disease. Nothing I can do about my disease of the brain. But this new dope makes me forget that.
The drugs he can get and that give him what he needs increasingly challenging the efficacy of Narcan, requiring multiple hits, until . . .
His free “subs” – the controlled, addictive opioid Suboxone provided by phone hook-up with his licensed supplier – mixed with the free benzos provided by another medical prescriber, a high-risk, naloxone-defeating combo known for decades – gives him what he needs. And defeats Narcan, contributing increasingly to overdose deaths combined with opioids.
His suppliers are unconcerned.
Despite worsening outcomes.
As does today’s new combo, “tranq dope” – gives the user what he needs.
The detection of xylazine in drug mixtures – particularly in combination with fentanyl – is increasing across the country. The fact that xylazine, a non-opioid, can cause respiratory depression similar to that of an opioid overdose may increase the potential for a fatal outcome at a time when overdose deaths in the United States continue to reach record highs. Treatment with naloxone will only counteract the effects of the opioid in a mixture, meaning the victim may require additional measures to survive. Responders may not be aware that xylazine intoxication is a factor and as a result may not know to apply additional life-saving methods when naloxone only partially reverses the symptoms.
. . . Indeed, focus groups with people who use drugs in Philadelphia have suggested that the addition of xylazine to fentanyl “makes you feel like you’re doing dope (heroin) in the old days (before it was replaced by fentanyl)” when the euphoric effects lasted longer. Users have suggested that xylazine gives them ‘the nod’ that heroin provided prior to the replacement of fentanyl in the drug supply. In Puerto Rico, xylazine use has been associated with use of ‘speedballs’, the combined use of heroin and cocaine. In semistructured interviews, Puerto Rican drug users indicated that the addition of cocaine to heroin and xylazine combinations was used to balance the ‘down’ of heroin and xylazine. Among 2019 decedents with positive detections for xylazine and an opioid in Philadelphia, 53% also had positive detections for cocaine, which may indicate speedball use locally (table 1).
Importantly, our results show that evidence of injection was more prevalent among decedents with xylazine and heroin and/or fentanyl detections. Despite limited literature on the health effects of chronic xylazine use, regular injection of xylazine has been associated with skin ulcers, abscesses and lesions in Puerto Rico. Semistructured interviews with people who use xylazine in Puerto Rico revealed that regular use of xylazine leads to skin ulcers. As skin ulcers are painful, people may continually inject at the site of the ulcer to alleviate the pain as xylazine is a potent α2-adrenergic agonist that mediates via central α2-receptors, which decreases perception of painful stimuli. People may self-treat the wound by draining or lancing it, which can exacerbate negative outcomes. While Philadelphia has seen a rise in skin and soft tissue infections relating to injection drug use, it is not yet clear whether or not this is due to increased presence of xylazine in the drug supply.
With opioid deaths and high-risk use incessantly surging, post-pandemic with fabricated pandemic stressors and bogus explanations dissipated, surging the more America’s proven, life-saving medical treatments are administered to diseased brains, America is betting the house on Narcan – when all bets are off.
The fentanyl-dominated recreational drug supply and the rapid rise of overdose deaths is unfortunately not the endpoint in the evolution of the North American drug market. Non-fentanyl-derived ultrapotent synthetic opioids that are several times more potent than fentanyl, such as nitazenes, are being increasingly detected in Canada and the USA. Despite having similar (and often more acute) physiological effects to heroin, these novel psychoactive substances are not well characterised, and there is little understanding of an effective treatment approach.
. . . These developments will challenge nearly all existing harm-reduction and treatment options, from reversing overdoses with the appropriate naloxone response to retention in opioid agonist treatment programmes, underscoring the importance of proactively collecting evidence and adjusting our health-care systems.
Naloxone saves lives, no additional justifications for continued campaigns and devoted resources needed.
And its rapidly increasing use, moderating prevalence of lethal overdose:
masks the continuously mounting levels of high-risk opioid use and potential for lethality, especially as synthetic and other new street drugs come into the mix, defeating reversals
shifts resources and focus away from the established causes of high-risk opioid use and need for focus on prevention and real treatment