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To curb the opioid crisis, some cities and states are opening overdose prevention centers where controlled substances can be used under professional supervision. Others are finding new ways to distribute naloxone, a medication that rapidly reverses an opioid overdose, to first responders and members of the public.
On Wednesday, June 21, 2023, SciLine interviewed: Dr. Brandon Marshall, a professor of epidemiology at Brown University. He discussed topics including: statistics about opioid overdoses and deaths in the U.S.; how naloxone works to reverse an overdose; what naloxone’s new over-the-counter status might mean for the U.S. overdose crisis; the effectiveness of overdose prevention centers; and common misconceptions about these and other strategies aimed at reducing negative consequences associated with drug use.
Professor Marshall serves as an expert advisor to the Rhode Island Governor’s Overdose Prevention & Intervention Task Force, and is a member of that state’s Opioid Settlement Advisory Committee. He has also served as an ad hoc advisor to the Food & Drug Administration. His research is funded by Arnold Ventures, Open Society Foundations, and the National Institutes of Health.
BRANDON MARSHALL: My name is Brandon Marshall. I’m a professor of epidemiology at the Brown University School of Public Health, and I study substance use epidemiology with a particular focus on overdose prevention.
Interview with SciLine
Can you share some statistics about opioid overdoses and deaths in the U.S.?
BRANDON MARSHALL: The number of overdose deaths in the United States continues to be unprecedented and is at crisis levels. More than 100,000 Americans—almost 300 people every single day—lose their lives to preventable drug overdoses. Recent data from the CDC shows that deaths in ’22 may have decreased slightly by about 2% Since their peak in 2021, although those statistics are provisional and may change. I think what’s important to keep in mind is that every community in all 50 states are impacted by the overdose crisis. Some regions are particularly highly impacted, like West Virginia and other parts of Appalachia, the mid-Atlantic, and New England. But throughout the COVID-19 pandemic every state has seen substantial increases in overdose deaths. And that demonstrates, I think, the national scale of the problem.
How does naloxone work to reverse an overdose?
BRANDON MARSHALL: So, naloxone also goes by the brand name Narcan, and it is an opioid-overdose antidote. Naloxone works by essentially bumping the opioid off receptors in the brain, which is what is responsible for causing overdose symptoms like slow breathing. Naloxone can be very easily administered by laypersons. It comes in a nasal spray and is also available in an intramuscular formulation as well. It’s a very safe medication. So, for these reasons, the surgeon general, the FDA, and other federal agencies recommend that every American learn to use and carry naloxone. And there are laws in all 50 states that allow Americans to obtain naloxone at pharmacies without a prescription.
Why doesn’t naloxone work on overdoses caused by xylazine, and why is that so concerning?
BRANDON MARSHALL: Xylazine is a tranquilizer that’s used primarily in veterinary medicine, particularly for equine sedation or horse sedation. There are no FDA-approved uses for xylazine in humans. However, the drug has been detected in the drug supply in multiple states, including right here in Rhode Island. Xylazine is not an opioid. So, naloxone isn’t effective at reversing the sedation that’s caused by xylazine. But what I want to note is that in our research, at least focused in Rhode Island, we found that xylazine is always present with an opioid like fentanyl. So, this means that it’s critical to administer naloxone whenever an overdose is suspected to reverse those symptoms that are caused by the opioid. But people who witness an overdose should also call 911 so medical professionals can address any health risks associated with xylazine specifically.
The FDA recently approved naloxone for over-the-counter use. What effect might this have on the U.S. overdose crisis?
BRANDON MARSHALL: Earlier this spring, the FDA approved over-the-counter use of naloxone, and this means that later this summer, pharmacies will be able to sell naloxone just like they do other over-the-counter products like allergy medications and smoking-cessation aids. This is a critically important step in expanding access to naloxone, particularly for rural and underserved communities. Research shows that when naloxone is made more widely available, overdose deaths decrease. So, the hope is that this policy change could make a real difference in putting a dent in our nation’s overdose crisis. One potential barrier I want to highlight to this happening is cost. Some pharmacies may charge upwards of $50 for just one naloxone kit, which could be unaffordable to many people who might benefit from having naloxone and administering it in the case of an overdose. So, it’s important for states and other jurisdictions to continue providing free naloxone through community-based efforts, educational events, syringe exchange programs, and so on. But overall, this is a really positive policy change that I’m hopeful will make a difference and save lives.
What are overdose prevention centers? Can you share some data about their effectiveness?
BRANDON MARSHALL: Overdose prevention centers are places where people can go to use drugs under supervision. It’s important to note that drugs are not provided at the overdose prevention center. Rather, these drugs are obtained elsewhere and brought on site. Staff are trained to reverse overdoses that happen at the center and address many other health issues. Importantly, though, there’s a variety of other services that are typically offered at an overdose prevention center, including health care, showers, laundry, counseling, and addiction treatment and social services. These are not a new intervention internationally. There are hundreds that exist in countries, especially throughout Europe. And research in those countries has shown that overdose prevention centers save lives, help connect people to treatment, and improve the neighborhood conditions in which they’re located by reducing the number of people using drugs in public and reducing drug-related litter like syringes. So really, we’ve seen from other countries a host of benefits to both people who use overdose prevention centers and the communities in which they’re located.
What are some common misconceptions about strategies aimed at reducing negative consequences associated with drug use?
BRANDON MARSHALL: One of the most prevalent misconceptions that I come across is that these tools somehow promote or enable drug use, and decades of research has shown that that is just not true. In contrast, these are public health strategies, which are aiming to connect people to health care, social services, and addiction treatment. So, they’re actually serving as pathways into treatment and recovery for people who are highly marginalized and who might have experienced very negative interactions with our health care, criminal justice, and social service systems. So, I think that’s one of the most important misconceptions that research can help tell us is definitively not true. And in fact, we see clear public health benefit by expanding access to many of these strategies.
What else should be done about the overdose crisis?
BRANDON MARSHALL: We’ve talked a lot about strategies to address overdoses as they’re occurring, and be that naloxone or overdose prevention centers, which are critically important. But we also need to consider and invest in addressing some of the underlying drivers of the overdose crisis in this country. One of the most important in my view is the housing crisis, which cities across the nation are experiencing that we know are leading people to experience homelessness and unstable housing conditions—that in turn put people at risk for drug use and overdose. So, we ultimately need, I think, a multipronged approach, where we invest in public health strategies focused on overdose prevention and also tackle what we call the social determinants of health—things like housing, jobs, recovery support systems to truly get a handle on the overdose crisis in this country.
How are reporters doing covering overdose prevention sites and naloxone?
[Posted June 21, 2023 | Download video]
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