While well-intentioned, Scott L. Bohn’s op-ed “Equipping first responders for the age of synthetic opioids” (April 28, TribLive) calling for expanded use of high dose and long-lasting opioid overdose reversal agents misstates the need for these products and ignores current research and best practices for reversing opioid overdoses.
The consensus from medical professionals and addiction experts is that high dose and long-acting overdose reversal agents are unnecessary and even harmful. I recently joined more than 30 experts in Pennsylvania in signing a letter in opposition to these agents. A summit of national experts was convened in Pittsburgh two years ago and their findings demonstrate that lower dose naloxone products are sufficient and effective in reversing opioid overdose and do not risk the reverse reactions that can occur with higher dose and longer lasting agents. Findings from the summit were published in a peer reviewed journal.
While fentanyl and other synthetic opioids in the illicit drug supply are stronger than previous illicit opioids, the research demonstrates that low dose naloxone remains effective in reversing overdoses caused by any opioid drug, including fentanyl. High dose and long-lasting reversal agents can put a person into precipitated and severe withdrawal, which is uncomfortable at best and agonizing at worst and can include pain, vomiting, anxiety and diarrhea. These symptoms can also make a person less willing to go to the hospital or access drug treatment and more likely to quickly use more drugs to reduce these symptoms. This can lead to a second overdose. These symptoms can also make law enforcement’s job in responding to overdoses more challenging. As a friend in EMS said to me, “with naloxone, less is more.” Other first responders have reported needing to sedate people after use of higher dose naloxone because of the agitation caused by severe precipitated withdrawal.
A better understanding of the current illicit drug supply has shown that more sedatives like xylazine, benzodiazepines and medetomidine are present in drugs and can complicate the overdose response, but these drugs do not respond to naloxone of any strength or duration of action. Emergency responders need to be trained to understand the current drug supply so they can continue to save lives with the help of standard doses of naloxone as well as CPR, oxygen and other supportive care.
In 2023 the American College of Medical Toxicology and the American Academy of Clinical Toxicology issued a joint statement opposing long lasting anti-opioid agents. In 2024 the National Association of State EMS Officials endorsed this statement. I know a number of colleagues experienced in emergency medicine and emergency response who agree with that approach based on their years of clinical experience.
An additional misunderstanding in the op-ed is that law enforcement can only access high dose and long-lasting products if the state revises its standing order to include them. There is nothing preventing law enforcement from acquiring these products, if they choose, under a standing order from their own medical director or other qualified prescriber. While I would not recommend this from a medical perspective, it is their choice to add these agents to standing orders.
I have worked as a nurse and nurse practitioner for over 30 years caring for people who use substances, including opioids, and have deep experience in opioid overdose prevention and response. I have dispensed naloxone to people at risk for having an overdose and for people who are likely to be present when one occurs for over 20 years. Many of my patients are alive and well thanks to standard dose naloxone, and many have relayed stories about being given too much and have suffered severe side effects and withdrawal that led them to use opioids again to relieve the symptoms.
The illicit drug supply is more complicated than just opioids these days and is continuing to change rapidly. We need to focus on understanding what is being sold in our communities. Then we can continue to develop new standards of care for overdose response and also how to treat substance use disorders humanely and effectively. This is how we can best protect and serve our communities and support the incredible work that first responders do every day.
Stuart Fisk is a 30-year health care provider, currently working as a consultant for the Allegheny County Department of Human Services. He helped to develop and legalize Prevention Point Pittsburgh and has worked as an addiction medicine provider at Prevention Point sites and in the Allegheny County Jail.