Chris Fleming, Tod W. Burke, Ph.D. and Stephen S. Owen, Ph.D.
Implementing overdose reversal programs has provided law enforcement agencies with a number of collateral benefits, including improved community relations. However, it is imperative to weigh both the benefits, as well as any potential drawbacks, before making any commitment.
In Wisconsin, police were dispatched to the scene of an unresponsive two-year-old after he allegedly consumed OxyContin® pills, an opioid derivative. Despite interventions from first responders, the toddler was pronounced dead at the scene. On March 15, 2017, law enforcement officials responded to a suspected opioid overdose in North Carolina. In this case, police were able to administer naloxone, a potentially life-saving drug used to combat the immediate effects of an opioid overdose.
Since 1999, opioid overdoses have quadrupled. With the increase of opioid addiction and overdose deaths, the 2017 report of the President’s Commission on Combating Drug Addiction and the Opioid Crisis “recommended that all law enforcement in the United States be equipped with naloxone.” With such a sweeping recommendation, it is important to understand the benefits, as well as implementation issues, related to naloxone.
In addition to this discussion, a listing of resources pertaining to naloxone use is provided with this article.
The Use of Naloxone
During the 1950s, researchers worked to find a safer drug which could reverse the effects of an acute opioid overdose. By 1961, pharmaceutical researchers Dr. Mozes Lewenstein and Dr. Jack Fishman applied for a patent for the drug naloxone. Unlike other drugs used at the time to treat opioid overdose, naloxone did not produce the effects associated with opioid use. Naloxone is effective because the drug forms a stronger bond than opioids to chemical receptors in the brain, replacing them and helping to reverse some impacts of opioid overdose.
In cases of severe opioid overdose, the central nervous system and respiratory systems are depressed to the point that a victim cannot breathe. However, after naloxone is administered, because it replaces opioids at the brain’s receptor sites, the victim’s breathing may be restored.
In 1971, the FDA approved the use of naloxone – intramuscularly, intravenously and subcutaneously – in part because of the drug’s safety. Intranasal use of naloxone has also been found to be effective in the initial treatment of overdose victims. This provides less risk to the responder administering the drug and requires less medical training, as no syringe or injection is required. By 2015, the FDA approved the use of naloxone in NARCAN® Nasal Spray, further equipping laypersons with the ability to immediately treat opioid overdose.
In recent years, prescriptions for opioids have increased drastically despite pain levels remaining relatively consistent among Americans. Opioid overdose deaths, from prescription and illicit drugs, have continued to rise since the 1990s, recently surpassing automobile accidents as the highest cause of preventable death in the United States. Community programs throughout the United States have begun to equip the public with naloxone to prevent fatal overdoses. Law enforcement agencies which work to provide their officers with naloxone can provide an additional line of defense against opioid deaths, both to the public and for accidental exposures to officers.
Benefits of Naloxone as They Relate to Law Enforcement
Accidental Exposure to Opioids
Exposure to opioids is becoming a greater problem for officers in the field. In 2015, the DEA warned that even trace amounts of opioids, such as fentanyl – an opioid 50 times stronger than heroin – can be fatal if an officer is unknowingly exposed. Recently, a police officer in Ohio overdosed after touching a white powdery substance, alleged to be fentanyl, after a traffic stop. The officer was treated with naloxone at the scene. Also according to the DEA, accidental opioid overdoses are becoming more common as first responders have begun to report an increase in symptoms related to opioid poisoning while performing their duties. In fact, the DEA has specifically recommended the immediate use of naloxone in such cases.
Police K-9s are also susceptible to opioid overdose. For instance, to ensure the safety of their K-9s, handlers in Baltimore County have begun carrying naloxone. Because the drug is administered in the same manner as it is for humans, no additional training is required. Police agencies armed with naloxone would act to limit vulnerability to accidental overdoses.
Timing of Naloxone Administration
Rapid administration of naloxone is essential to the drug’s effectiveness because death can occur within three hours of overdosing. This small margin of time becomes important as witnesses of the overdose may delay calling for medical attention out of fear of receiving criminal charges. Witnesses also may not immediately recognize that an overdose has occurred.
Some believe that only paramedics and other highly trained medical staff should be tasked with administering naloxone. However, medical responders may have longer response times than law enforcement, especially in rural areas. In addition, in some jurisdictions, emergency medical technicians may be prohibited from administering naloxone. Law enforcement officers have also demonstrated that they can perform basic medical procedures – such as CPR (CardioPulmonary Resuscitation) and AED (Automated External Defibrillator) services – to prolong life prior to EMS response. By providing and training police to use naloxone, an initial dose of the drug could be administered in the valuable minutes before paramedics arrive at the scene.
Protecting the Public
Law enforcement agencies across the United States have been supplying their officers with naloxone since 2010. Naloxone administered by police has proven effective as countless overdoses have been reversed. While some oppose extending naloxone access because it is believed to increase drug misuse among addicts, there is no empirical evidence to support this claim.
Finally, police deployment of naloxone could help to build positive relationships with the public. A study of California law enforcement officers trained in naloxone administration found that the public conveyed their appreciation to officers for using naloxone when necessary and that officers themselves found its life-saving effects to be rewarding. The study also suggested that public awareness of law enforcement’s helping role could lead to a greater willingness to call 911 for police response in overdose situations, especially when coupled with laws or policies which preclude charging callers for drug offenses, such as personal possession of narcotics and paraphernalia (California has such a law).
Possible Issues for Police Departments
Cost of Naloxone and Training
Research suggests that supplying officers with a naloxone kit which provides two doses has proven effective in limiting deaths; however, additional doses are occasionally required to reverse an overdose. While naloxone kits at one time were relatively cheap, prices have recently increased with the the greater demand for the drug. For instance, providers have witnessed markups as high as a 500% price increase in the past three years. Depending upon supply, the cost of nasally administered naloxone ranges from $70 to $150 per dose; injectable forms of naloxone cost as much as $4,500 (for two doses). In addition, naloxone typically loses potency within a year and a half to two years, requiring agencies to resupply their inventory (as well as maintaining current and accurate records to track inventory and its expiration dates). At the same time, some agencies may utilize grant funding to maintain naloxone supplies.
States require individuals who administer naloxone to be trained; however, there are a variety of types of training sessions. Programs largely resemble receiving certification to perform CPR, but, in this instance, training includes learning about opioids, detecting an overdose and properly administering naloxone through various routes. These courses take about 40 to 90 minutes to complete and some training can be completed online.
Naloxone’s Possible Physiological Effects
While naloxone causes no response in persons without opioids in their system, it can cause an intense opioid withdrawal in opioid addicted patients. Although largely non-life-threatening, acute withdrawal can make patients violent. In 2016, two Pennsylvania state troopers were assaulted after reviving a man with naloxone. However, experts consider incidents of this nature to be exceptions to the rule, noting that most patients feel sick or groggy upon revival rather than becoming agitated. Serious side effects, such as cardiac arrest and epileptic seizures, have been linked to naloxone administration, but typically only occur when in conjunction with preexisting conditions and are extremely rare.
This raises an important consideration about naloxone which should be addressed in agency policy. Naloxone administration by itself does not provide complete treatment. Rather, evaluation by a medical professional is still necessary. The effects of opioid overdose may be longer lasting than naloxone’s revival, placing patients back in respiratory arrest after naloxone wears off. Patients who do not receive follow-up care may become fatalities even after being revived with naloxone.
Law enforcement officers likely face little liability in cases of naloxone administration. Responses to opioid overdose are largely covered by “good faith” provisions allowing an officer to perform tasks deemed necessary to sustain life. Many states have enacted laws providing further protection to officers and laypersons from liability when administering naloxone. Additionally, naloxone does not produce any negative effects if improperly administered.
Qualified immunity can also provide protection to law enforcement officers who administer naloxone in the course of their duties. However, agency legal counsel should review naloxone administration policies along a number of lines, at the very least including training protocols (e.g., sufficient to withstand claims of the Canton v. Harris “deliberate indifference” standard) and distinguishing between positive duties to act (in which law enforcement’s efforts for medical care may be protected) and failure to act (in which failure to provide care, including requesting EMS treatment and transport, can incur liability). One important issue to address is guidance on when naloxone should be administered. Sound policy guidance can address these and other issues while ensuring naloxone availability for use in medical emergencies.
Naloxone use by law enforcement professionals offers many benefits. As a tool which promotes life safety to responders and to the public, it merits sound consideration. Several recommendations follow, but readers are also directed to the listing of resources at the end of this article for additional guidance in developing a full agency policy.
To receive the medication, agencies should begin by immediately training their officers through appropriate public health entities. Naloxone is a prescription medication, but, in some jurisdictions, it may be purchased with the approval of a pharmacist. To address liability concerns, certification is required to receive and administer the drug.
Naloxone access for rural police agencies is especially crucial for three reasons. First, in many states, EMT basics are unable to administer naloxone due to current scopes of practice. In rural areas, EMT basics frequently respond before advanced medical personnel, limiting the intervention a subject receives until the arrival of paramedics. Although these protocols appear to be changing to accommodate nationwide addiction rates, supplying a police department with naloxone could bridge the transition for EMS once restrictions are lifted. Second, between 1999 and 2004, rural counties saw a 159% increase in fatal opioid overdoses. Third, in comparison to other first responders (e.g., EMS), police respond more rapidly to emergencies in rural areas.
Naloxone deployment may also be useful for school resource officers, as well as by agencies that police institutions with heavy volumes of traffic (or significant residential or transient populations), such as universities and airports. These locations may well have a need for emergency opioid response, due to the sheer number of persons who traverse them on a given day.
Finally, widespread distribution of naloxone to police agencies – consistent with the recommendations of the President’s Commission on Combating Drug Addiction and the Opioid Crisis, is one positive and life-saving step in which law enforcement can help to address a public health crisis. And, in doing so, they may help to establish meaningful police-community relationships.
Naloxone has the potential to be an invaluable tool for law enforcement agencies, particularly with current levels of opioid addiction and use. While the drug will not serve as the “silver bullet” for the opioid epidemic and will require the development of sound agency policies to guide its deployment, it has worked to prevent many overdose deaths. Arming officers with the training and resources necessary to save lives is essential as overdose rates continue to escalate.
References available upon request.
Mr. Fleming is a Criminal Justice major and a member of the Honor’s Academy at Radford University, Radford, Virginia. Mr. Fleming can be reached at firstname.lastname@example.org.
Dr. Burke, a former Maryland police officer, is a retired professor of criminal justice. He can be reached at email@example.com.
Dr. Owen is a professor and chair of the Department of Criminal Justice at Radford University, Radford, Virginia. Dr. Owen can be reached at firstname.lastname@example.org.
The following resources may prove useful in considering and developing naloxone policies for law enforcement agencies:
- Report of the President’s Commission on Combating Drug Addiction and the Opioid Crisis, issued November 1, 2017: https://tinyurl.com/yclwvj4g
- Bureau of Justice Assistance National Training and Technical Assistance Center, Law Enforcement Naloxone Toolkit: https://tinyurl.com/ycbcdcxr
- Substance Abuse and Mental Health Services Administration’s Preparing for Naloxone Distribution: Resources for First Responders and Others: https://tinyurl.com/y9qvungg
- International Association of Chiefs of Police naloxone resource page, including a model policy (membership required): http://www.theiacp.org/naloxone
- Drug Enforcement Administration, Fentanyl: A Briefing Guide for First Responders, issued in June 2017: https://tinyurl.com/yavnp27t