The Amount of Naloxone We're Giving Cops Is Too Damn High

With capital punishment news momentarily slowing (though we’re less than a week out from the next scheduled execution), I thought I’d take a brief break from death to discuss the saving of lives, and a development I’ve been tracking for a while:

America’s opioid crisis continues apace, with deaths continuing to rise despite a variety of approaches intended to tackle it, from the tried-if-not-true method of ratcheting up penalties to aborted decriminalization attempts alternately described as “proof it doesn’t work“ and “proof it doesn’t work if you’re not really trying.“ One thing we all generally agree on, however: we need more naloxone on the streets.1

Better known by its trade name Narcan, naloxone works by binding to the same receptors as opioids, but not activating them, thereby not allowing the drug to take effect. The wonder of naloxone is that, since it’s highly bioavailable via mucous membranes, it’s extremely effective by intranasal administration, meaning that someone with just a few minutes of medical training can administer it. While harm reduction advocates have leveraged this to great effect in bystander naloxone programs, it’s been especially effective at improving 911 response to opioid overdose because police, who are often first on scene of a medical emergency, can perform a time-sensitive intervention without waiting for better-trained EMS personnel.

Bystander narcan formulations have traditionally come at 4 mg, an amount that reflects the reduced bioavailability of drugs in intranasal administration as opposed to giving it through an IV (though some evidence suggests this is might be overkill, and I’ve personally never seen more than 0.4 mg IV necessary). The FDA, however, has approved doses as high as 8 mg, and since 2021 Hikma’s Kloxxado intranasal spray has been marketed to police as “allowing you to carry more naloxone in your belt.“ However, as the toxicologists are fond of saying, the dose makes the poison.

Too Much of a Good ThingHarm reduction advocates like to say naloxone has no adverse effects; if that’s not the undisputed truth, it’s definitely close enough for their target audience. Certainly, there are no side effects that are less trouble than the overdose itself. It's important, however, that we understand what naloxone is and isn’t doing.

While I don’t want to dismiss the chronic effects of disordered opioid use, opioids kill acutely by suppressing the sympathetic nervous system and with it the respiratory drive (your automatic, reflexive breathing). Naloxone works by reversing that depression and consequently restoring breathing. There is nothing else in this equation, and any amount of naloxone beyond what’s needed to restore the respiratory drive is too much.

Even if the potential life threats posed by too much naloxone (which we’ll get to later) are speculative or overstated, there are legitimate patient-centered reasons it’s a problem. Completely reversing the effects of opioids immediately induces withdrawal, which sufferers like Johns Hopkins bioethicist Travis Rieder describe as the worst feeling on earth:

Rieder also described how the crushing sickness from opioid withdrawal actually fueled his continued addiction. And while the concomitant vomiting and diarrhea is rarely fatal, the possibility indicates costly and resource-straining patient management. Absent real improvements in patient outcomes, it’s a risk we shouldn’t tolerate.

And the data suggests those improved outcomes are absent: a study conducted using the New York State Police revealed that 8mg naloxone doses didn’t beat 4 mg in survivability but significantly increased the likelihood of adverse effects.2

Worse Outcomes Are Speculative, Overstated—and Still Best AvoidedIn addition to the obvious concerns above, one controversial side effect has to be discussed here: patients given naloxone occasionally exhibit flash pulmonary edema, a life-threatening condition where fluid builds up in the lungs, making breathing difficult. It’s both extremely rare and well-documented in opioid overdose itself, making it a poor argument against the administration of naloxone, but its propensity to show up in higher doses makes for a pretty good argument against arbitrary increases in dosage.

Finally, I’d be remiss—and would get a lot of comments—if I didn’t at least mention the concept of a “combative” naloxone recipient. The idea that opioid overdoses become hostile when revived, allegedly because “their high got ruined,” is at best extremely controversial, with anecdotes on one end and evidence-based medicine on the other. Personally, I have one anecdote that might support the theory, and “suddenly waking up feeling the worst you’ve ever felt, towered over by four large men trying to hook her to machines“ explains her behavior just as well. That said, to the extent “naloxone-induced assault“ is real, it’s another reason not to carelessly dose naloxone.

Pay No Attention to the Man Behind the SirenFinally, I’d like to reiterate that this argument is about the system; lay naloxone providers can feel free to disregard it. EMS and the subsequent care teams can be careful with naloxone because we can measure and manage these complications, none of which produce worse outcomes than letting your loved one not breathe. Whatever dose of naloxone you can get your hands on, please carry it, and please give it if you suspect it’s indicated.