The role of take-home naloxone in the epidemic of opioid overdose involving illicitly manufactured fentanyl and its analogs

ABSTRACT

Introduction: There has been an exponential increase in overdose fatalities as illicitly manufactured fentanyl and its analogs (IMF) are becoming more prevalent in the illicit drug supply. In response, overdose education and naloxone distribution (OEND) programs have been implemented throughout the United States as a harm reduction strategy. However, there are increasing reports that higher naloxone doses or repeat administration might be required for overdose victims involving IMF.

Areas covered: In this article, we provide a comprehensive review of the epidemiology, public health impact, and pharmacologic properties of IMF. The pharmacokinetic properties of currently available take-home naloxone (THN) kits, the role of THN as a harm reduction strategy and available data on its clinical use are discussed. Implications of occupational IMF exposure for first responders are also described.

Expert opinion: THN administration by a bystander is an effective harm reduction intervention. However, there is growing evidence that higher dose or multiple administrations of naloxone are required to fully reverse IMF related toxicity. Recently, the US Food and Drug Administration approved THN kits with a concentrated naloxone dose that produce high bioavailability. However, limited presence of OEND programs and cost of these new devices impede their accessibility to the general public.

KEYWORDS:

• Illicitly manufactured fentanyl
• fentanyl analogs
• take-home naloxone
• opioid overdose
• opioid abuse
• occupational exposure

Article highlights

• Opioid overdose epidemic continues to worsen due to increasing availability of novel synthetic opioids, especially illicitly manufactured fentanyl and its analogs.

• Fentanyl and its analogs are easily manufactured at a low cost and mixed with illicit drugs (e.g. diacetylmorphine) to increase drug’s potency and distributors’ profit.

• Newly approved intranasal naloxone kit with a concentrated naloxone formulation offer higher bioavailability compared to previously available kits.

• Geographical variation in the presence of naloxone distribution programs and the high cost of the kits limit their access by laypersons.

• The risk of opioid toxicity to first responders from dermal or inhalational exposure to novel synthetic opioids is low and can be minimized through universal precautions.

This box summarizes key points contained in the article.

Acknowledgments

The manuscript was copyedited by Linda J. Kesselring.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.