Does access to naloxone influence an opioid user’s decision to use?
That is the crux of a recently published (on-line) economics paper, The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime, which argues that increasing access to Naloxone sanctions risky behavior, unintentionally increases opioid abuse, leads to greater crime, and may increase the death rate.
The paper has generated a great deal of controversy. (The authors have rewritten some of their paper to accommodate some of these expressed concerns.)
The moral hazard of life-saving innovations: Naloxone access, opioid abuse, and crime (Blog Post)
The ‘moral hazard’ of naloxone in the opioid crisis
Why a Study on Opioids Ignited a Twitter Firestorm
Research Analysis: Conclusions about ‘moral hazard’ of naloxone not supported by methodology
Their underlying assumption seems to be that naloxone creates a safety net whereby opioid usage will increase because users have less risk knowing if they overdose they can be revived. The authors cite a legislator who told a Congressional hearing “Kids are having opioid parties with no fear of overdose,” news reports of police finding naloxone at overdose scenes, and an Ohio police officer who is quoted as saying “We’ve Narcan’d the same guy 20 times.” The researchers say their data proves these anecdotes represent valid concerns, even if the “Narcan Parties” anecdote seems to have little substance in truth.
I am not well enough versed in economic theory and concepts to discuss the quality of the paper or the methods they have used to build their findings. I can say other papers have found the opposite.
No evidence of compensatory drug use risk behavior among heroin users after receiving take-home naloxone
Are take‐home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria
The authors use the concept of moral hazard, which is an economic term, that suggests that people may not do what is right for them if the consequences of their action are covered by someone else. It is a term used often in insurance, where if you have car insurance, you may drive with less care than someone driving without insurance who would have to bear the full cost of an accident.
Translated to the opioid crisis, a user doesn’t have to worry about overdosing because a system is in place to revive him. He will consequently use when otherwise he might not have and/or will use with less concern than he might otherwise have had. I have doubts that this risk/reward thought process applies well to addicted individuals who no longer have a good concept of risk due to the damaged circuitry in their brains that opioids have inflicted on them.
As as a paramedic with experience dealing with opioid users, and as member of an overdose working group that seeks to increase access to naloxone, I can say the following:
1. Users are going to use. I don’t think they are going to put off their next hit because they are out of narcan or there is no person available to call 911 if they keel over.
2. Users hate Naloxone. They will have it around to save their lives if they have to, but no one is deliberately dosing with the intention to let themselves get “Narcan’d.”
3. Yes, by keeping people alive, Naloxone will allow a user to use again. The user instead of dying, may commit more crimes (if that is how the user supports his habit). That is a trade-off I am sure we all are willing to make as human beings.
4. No one has ever said that Naloxone alone is the key to ending the epidemic. Naloxone is about keeping people alive until they are ready to recover. I agree with the mantra of the Harm Reduction Community: Dead people can’t recover.
Here is the CDC’s three pronged response to the Heroin Epidemic: