The neuroscience behind naloxone

[sue_frantz]

A couple months ago I wrote a suggestion on how to incorporate coverage of the opioid epidemic into Intro Psych (Frantz, 2017). There I put it in the context of the availability heuristic. Here I will suggest covering the opioid epidemic in the context of neurons and neurotransmitters.

The opiates work in a complex way to produce feelings of euphoria. Under non-opiate conditions, neurons release the neurotransmitter GABA that, in turn, inhibits the release of dopamine. When endorphins are released during sympathetic nervous system arousal or you take an opiate – legally or illegally, the body doesn’t care – the endorphins or opiates (endorphin agonists – drugs that look and act like endorphins) block GABA from being released. Without GABA’s inhibition, dopamine is free to flood synapses and attach to dopamine-receiving neurons resulting in warm, fuzzy feelings (Genetic Science Learning Center, 2013; Vaughan, et.al., 1997).

That explains why people choose to use opiates. But how do people overdose on opiates?

Part of the cause is that fentanyl, an opioid "that is similar to morphine but is 50 to 100 times more potent" (NIDA, 2016). "In 2014, 35 percent of [Rhode Island's] fatal overdoses occurred because of fentanyl, but it was involved in 56 percent of drug deaths by 2016" (Brown University, 2017). There is no question that fentanyl has entered the illegal drug supply and is contributing to the number of overdoses.

Here's another factor that contributes to opiate overdoses. Opiates, in addition to producing euphoria, also act on the brainstem to reduce breathing. Take too much and you stop breathing. Like many drugs, the more you use, the greater your tolerance, meaning you need more opiates to get the euphoria. But here's a problem. Unfortunately, your brain’s ability to tolerate more opiates does not extend at the same rate to breathing. In other words, while you need more for the high, your brainstem isn’t keeping up. With continued opiate use, the window is closing. The amount of opiate it takes to feel the high is getting closer and closer to the amount that stops breathing (Boyer, 2012).

Enter naloxone, brand name Narcan. Naloxone is an opiod antagonist. It blocks the receptor sites, but doesn’t activate the neurons. With the opioid receptors blocked, the opiates cannot have their effects – and breathing returns to normal (NHPR Staff, 2016). Because naloxone binds more strongly to the receptor sites than the opiates do, naloxone actually bumps them out and takes their place. That’s why naloxone acts so quickly, showing effects within five minutes (College of Pharmacists of British Columbia, 2016).

Prevention Point Philadelphia provides naloxone and the training of its use to the librarians at McPherson Square Library, a library located in a high drug use area of the city. “While other libraries practice fire drills, McPherson began overdose drills.” It’s needed. Philadelphia is looking at a 30% increase in overdose deaths in 2017 as compared to 2016. That’s 1,200 expected ODs. When people started overdosing on heroin in the library and in the nearby park, the librarians decided it was time to get training on using the naloxone kits – and they’ve used them to save lives (Newall, 2017; Wootson, 2017).

The opioid epidemic is not bypassing colleges and universities. “Last fall, three Washington State University students overdosed and died in Pullman, Wash.; a 25-year-old died from an overdose on the potent opioid fentanyl and heroin in a bathroom at Columbus State Community College in Ohio; and a student died from a suspected overdose at State University of New York at Geneseo. Fatalities in recent years have also hit campuses in New Mexico, Louisiana and beyond.” Institutions of higher learning are starting to step up to the plate by “distributing the anti-overdose drug naloxone to campus police and even students. Drug company Adapt Pharma Ltd. announced last month that it would offer 40,000 free doses of its branded version, called Narcan, to colleges nationwide. So far roughly 60 schools have reached out, according to company officials... The University of Texas at Austin now stocks naloxone at the front desk of its residence halls” (Korn & Kamp, 2017).

Ask students to investigate who at your institution, if anyone, has been trained to administer naloxone. Do students feel like the number of people trained is sufficient? If not, what can students do to make a difference?

References

Boyer, E. W. (2012). Management of opioid analgesic overdose. New England Journal of Medicine, 367(14), 1370-1373. doi:10.1056/nejmc1209707

Brown University. (2017, June 7). Feared by drug users but hard to avoid, fentanyl takes a mounting toll. ScienceDaily. Retrieved June 28, 2017 from www.sciencedaily.com/releases/2017/06/170607123841.htm 

College of Pharmacists of British Columbia. (2016, April 4). Naloxone: Frequently asked questions. Retrieved from http://library.bcpharmacists.org/6_Resources/6-5_Pharmacy_Resources/5183-Naloxone_FAQ.pdf

Frantz, S. (2017, April 16). Do you cover drug abuse in Intro Psych? If not, it might be time to. Retrieved from https://community.macmillan.com/community/the-psychology-community/blog/2017/04/16/do-you-cover-drug...

Genetic Science Learning Center. (2013, August 30) Mouse Party. Retrieved June 22, 2017, from http://learn.genetics.utah.edu/content/addiction/mouse/

Korn, M., & Kamp, J. (2017, May 07). Fatal student opioid overdoses prompt colleges to action. Retrieved from https://www.wsj.com/articles/colleges-take-action-on-opioid-epidemic-1494158403

NHPR Staff. (2016, June 6). Primer: How does Narcan work? Retrieved from http://nhpr.org/post/primer-how-does-narcan-work

Newall, M. (2017, May 21). For these Philly librarians, drug tourists and overdose drills are part of the job. Retrieved from http://www.philly.com/philly/columnists/mike_newall/opioid-crisis-Needle-Park-McPherson-narcan.html

National Institute of Drug Abuse (NIDA). (2016, June 06). Fentanyl. Retrieved June 28, 2017, from https://www.drugabuse.gov/drugs-abuse/fentanyl 

Vaughan, C. W., Ingram, S. L., Connor, M. A., & Christie, M. J. (1997). How opioids inhibit GABA-mediated neurotransmission [Abstract]. Nature, 390, 611-614. Retrieved from http://www.nature.com/nature/journal/v390/n6660/abs/390611a0.html

Wootson, C. R., Jr. (2017, June 02). ‘Drug tourists’ keep overdosing at this library. Here’s how employees are saving their lives. Retrieved from https://www.washingtonpost.com/news/to-your-health/wp/2017/06/02/drug-tourists-keep-overdosing-at-th...