Which of these opioid antagonists work best to medically treat opiate addiction? Is naloxone the same as naltrexone?
Do you know the difference between naltrexone and naloxone? The names of these two drugs are very similar. How do these two drugs work, and which is best when it comes to harm reduction and treating addiction?
If you look at a diagram of the two molecules, they look nearly identical. Both drugs act on the opioid receptors in the human body and receptors in the brain. The receptors are blocked, so opioids are not able to activate those receptors.
Does this mean that naltrexone and naloxone work the same in every way? Are they interchangeable? Not exactly. They are like keys that open the same lock.
Many cars have a regular ignition key and a valet key. Both keys open the door and start the vehicle. However, the similarity ends there. Otherwise, the keys work in different ways, and they serve different purposes.
What is the difference between naloxone and naltrexone?
Naltrexone and naloxone both cross the blood-brain barrier and work on opioid receptors in the central nervous system. Both drugs displace opioids from these receptors and prevent opioids from binding. The similarities end here.
Naltrexone takes longer to start working, and it lasts longer, compared to naloxone. Naltrexone is available as an oral tablet. Naloxone does not work if swallowed. So, these minor differences make all the difference in the world in how these two drugs work.
Naloxone is a rescue drug to reverse opioid overdoses.
When someone is dying from an opioid overdose, it is critical to provide treatment as soon as possible. If someone nearby has naloxone, injectable, or nasal spray form can save the victim’s life.
The bystander gives the person overdosing a dose of naloxone, available as the brand, Narcan, and the overdose ends. Naloxone acts quickly. The victim starts breathing again and wakes up.
What if you saw someone overdosing on opioids and had a bottle of naltrexone tablets in your pocket?
First of all, you would not be able to give the victim the tablets because they are passed out and unable to swallow a pill. Even if you could provide them with naltrexone, it would take too long to work. When seconds count, you don’t want to give treatment that will take over 30 minutes to start taking effect.
Unfortunately, in an overdose situation, naltrexone would not be the right tool for the job. If you witness an overdose, it is vital to activate the emergency response system as fast as possible. Call 911 or have another bystander call immediately.
Find out if anyone in the area has naloxone. The naloxone that you will need is in the form of a nasal spray, injectable, or autoinjector. Narcan is the best-known brand of naloxone.
Evzio the brand-name of a talking autoinjector.
Few people carry the Evzio device because of the cost and difficulty in getting insurance to cover it. However, if you do have access to it, it is highly effective and easy to use. The device is small, light, and easy to carry everywhere.
It talks you through the operation of the unit. You press it against the patient’s thigh and then press a button. The device then injects the patient with naloxone into the muscle. It is capable of delivering five injections.
Multiple injections are important because naloxone is short-acting and can wear off long before the opioid has worn off. After reviving a person who is overdosing on opioids, they may fall back into the overdose and stop breathing again after the naloxone wears off. It is crucial to call 911, even after administering Narcan. If paramedics do not arrive quickly, be prepared to give another dose if necessary.
Where should I be prepared to give Narcan?
Opioid overdoses can happen nearly anywhere. Heroin use is epidemic, and almost all street heroin contains dangerous fentanyl. You never know who is using opioids. The common perception that a heroin addict is homeless and shooting up in the dark, back alley is inaccurate.
While there are homeless people addicted to heroin, opioid use has infiltrated all levels of society. It could be your friend, neighbor, mailman, doctor, lawyer, or a stranger traveling on a train or airplane across from you. There is always the possibility of getting a super-potent batch of heroin/fentanyl. An overdose might happen at any time.
How do I know if someone is overdosing on an opioid?
One common sign to look for is a person who is nodding off. Sometimes people do get sleepy and fall asleep spontaneously during the day. However, if the person is moving slowly, has a glazed look in their eye, is slurring their speech, and then nods off, this is concerning.
People refer to it as “nodding.” When a person has taken too many opioids dozes off, their head starts to fall.
How do I know if I should give Narcan?
If you have taken a training course in giving Narcan and now have it in your possession, how can you be sure when to use it? What if you discover a person who is unconscious with shallow breathing. If you did not observe them using opioids, how do you know it was an opioid overdose?
Fortunately, naloxone is a safe drug. For someone who is not on opioids, it does not affect them. So, if you give Narcan to someone who is not overdosing on opioids, you will most likely not make things worse. If the person happens to take opioids for medical treatment, you may induce opioid withdrawal symptoms, but the opioid withdrawal side effects, while uncomfortable, is rarely dangerous.
Paramedics and doctors have administered medical cocktails to unresponsive patients that include naloxone. When you don’t know why a patient is in that state, it could be due to an opioid overdose. If so, naloxone will be life-saving.
An ER doctor once told me a story about a patient who overdosed on fentanyl right in the middle of a Narcotics Anonymous meeting. You may think that this is a sign of the world going crazy. Even people who are trying to get help are going into meetings high on fentanyl.
It turns out that this is not such an unlikely scenario, and it is also not a new phenomenon. People who use drugs and are ready to commit to getting help often decide to get high just one more time before walking into a rehab treatment program or a recovery meeting.
If you were to walk through the parking lot of a drug rehab facility, you would probably spot at least a few people hiding in their cars, using their drug of choice just “one more time.” Of course, we expect a rehab or detox program to have Narcan on hand and ready to use it.
Unfortunately, NA meetings are different. These are public meetings organized by local members of a worldwide fellowship. Narcotics Anonymous members state that the organization is spiritual and not religious, yet the NA world services corporation has a tax structure similar to a church.
Are churches responsible for emergency medical treatment?
I have asked the question in NA online forums if Narcan is available at any group meeting. The typical response was that this is not the responsibility of NA or its groups. They do not offer medical treatment of any kind.
While I don’t doubt that there are many churches with automated electronic defibrillators hanging on the wall, most probably have no life-saving equipment available. On the other hand, you will likely see fire extinguishers on the walls of most churches.
That is because of standard state building codes that require fire safety equipment and an evacuation map. Some states require emergency medical equipment in specific establishments, as described in this article about AED state laws.
For example, in my state of Florida, physical fitness facilities must have at least one automated electronic defibrillator. The need for these devices in a gym is clear. People are working out and stressing their hearts. There is an increased risk of cardiac arrhythmias.
What about spiritual fitness facilities?
At locations where spiritual addiction recovery group meetings occur, there is an increased risk of newcomers walking in high on heroin and fentanyl. Would it make sense to require buildings that rent space for these meetings to have at least one naloxone rescue kit?
If you are concerned about the excessive burden of setting requirements for buildings that host AA and NA meetings, you should not be concerned. The cost of Narcan is relatively low. While it is still overpriced compared to the cost of production, you can probably buy a kit for about the same price as your fire extinguisher. It is far less expensive than an AED.
What can we do in the meantime to protect the public at risk for overdose?
A while back, I had this conversation with Adam Bisaga, MD, during a podcast interview about the possibility of legislation requiring Narcan in buildings just like they must have fire extinguishers or AEDs. He agreed that this was an excellent idea. Since that talk, my thinking about the topic has changed. On a more recent naloxone podcast, I outlined my new thoughts on the topic.
It would be great to have legislation requiring buildings and businesses to provide emergency naloxone. Yet, we can start by carrying naloxone and encouraging others to do the same. In more recent conversations on the topic, I have compared naloxone to hand sanitizer. When I first started comparing the act of carrying Narcan to carrying a small hand-sanitizer bottle, not everyone had a hand-sanitizer in their pocket or handbag.
Now, in the world of COVID-19 and the fear of infection with the novel coronavirus, people are more aware of having to take precautions. We now must stock up on and carry both hand-sanitizer and a face mask. While the coronavirus pandemic is the top news story, we must not forget about the opioid pandemic and what we can do to minimize overdoses.
Going back to that NA meeting where a person passed out and turned blue in the face halfway through the meeting, we can imagine a different outcome. Imagine multiple meeting attendees standing up and taking out their Narcan. While the victim would only need one person to administer the naloxone nasal spray, it would be nice to see overwhelming preparedness.
Naloxone vs. naltrexone: is naloxone the clear winner?
So far, it would seem as if naloxone, the ingredient in Narcan, is the clear winner in saving lives from the dangers of substance abuse. It works fast, by nasal spray or injection, to save lives.
Paramedics and police officers carry naloxone. Hospitals have it in the ER and give it by injection or IV. We know that if naloxone kits were in the hands of more people, more overdose victims would survive.
What about naltrexone?
Naltrexone cannot save the victim of an overdose. It works too slowly. No one carries naltrexone tablets intending to save the life of someone who stops breathing due to a heroin or fentanyl overdose.
Yet, some people do carry naltrexone tablets to save their own lives. How is this possible?
Naltrexone is an effective treatment for opioid and alcohol addiction.
There is more to saving lives from addiction than providing emergency overdose treatment. We must also consider the long-term treatment of addiction.
One of the most effective treatments for both opioid and alcohol addiction is medication-assisted treatment (MAT). In the case of both opioid and alcohol use disorder, naltrexone works to promote long-term recovery.
Like naloxone, naltrexone is an opioid receptor blocker. The difference is that naltrexone starts working slower, yet it lasts much longer. Because of these properties, naltrexone works well for daily treatment.
How does naltrexone help people addicted to opioids to stay in recovery?
Naltrexone helps to prevent opioid cravings. There are two forms of naltrexone available, generic pill forms and a monthly shot. When a person takes their naltrexone every day or gets the monthly Vivitrol shot, which is extended-release naltrexone, they are less likely to have thoughts about using opioids. If you are dependent on opioid drugs or medications, naltrexone may be a good long-term treatment option.
Naltrexone also helps with alcoholism in the same way. It reduces cravings and thoughts of drinking.
In treating alcohol use with naltrexone, there are two ways for doctors to prescribe it. They can prescribe daily use of the naltrexone tablet or the monthly injection.
They may also recommend The Sinclair Method, which requires taking the tablet one hour before having a drink. Then, the patient must restrict themselves to no more than one or two small glasses. Less is better. The effects of naltrexone help them to limit drinking and eventually extinguish any desire to drink further.
Getting back to the treatment of opioid addiction, some people have the impression that naltrexone is not the best option when it comes to MAT. There are two other drugs available in the MAT category for opioid addiction treatment, methadone, and buprenorphine. Buprenorphine is the main ingredient in Suboxone, Subutex, ZubSolv, Bunavail, Sublocade, Probuphine, and Brixadi.
Some people, including addiction experts, believe that Suboxone treatment is the best overall medical treatment for opioid use disorder. While this may be the case in many situations, naltrexone is also a very effective treatment.
At least one study demonstrates that naltrexone injections have the same efficacy as Suboxone films in treating opioid addiction. While we need more research in this area, there is no doubt that naltrexone is effective.
Naltrexone would be an ideal medical treatment to start during an extended inpatient residential rehab admission. We should encourage education or rehab administrators and counselors of the benefits of long-term treatment with naltrexone, a non-controlled, non-opioid drug.
Naloxone vs. naltrexone: these are two vitally essential treatment drugs.
In conclusion, we now see that these two very similar drugs serve different but essential purposes in the world of addiction treatment for opioid and alcohol addiction. It would be hard to rate one as more important than the other. The differences between naloxone and naltrexone give each drug a unique advantage.
When seconds count during an opioid overdose, naloxone is the drug that you want to have present. However, when a person is in recovery from opioid use disorder or alcohol use disorder, naltrexone is a highly effective treatment that can keep people in recovery, living productive, successful, and fulfilling lives without the ongoing mental health issues caused by active addiction.