In February I wrote about opioid epidemic opportunists who were playing on people’s fears to make profits. Among them are the OPVEE people who are targeting police departments to try to get them to help market their high-dose nalmafene, a long lasting opioid antagonist that medical professionals believe is both unnecessary and dangerous.
These opportunists have struck again this time in Pennsylvania where they likely co-opted Scott L. Bohn, executive director of the Pennsylvania Chiefs of Police Association, to write a commentary piece, Equipping first responders for the age of synthetic opioids mouthing all the Pharma talking points about the need for stronger longer lasting opioid reversal drugs than naloxone alone. While he never mentions the product in his piece, he is clearly talking about OPVEE (nalfemene) the opioid antagonist medical professionals are concerned hasn’t been sufficiently tested and may cause more severe opioid withdrawal in addition to requiring a lengthy observation period post-resuscitation.
Here in Connecticut, like many states, nalfemene is not in the EMS protocols so Indivior, the pharmaceutical company that markets OPVEE, can’t it sell it to first responders. The only way they could in Connecticut would be if an individual sponsor hospital medical director permitted it for a sponsored service. No one in Connecticut has done so.
Fortunately, an opposing viewpoint was published on May 9th Stuart Fisk: Medical professionals respond to call for higher dose naloxone. Here is an excerpt:
The consensus from medical professionals and addiction experts is that high dose and long-acting overdose reversal agents are unnecessary and even harmful. … A summit of national experts was convened in Pittsburgh two years ago and their findings demonstrate that lower dose naloxone products are sufficient and effective in reversing opioid overdose and do not risk the reverse reactions that can occur with higher dose and longer lasting agents. Findings from the summit were published in a peer reviewed journal.
There is a false narrative that Big Pharma is pushing that today’s synthetic fentanyls require either stronger doses of naloxone or longer acting opioid antagonists like nalfemene that many people have bought into. The issue is not that people are not responding to naloxone; it is that the addition of sedative drugs such as xylazine and metodomide that don’t respond to naloxone may keep people sedated after naloxone has restored their breathing. People believing the patients are still overdosed, continue to administer naloxone, which is unnecessary. The job of naloxone is to restore breathing, which it does effectively when given in time. People don’t have to wake up to be resuscitated.
The dangers of OPVEE are described here in the The American College of Medical Toxicology and the American Academy of Clinical Toxicology position statement.
Newer synthetic fentanyls simply do not require more doses of naloxone than traditional to reverse an overdose. While the opposite has been widely reported, studies have refuted this. In Connecticut, a review of EMS data over the years 2020-2023 showed there was no year-to-year increase in naloxone dosing. 84% of patients responded to one full dose or less of naloxone with the one full dose being either 2 milligrams or less by the IV or IM route or 4 milligrams or less by the intranasal route. EMS often gives small amounts of naloxone (less than a full dose) titrated to effect to help avoid precipitated withdrawal. Naloxone just needs to regain 50% of the receptors responsible for breathing to reverse an opioid overdose, and to date no opioid has been found not to respond to naloxone.
Naloxone Dosing After Opioid Overdose in the Era of Illicitly Manufactured Fentanyl
The OPVEE web site uses this pitch on the photograph of a tearful mother being hugged by a police officer (actor portrayals): Made for the moment/you can help give her daughter another chance/Fight overdose from fentanyl and other synthetic opioids with OPVEE® The web site includes a quote Sheriff Michael J. Bouchard, Oakland County Sheriff’s Department “Tools like OPVEE give us the ability to reverse the effects of opioid overdose in critical moments, adding to our choice of resources as our nation continues to battle fentanyl-related overdoses.”
Guess they couldn’t get any emergency physicians, toxicologists or paramedics to say anything similar.
Carpenter J, Murray BP, Atti S, Moran TP, Yancey A, Morgan B. Naloxone Dosing After Opioid Overdose in the Era of Illicitly Manufactured Fentanyl. J Med Toxicol. 2020 Jan;16(1):41-48. doi: 10.1007/s13181-019-00735-w. Epub 2019 Aug 30. PMID: 31471760; PMCID: PMC6942078. https://pubmed.ncbi.nlm.nih.gov/31471760/
Department of Public Health, Office of Emergency Medical Services, “CT EMS SWORD Statewide Opioid Reporting Directive Newsletter,” CT EMS SWORD Statewide Opioid Reporting Directive Newsletter Issue XLVII (April 2023): 2–4, https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/dph/ems/pdf/SWORD/SWORD-newsletters/2023/SWORDApril2023NL_FINALrev.pdf.
J Melichar, David Nutt, and Andrea L. Malizia, “Naloxone Displacement at Opioid Receptor Sites Measured in Vivo in the Human Brain,” European Journal of Pharmacology 459, no. 2–3 (January 1, 2003): 217–19, https://doi.org/10.1016/s0014-2999(02)02872-8.