The Naloxone Debate — To Carry or Not to Carry

By Allison Colman | Posted on February 6, 2020

Naloxone Debate 410

You’ve seen the headlines:

Overdoses in parks. Discarded needles. Youth sports leagues suffering. Park rangers carrying Narcan®. Wildlife destruction. These are just a few of the headlines linking the opioid crisis to parks and recreation over the past year. Unfortunately, there are many more of these. As the opioid crisis continues to grow, devastating lives and communities and directly impacting our field, park and recreation professionals are continually challenged with how best to respond.

One of the most popular and widespread response strategies to the opioid crisis is focused on expanding access to naloxone (commonly referred to by its brand name, Narcan®). This effort has been widely endorsed by federal agencies including the U.S. Department of Health and Human Services and the Surgeon General, the Substance Abuse and Mental Health Services Administration, and the healthcare field more broadly. Despite this recommendation from our nation’s top public health officials, the decision for park and recreation professionals to carry naloxone remains debatable and somewhat contentious across the field for a variety of reasons.

What Is Naloxone?

Naloxone is a medication often referred to as an “opioid antagonist,” meaning that it can reverse and block the toxic effects of opioids. It’s used to rapidly counter the life-threatening effects of an opioid overdose, including morphine, oxycodone, fentanyl and heroin overdoses. Naloxone is administered when an individual is showing signs of an opioid overdose. The medication is available in a variety of forms, including intranasal spray or through injections to the muscle, under the skin or intravenously. Naloxone has been approved by the Food and Drug Administration (FDA) and used for more than 40 years by emergency medical services.

Symptoms of an opioid overdose may include:

  • Loss of consciousness
  • Unresponsive to outside stimulus
  • Awake, but unable to talk
  • Breathing is very slow and shallow, erratic, or has stopped
  • For lighter-skinned people, the skin tone turns bluish purple, for darker-skinned people, it turns grayish or ashen.
  • Choking sounds, or a snore-like gurgling noise (sometimes called the “death rattle”)
  • Vomiting
  • The body is very limp
  • The face is very pale or clammy
  • Fingernails and lips turn blue or purplish black
  • Pulse (heartbeat) is slow, erratic, or not there at all

Differing Views Across the Field

There are many different views across the field when it comes to park and recreation professionals carrying naloxone on the job, and there are valid arguments to be made on all sides. And of course, outside of differing views, there are local and state policies or regulations that may determine your agency’s ability to carry naloxone. The primary concerns that those in the field have expressed over the years (outside of local policies prohibiting carrying naloxone) include safety and liability, stigma and bias around substance use disorder, and public perception.

Safety and Liability

One of the greatest concerns expressed by park and recreation professionals — and the public — centers on safety. The safety of the medication itself, the safety of staff administering the medication (including liability), and the physical safety of staff and park users in the vicinity of an overdose. While there are common misperceptions about the safety of naloxone, the medication is extremely safe. It can only affect people with opioids in their system and has no adverse effects on people without opioids in their system.

Another safety factor centers on liability protections. Just eight years ago, only six states had laws that expanded access to naloxone outside of emergency medical providers or limited criminal liability. By mid-2017 however, in response to the alarming rise in opioid overdose mortality rates nationwide, almost every state enacted statutes that provide criminal and civil liability protections to both first responders and laypersons who administer naloxone. In addition, most states offer liability protections — civil and criminal — for prescribing or distributing naloxone to third parties. To find relevant laws for each state, visit the Prescription Drug Abuse Policy System.

There is often another concern around carrying and administering naloxone — the physical safety of staff and community members in the vicinity of an overdose situation. It’s important to note that naloxone itself does not cause violence, rather, if someone is dependent on opioids, including chronic pain medication, they will be very uncomfortable when revived by naloxone. Naloxone reverses the effect of the opiate, causing intense discomfort and withdrawal symptoms, which can sometimes result in physical reactions that may include violent outbursts. It’s important that staff who may administer naloxone call emergency services for support and are aware of their surroundings, including other park users that may be present. When naloxone is used, it’s advised by the Harm Reduction Coalition to explain to the individual that these uncomfortable symptoms are temporary and will only last a short time to reduce the risk of violent behavior.

Stigma and Bias Around Substance Use

Another reason for hesitation from the field to carry naloxone relates to a misunderstanding of substance use disorder as a choice or lifestyle, rather than a disease. As NRPA has navigated the opioid crisis over the years, it’s become clear that the stigma and prolonged narrative that positions those struggling as “substance abusers” rather than “people with substance use disorder” impacts our ability to respond to the epidemic with empathy and through a public health lens. Our field is not alone in this. Other organizations, like public libraries, schools, universities and even social services, have experienced many of the same challenges. It’s not a surprise, as substance use disorder and other mental health conditions are some of the most stigmatized conditions across the world.

As overdose rates continue to rise and people from all walks of life are impacted — directly and indirectly — we must build a greater understanding and promote a narrative in which we clearly identify substance use disorder and addiction as a disease. As public health providers, we should acknowledge the biases and judgments that are held in our communities, work to change the narrative that currently exists, and provide education on the science of addiction. We should work to build a greater understanding of how experiencing trauma, toxic stress and other adversities in life can increase your risk of developing substance use disorder. We should create a space where stories can be shared from those struggling and from those who’ve lost loved ones. When we have a better understanding of addiction and see it as a disease, we can promote empathy, understanding, and support those who often desperately want help to be contributing members of the community.

Public Perception

Another question that rises to the top when considering whether to have park and recreation staff carry naloxone is, “what will our community think?” Local government organizations are all too familiar with the power of perception — it can create staunch advocates or strong adversaries. Public perception often weighs heavily on any organization when it comes to policy adoption, programming changes, infrastructure improvements, etc. With an issue as stigmatized and intense as the opioid crisis, it’s fair for agencies to be concerned about what the public may think of a decision to equip facilities and professionals with naloxone.

As with any decision that may impact your constituents, there are opportunities to bring the public into conversations around this very issue. We make every effort to implement meaningful community engagement strategies when it comes to park planning and policy adoption, why not this? It’s important to be transparent in decision making and provide an opportunity for input, sharing of concerns and build support. And, it’s certainly important to have the support and buy-in of local leadership and other partner organizations to help make your case.

There is good reason to be hopeful that efforts to address the opioid crisis in parks and recreation will be well-received by community members. In a recent report published by OCLC Research and the Public Library Association, efforts from local public libraries to support their communities through the opioid crisis — including equipping libraries with naloxone and training staff and community members on how to administer it — resulted in increased positive perception of the library. According to the report, “the Salt Lake County Library Director shared, ‘We’re not just a warehouse of books, we’re helping to create content, as well as deliver on promises to enrich the community. Our opioid response activities help raise our profile and the appreciation of our services.’ This was confirmed by community members who shared their appreciation for the library’s diverse work and found themselves reconnecting with it in new ways. The engagement in the opioid crisis also highlighted the many social issues libraries are often faced with, including mental health and homelessness.”

Should You Carry Naloxone Personally?

In addition to park and recreation agencies considering carrying naloxone, we all have a decision to make when it comes to carrying naloxone as an individual. In most states, you can request naloxone at your local pharmacy without a prescription. In some cases, physicians may prescribe a prescription to those at risk of overdose or family members. If you have loved ones, friends or neighbors at risk for overdose, or you generally have concerns about coming in contact with someone experiencing an overdose, you may want to make the personal decision to carry naloxone and be trained on how to properly administer it.

Consider attending a training on how to properly administer naloxone in the event of an overdose. Local organizations, including public health departments, substance use coalitions, and others frequently offer training for community members, or access an online training here. Your park and recreation agency may even consider hosting a training for the community.

While naloxone has the potential to save many lives, it is not the singular solution to the opioid crisis. Naloxone can only be used to reverse the effects of someone actively overdosing. It does not prevent future use, deter symptoms of addiction, or provide the long-term, multi-dimensional treatment and recovery services that are needed to overcome substance use disorder. Comprehensive, community-wide approaches that are inclusive of policy change and investment in prevention, response and treatment are needed to create long-term, sustainable solutions to the substance use crisis. In addition, we must work together to implement cross-sector strategies that address the root cause of substance use, including economic decline, lack of good-paying jobs, social isolation, trauma and adverse childhood experiences. As key government entities who serve our communities each day, parks and recreation should be part of the solution.

Next Up in this Blog Series: Breaking Down the Stigma of Substance Use

Substance use disorder and mental health conditions continue to be some of the most stigmatized illnesses around the world. In the park and recreation field we see the impact of stigma in a few ways:

  1. We see a failure of the public to see substance use disorder, addiction and mental health conditions as diseases;
  2. We see how the misunderstanding of substance use disorder impacts our views on providing services and treatment;
  3. We see the personal shame of those battling addiction and mental health challenges, which often prevents people from seeking the help they need; and
  4. We see the misperception of the danger of certain substances.

As a field dedicated to enhancing quality of life and improving health outcomes for every member of every community, it is imperative that we work to break down the stigma of substance use. Our work should focus on the education of the public and the community at large, as well as educating and providing support to those directly impacted by these crippling diseases.

Previously in this Blog Series

*Do you have a story to tell about this epidemic or how your agency is responding? Feel free to email it to me! We firmly believe that through shared stories and experiences, park and recreation professionals can continue to support and elevate the work we do as public health advocates, creating healthier, stronger communities for all.

Allison Colman (she/hers) is NRPA’s Director of Health.