BONUS: Mailbag – Does Naloxone Increase Opioid Misuse?

Naloxone and nalmefene are reaching more hands than ever—through bystander programs, pharmacy dispensing protocols, and over-the-counter sales. But as access expands, one question keeps coming up:

Does easier access to naloxone or nalmefene actually make opioid misuse worse?

In this BONUS mailbag episode of Rumor vs Truth, we answer a listener question about whether increasing naloxone and nalmefene access encourages opioid misuse or overdose. Hosts Don Weinberger, PharmD, and Steve Small, PharmD, bring in addiction medicine specialist Dr. Nicole Gastala, MD, to unpack what the evidence actually shows.

Together, they discuss:

• Whether increasing naloxone or nalmefene access actually encourages riskier opioid use
• What a large systematic review and 2025 American Heart Association guidance say about public-access naloxone
• Why carrying naloxone is more like carrying an EpiPen than a “permission slip” for risk
• The one real risk to watch for after a reversal: precipitated withdrawal
• Why OTC naloxone and statewide pharmacy dispensing protocols matter for practice

No CE credit is available for this bonus episode.
Want the full breakdown? CE credit is available for our full episode on opioids.

******

🎧 Related Episode (CE Available)

• Rumor vs Truth: Laxatives
  (Opioid FACTS OR FEARS?)
  🎧Listen: https://rumorvstruth.buzzsprout.com/episodes/19647733
  ▶️ Watch: https://youtu.be/sl3upSCxfwM 

******

TRC Healthcare Editor Hosts

• Steve Small, PharmD, BCPS, BCPPS, BCCCP, CNSC
• Don Weinberger, PharmD, PMSP

Guest

• Dr. Nicole Gastala, MD

******

Clinical Resources: 

• FAQ: Meds for Opioid Overdose
• Checklist: Opioid Reversal Agents Quick Start Guide

🏷️ Our listeners can get 10% off a new or upgraded subscription with code rvt1026 at checkout. 

******

Email us: rumorvstruth@trchealthcare.com

The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

Find the show on YouTube by searching for ‘TRC Healthcare’ or clicking here.

Learn more about our product offerings at trchealthcare.com.

Transcript

Copy Transcript Copied

This transcript is automatically generated. 

00:00:12 Steve Small

Welcome to Rumor vs Truth, and this is a bonus mailbag episode where we answer one listener question outside of our regular full episode.

00:00:20 Don Weinberger

You know, we're dropping this as a separate bonus, so our main episode stay focused and clean. Keep in mind, there is no CE available for this episode.

00:00:29 Steve Small

Now, this question is about opioids, and a listener asked, does increasing access to naloxone or nalmefene encourage opioid misuse or abuse?

00:00:39 Don Weinberger

This is a concern we've heard in the lay press. Intranasal naloxone and other meds for opioid overdose were increasingly handed to bystanders to treat opioid overdose. The thought here is that giving patients the safety measure will make them feel more comfortable, taking greater risks, leading to more opioid use and overdoses.

00:00:58 Steve Small

Yes, and this question starts moving away from the science of medicine and more towards the murkiness of things like sociology, ethics, and so on.

00:01:06 Don Weinberger

Can't wait to wade into that one, But we heard this type of claim with other meds intended to prevent or treat conditions associated with charged social debates, you know, things like substance use disorder or sexual practices. We've seen this with PrEP to prevent HIV, the HPV vaccine, which protects against cervical cancer and genital warts.

00:01:31 Steve Small

Right, we keep on hearing it. And to help us answer this question, I got in touch with one of our specialty consultants, Dr. Nicole Gastala. She's the Chief of Integrated Behavioral Health and Addiction at the Mile Square Health Center in Chicago. And she's also an associate professor at University of Illinois Chicago.

00:01:48 Don Weinberger

You know, she sounds perfect for this naloxone addiction questions. So let's see that tape.

00:01:57 Steve Small

Welcome, Dr. Gastala. So glad we could have you with us here today. Now, to address this audience question about whether naloxone or nalmefene increases opioid misuse or abuse, what's the evidence here? Does it ring true in any way?

00:02:12 Nicole Gastala

That's a really great question. So there was in fact a pretty large systematic review that was done, and not one of them found an increased heroin or other substance use use. And in fact, most showed either no change or actually a reduction in overdoses. And so this sort of has led to where in 2025, the American Heart Association guideline said directly that there is no evidence that public access naloxone increases opioid use or overdoses.

00:02:45 Nicole Gastala

So just a really important… studies to sort of understand that it in fact helps patients and does not hurt them.

00:02:54 Steve Small

Yeah, that's key. And with that data in mind, what should be the key takeaway message for pharmacists and other healthcare providers when it comes to naloxone then?

00:03:04 Nicole Gastala

Absolutely. So we know that naloxone saves lives and we know that it's safe in all individuals' hands, including lay individuals.

00:03:13 Nicole Gastala

So really the most important thing is overdose education. Naloxone distribution, we know that saves lives, including when it's administered by ordinary bystanders. This can reduce opioid-related deaths. So really the practical message is carrying naloxone is like carrying an EpiPen or knowing CPR. It's a tool that helps you save someone and not a license for riskier behavior.

00:03:39 Steve Small

That's a great call out. And with that, I'm sure some audience members are wondering, are there any risks with evidence that we should be thinking about when it comes to naloxone, things like side effects or things like that?

00:03:50 Nicole Gastala

Yeah.

00:03:51 Nicole Gastala

So the biggest risk to the patients is reuse of opioids after because naloxone can cause a precipitated withdrawal in patients. Patients may refuse further care and may go use in place to then help with those withdrawal symptoms. So really important to support patients use the lowest amount that's effective, right, to restore breathing and support patients when they are recovering from that naloxone or nalmefene so that they can then feel supported and not at increased risk of overdose after by going and using and trying to overcome those withdrawal symptoms.

00:04:34 Steve Small

That's great. Excellent points. I'm excited to share this with Don. And thank you again for helping us answer this question. Untangle it for our audience about naloxone and opioid misuse.

00:04:44 Nicole Gastala

Absolutely. Thanks for having me.

00:04:50 Don Weinberger

Okay, so many thanks to Dr. Gastala for helping us sort this out. She pointed out strong evidence that increased misuse and abuse doesn't occur. But naloxone does increase the most important outcome, survival.

00:05:03 Steve Small

That's right. And that's why over-the-counter naloxone and statewide dispensing protocols at the pharmacy for naloxone are one of the most important tools we have as pharmacists to help address this ongoing opioid epidemic.

00:05:15 Don Weinberger

And although we talk a lot about naloxone, these same concepts apply to nalmefene, especially when Dr. Gastala talked about withdrawal. To help you get comfortable dispensing and teaching patients how to use naloxone or nalmefene, get our meds for opioid overdose FAQ along with our opioid reversal agents quick start guide.

00:05:36 Steve Small

Those are great resources, and I'm glad we could sniff out the facts about that question for intranasal naloxone and other meds for opioid overdose.

00:05:45 Steve Small

Thanks for listening to this bonus mailbag episode. Keep sending us questions through the link in the show notes or our email.

00:05:51 Don Weinberger

We'll be back with our next full episode on generic meds coming soon on September 15th. See you then.