It has been a question swirling around communities for quite some time now, and it’s finally coming to a head: If you can’t save your loved one by convincing them to get into treatment, should you carry naloxone to prevent a deadly overdose, just in case?
This is no longer the “elephant in the room,” as some states, such as Pennsylvania and Florida, already have made it available over the counter. Many insurance companies even cover it with a small co-pay.
Yet people still are dying en masse in our country from opioid overdose. In fact, the latest statistics from the U.S. Centers for Disease Control and Prevention (CDC) show more than almost 100 people per day in the U.S. perish from opioid overdose.1
Several things are keeping naloxone from getting into the hands of those who could save lives – even their own. Perhaps the fiercest barrier standing between saving a life with naloxone and losing one? Stigma.
Stigma is keeping naloxone from saving lives in myriad ways.
People don’t want to accept a prescription for naloxone when they are given opioids for treatment of long-term pain. Who wants to think they may become an “addict” or accidentally overdose on their prescription medications? Who wants to tell their friends and family that they are taking so many opioids it’s possible they could stop breathing, so if they do, “Be sure to get the naloxone out of my purse and revive me?”
Among physicians, many don’t want to prescribe naloxone. Even some doctors subscribe to the arcane idea that naloxone is encouraging an addict’s behavior.
Some public officials have been so crass as to say money should not be wasted on saving people who simply appear set on killing themselves anyway. It’s adding to an already enormous financial challenge of providing naloxone to everyone in this country who needs it – or should have it, just in case.
More and More States Making Naloxone Available Over the Counter
For these reasons, making naloxone available over the counter – in some states it’s as easy to obtain as a home pregnancy test – appears to be a long overdue solution to overdose deaths, per public health officials.
In a report by CNBC, Dr. Leana Wen, health commissioner for the city of Baltimore, explains why she made naloxone available to every single person in Baltimore. By declaring opioid overdose a public health emergency, she thereby issued a prescription for naloxone to every person in the city. “I’ve seen how it saves someone’s life within seconds,” she told the network. “Everyone should have naloxone in their first-aid kids. Everyone should carry it in their purse, their bag, their worksites. Because if we can save someone’s life in a couple of seconds, it’s our obligation and our duty to do so.”2
The problem, of course, continues to be cost. Many insurance plans cover naloxone, some with a small co-pay. But others don’t.
Many people – addicts, in particular – do not have insurance. They may not currently be employed. If they are self-employed, or make too much to qualify for Medicaid in a job that doesn’t provide insurance, they may not want to spend the extra money to buy insurance off the exchange.
Or even if they do qualify for Medicaid, they may not have taken the time to file the proper paperwork for it, even though many states have now made Medicaid available to millions.
The price of naloxone has been skyrocketing nationwide, even though there are multiple companies making generic versions of it. A milliliter of generic naloxone costs about $20 – about 20 times what it cost 10 years ago, according to the CNBC report.
There also are costs associated with administering it and with educating the public about it. A new auto-injector that talks and tells people how to administer naloxone, called Evzio, is about $5,000 for two doses. The price has more than quintupled in less than three years, CNBC reported.
Congress is investigating the price of naloxone and has asked pharmaceutical companies to cough up answers.
Charitable Groups Stepping Up to Provide Naloxone
Many charitable organizations and even pharmaceutical companies who manufacture naloxone are making grant money available to get naloxone into the hands of first responders, such as police officers and paramedics. Other groups are simply passing it out for free to friends and loved ones of addicts and to addicts themselves, in states where it is legal to do so.
In Lake County, Ill., in the suburbs of Chicago, the Jordan Michael Filler Foundation of Highland Park donated 1,500 doses of naloxone to police to use during 2017, the Chicago Tribune reported. In the past three years, police have made 130 saves.3
Naloxone works by removing opioids from brain receptors that can cause breathing to stop. Sometimes, a person is brought back in a jolting manner. Other times, it can take multiple doses of naloxone to revive a person. Because some opioid addicts are now overdosing on sedatives used to tranquilize elephants, the amount of naloxone needed to save a life can be far more than what is used even for heroin. Often, it takes more than one dose.
Naloxone generally is administered one of two different ways. It can be injected into the thigh, or it can be squirted into the nostril when obtained as a nasal spray. Often, it needs to be squirted into the other nostril, too.
While some agencies have saved money by creating makeshift injection devices for the naloxone, this method also requires educating people who administer the naloxone about proper delivery. For many people needing naloxone, time is of the essence. In theory, it should always be as simple as possible to administer.
Law Enforcement Getting Creative About Getting People into Treatment
“We need to give people a second chance to get where they need to be,” said Undersheriff Ray Rose, part of the Lake County Opioid Initiative, in the Tribune interview. “But that alone is not the solution. One guy we saved – it was the fourth time we saved him. That’s why treatment is the next step. That’s how will be able to solve this epidemic.”
For those who end up in jail because of their addiction, Lake County has come up with a way to help them get sober while incarcerated, even if only for a short time. They are giving Vivatrol shots to opioid addicts. Vivatrol can help reduce cravings for up to 28 days. Unlike naloxone, which has skyrocketed in price, Vivatrol’s cost has dropped from $1,100 per treatment to just $3, per the Tribune.
“It’s the best option in terms of treatment,” Rose said. “It cuts the craving and the need for opioids, and it does a good job of doing it. This really seems to be a success. The problem is once they are out, they need to seek treatment on their own.”
Chelsea Laliberte founded the Lake County Opioid Initiative after she lost her brother, Alex, to overdose. She told the Tribune the success of the initiative, which even has a clinic open three days per week where parents can get information if they suspect their child has a problem, has trained 600 people on how to use naloxone. In Illinois, “Lali’s Law” – named for Laliberte’s brother – allows someone to ask for naloxone at a pharmacy.
She said the success in Lake County, where visible progress has been made, is the result of cooperation between the community, advocates, law enforcement and the health department. And it’s not the sort of cooperation that is easily found elsewhere, at least not right now.
Elected Officials, Parents, Police Need to Be Educated About Naloxone
Indeed, public officials in some places have made downright hateful, not to mention ignorant, comments about making naloxone more available.
In hard-hit Maine, Gov. Paul LePage vetoed legislation to expand access to naloxone and make it available without a prescription. He also said people should have to pay for the drug if they are receiving a dozen or more doses. The legislature overrode his veto.
“Naloxone does not truly save lives; it merely extends them until the next overdose,” he wrote in his veto letter, as quoted by the Portland Press Herald.4 “Creating a situation where an addict has a heroin needle in one hand and a shot of naloxone in the other produces a sense of normalcy and security around heroin use that serves only to perpetuate the cycle of addiction.”
Marlon, Ohio, Fire Capt. Wade Ralph said naloxone has taken an “extremely expensive” toll on his department. But, he added, it’s the right thing to do. “There’s a human factor to that that some people, I think, just forget about or maybe they ignore it and say, ‘Hey screw it, let them die.’ I’m like, you can’t do that,” he told the Associated Press.5 “We have people here, we have guys at the firehouse, whose kids have been hooked on stuff like that.”
Sometimes parents don’t even know their child has an opioid problem – or at least not a serious one. Part of the reason is because of HIPAA laws. A parent may not even know their 18-year-old child ended up in an emergency room once due to overdose.
And when people do end up in emergency rooms due to overdose, often they are just sent home after revival and not even referred to treatment, per a story published by Scientific American.6
Stigma Is Naloxone’s Biggest Blockade to Saving Lives
In one small study of 24 adults being prescribed high doses of opioids for non-cancer pain management, certain themes emerged as to why people at risk for overdose aren’t arming themselves or people around them with naloxone, even when offered a prescription for it.
“In addition to pragmatic barriers, such as medication cost, barriers to naloxone acceptance included the perception that overdose risk stems from medication misuse and that providers might infer that they were misusing their opioid medication if they accepted a naloxone prescription, prompting an opioid taper,” the authors wrote. “Facilitators to the acceptance of naloxone included medical providers’ using empowering, non-judgmental communication practices, framing naloxone for use in ‘worst case scenarios’ and providing education and training about opioids and naloxone.”7
The study was published the Journal of General Internal Medicine. In another study published in the journal Substance Abuse, 164 patients being given large amounts of opioids to manage chronic pain were provided with naloxone rescue kits, as well as education on how to use them. No overdose occurred among a one-year period.8
“The ambulator co-prescribing of naloxone in a Universal Precautions model for all patients prescribed chronic opioid therapy can be adopted as a useful public health intervention,” the study concluded. “This study illustrates a model that can be used to educate patients, caregivers and an interdisciplinary team of health care professionals in an academic medical center.”
Meanwhile, more and more states are making naloxone as easy to get as possible for those who are keenly aware of a loved one’s addiction and want to be ready to save them. In fact, the latest state to do so is Iowa – surely not the first place most Americans think of when asked about the opioid epidemic.
“This is pretty much the same way we do flu shots and the different vaccinations,” pharmacist Bill Drilling told the Sioux City Journal.9 “If somebody would come in off the street, then we would be able to prescribe it to them using this doctor’s (medical director Patricia Quinlisk of the Iowa Department of Public Health) name.”
At Drilling’s pharmacy, Narcan costs $150 for two single-use nasal sprays. “I think that it’s important that people know that this is available. If they’re on an opiate, it’s probably a good idea to have it.”
Yet in Florida, birthplace of the infamous “pill mills” that led to the opioid epidemic, a similar new law isn’t being very well utilized, per a story published in New Times.10 “Calls to 32 pharmacies in Broward County (home of Fort Lauderdale, just north of Miami) all yielded the same answer: None had naloxone in stock,” New Times reported. “In many cases, the pharmacist had never heard of the drug. Only one pharmacy – CVS at 255 FL-7 in Margate – said it was available.”
James Hall, an epidemiologist at Nova Southeastern University, told New Times: “It’s dangerous if it’s not available and if people are discouraged from getting it. If you’re told to come back in six days, you may or may not come back in six days.”
Sources1. Injury prevention and control: Opioid overdose. U.S. (2016, Dec. 16). Centers for Disease Control and Prevention. Retrieved Jan. 22, 2017, from https://www.cdc.gov/drugoverdose/epidemic/index.html2. Tirrell, M. (2017, Jan. 4). As opioid epidemic worsens, the cost of waking up from an overdose soars. CNBC. Retrieved Jan. 22, 2017, from http://www.cnbc.com/2017/01/04/as-opioid-epidemic-worsens-the-cost-of-waking-up-from-an-overdose-soars.html3. Abderholden, F. (2017, Jan. 19). Despite progress, Lake County’s fight against opioid epidemic sees early setbacks in 2017. Chicago Tribune. Retrieved Jan. 22, 2017, from http://www.chicagotribune.com/suburbs/lake-county-news-sun/news/ct-lns-naloxone-saves-opioid-epidemic–st-0119-20170119-story.html4. Portland Press Herald. (2016, April 29). Lawmakers override vetoes in order to fight overdose epidemic, add jail funding. Retrieved Jan. 22, 2017, from http://www.pressherald.com/2016/04/29/legislators-unanimously-override-veto-of-added-maine-jail-funding/5. Sewell, Dan (Association Press). (2016, Sept. 27). Just say no to Narcan? Heroin rescue efforts draw backlash. Journal of Emergency Medical Services. Retrieved Jan. 22, 2017, from https://www.cbsnews.com/news/just-say-no-to-narcan-heroin-rescue-efforts-draw-backlash/6. Szalavitz, M. (2016, May 13). Opioid overdose: Emergency treatment is crucial, but it’s not enough. Scientific American. Retrieved Jan. 22, 2017, from https://blogs.scientificamerican.com/guest-blog/opioid-overdose-emergency-treatment-is-crucial-but-it-s-not-enough/7. Mueller, S.R. et al. (2016, Oct. 31). Attitudes toward Naloxone prescribing in clinical settings: A qualitative study of patients prescribed high-dose opioids for chronic non-cancer pain. Journal of General Internal Medicine. Retrieved Jan. 22, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/277987758. Takeda, M.Y. et al. 2016 Oct-Dec; 37(4): 591-596 Co-prescription of naloxone as a Universal Precautions model for patients on chronic opioid therapy – observation study. Substance Abuse. Retrieved Jan. 22, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/27093559. Butz, D. (2017, Jan. 20). Iowa law provides greater access to opioid antidote, but treatment options remain scarce. Sioux City Journal. Retrieved Jan. 22, 2017, from http://siouxcityjournal.com/lifestyles/health-med-fit/iowa-law-provides-greater-access-to-opioid-antidote-but-treatment/article_08f81f54-af41-5088-9c8b-7620f829c2ba.htm10. Noori Farzan, A. (2016, July 11). Narcan is available over the counter now, but good luck trying to find it. Broward County-Palm Beach New Times. Retrieved Jan. 22, 2017, from http://www.browardpalmbeach.com/news/narcan-is-available-over-the-counter-now-but-good-luck-trying-to-find-it-7908959Written by David Heitz