In every first-aid kit in America, next to the gauze, Band-Aids, and ibuprofen, there should be naloxone. Sold either as a nasal spray or as an easy injectable similar to an EpiPen, naloxone can rapidly reverse an opioid overdose. It does this by binding to the same receptors in the brain that opioids like heroin, oxycodone, and fentanyl bind to, temporarily knocking them off. In this way, naloxone can very quickly restore normal breathing, which can slow or stop after an overdose. Its effect, however, wears off within 30 to 90 minutes. Since time is of the essence, the faster naloxone is given to a person—while help is on the way—the greater is the likelihood of averting an overdose-related death.
Overdoses can happen even in people who appear in the clear from heavy drug use, as in a famous example: In July 2018, singer Demi Lovato overdosed on opioids after nearly six years of sobriety. Found unresponsive at her Los Angeles home, her friends reportedly used naloxone to reverse her overdose and save her life. Naloxone has saved tens of thousands of lives. Importantly, it’s easy to administer and extremely safe. The risk of handing it out to everyone in America is almost nil: It has minimal negative side effects, even if given to someone who is incorrectly identified as experiencing an overdose.
Naloxone access matters during a pandemic more than ever. The opioid epidemic, which claims the lives of over 130 Americans daily, has drastically intensified as the country also deals with COVID-19. Nationally, suspected overdoses—not all of them fatal—spiked 18 percent this March compared with last year, and nearly 30 percent in April and 42 percent in May. In some jurisdictions, the numbers are even more alarming. King County, Washington, for example, which includes Seattle, has seen synthetic opioid-related fatalities skyrocket by 133 percent in the second quarter of this year compared with 2019. And with red flags all around, the American Medical Association recently released a grim statement cautioning Americans that “more than 40 states have reported increases in opioid-related mortality.”
It makes sense that in times of extreme stress, many Americans are turning to substance use to ease the pain. Experts point to pandemic-induced social isolation, dilution of social support groups, disruption in addiction recovery services, and the plunge in employment as possible reasons for the rapid uptick. And since the future of the pandemic remains uncertain, some projections estimate that over the next decade, COVID-19’s impact coupled with slow economic recovery could additionally claim over 150,000 Americans through drug use, alcohol, and suicide, on top of burgeoning daily overdose fatalities.
To help reduce those deaths, it is absolutely critical that we think outside the box and implement nuanced strategies for overdose prevention as soon as possible. Overdose education programs, once given to opioid users specifically, are now available to anyone; participants leave with naloxone to have on hand just in case. Now, the pandemic poses logistical challenges to distributing naloxone in person. But even pre-coronavirus, there was a need for wider distribution.
The past decade has seen an increase in community-tailored training programs and expanded Good Samaritan laws, which protect everyone involved from arrest for drugs or intoxication. But these have led to mixed success in the actual administration of naloxone during suspected overdoses. Data from the Centers for Disease Control and Prevention published in 2018 show that bystanders were present in over 40 percent of fatal opioid overdoses, and yet naloxone was administered only 4 percent of the time. While the reason for this discrepancy is unclear, there are likely gaps along the naloxone distribution cascade—including in awareness, access, training, possession, and use. Awareness, a necessary first step in motivation to change behaviors, is only nominally helpful unless there is easy access to lifesaving medications and other preventative tools. One study of opioid users in Baltimore showed that even though naloxone awareness was high among this cohort, only 25 percent reported always or often carrying the drug with them. The percentage of general population carrying naloxone is likely even lower.
One issue is that to get naloxone outside of a special program, you’d need to see a pharmacist. Federally, it’s a prescription drug; despite several citizen petitions over the past decade, the Food and Drug Administration has not modified naloxone’s prescription status. The secretary of health and human services or the FDA commissioner has the power to make that change unilaterally, but neither has done so yet, despite the rising toll of the opioid epidemic. Many states have taken things into their own hands: At present, people can ask for and obtain naloxone at pharmacies without a prescription in every state except Nebraska. While Narcan can cost $150 for two nasal-spray doses, and Evzio is $4,500 for a two-dose package, most plans will cover this with the buyer owing only a small copay, even if the buyer doesn’t have a diagnosis of opioid use disorder. Some state health departments have copayment assistance programs to offset these costs.
This might make the process of getting naloxone sound easy enough. You could very well be able to run out to your local drugstore right now and grab a supply of naloxone for a small copay (if you can, you should!). A pharmacist will explain to you how to use it if you aren’t familiar. It’s extremely easy, as illustrated by these draft pictograms from the FDA, which could appear on the side of over-the-counter naloxone sprays or injectables. But the FDA should just go ahead and make it an OTC drug, fully dropping barriers to access, as soon as possible. Making naloxone OTC would allow for competitors to make cheaper generic brands, which would be useful because routes like insurance for paying for the drug are not available to everyone. Even for people who have access to financial assistance, seeking out that assistance is an administrative hurdle at best, and a potential nightmare if you need naloxone in an emergency. While you probably don’t need a prescription, you do need to get naloxone during pharmacy hours, which may not be 24/7. If you are in the presence of someone who has overdosed, you shouldn’t have to worry about whether you can access naloxone, whether the pharmacy is open, and if the person behind the counter might be judging you. You shouldn’t have to go through these hurdles, even if you do have time to get to the nearest CVS and back before the person who needs help stops breathing.
Naloxone should simply be where you are, already. It should be a standard in all first-aid and rescue kits sold on Amazon; you should be able to throw it in your shopping basket while restocking Band-Aids and cold medicine. Public health departments should distribute it to bars, restaurants, grocery stores, public transit kiosks, places of employment and worship, and homeless shelters. It should be found near every fire extinguisher and paired with the placement of automated external defibrillators—portable electronic devices tucked away in most public places that can help with life-threatening sudden cardiac arrests. It should be everywhere, just like medicine for headaches or bandages for minor scrapes and bumps. If you happen to be away from your own naloxone device, you should be able to shout “Hey, does anyone have some naloxone?” and have the answer reasonably be “Yes, of course.”