Paper Towels, Flip Flops, Shampoo, and Narcan

narcan shopping

If the title of this article sounds like a shopping list from a local large chain pharmacy then you guessed correctly.  You might wonder what is curious about this list, though.  Maybe the Narcan? With an opioid epidemic raging out of control, access to Narcan can make the difference between life or death. 

“Over the past two decades, the United States has experienced a growing crisis of substance abuse and addiction that is illustrated most starkly by the rise in deaths from drug overdoses. Since 2000, the annual number of drug overdose deaths has nearly quadrupled from 17,500 to 67,400 in 2018.1,2 Most of these deaths involved opioids, including heroin, prescription painkillers, and synthetic opioids such as fentanyl.3 In the years since the U.S. Centers for Disease Control and Prevention (CDC) declared overdoses from prescription painkillers an “epidemic” in 2011, the opioid overdose crisis has evolved rapidly from a problem tied mostly to prescription opioid painkillers to one increasingly driven by illicitly trafficked heroin and synthetic opioids.”

What exactly is Narcan? Narcan is the brand name for Narcan Nasal Spray, “the first nasal formulation of naloxone to be FDA approved for the treatment of known or suspected opioid overdose.” 

“Naloxone is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. This means that it attaches to opioid receptors and reverses and blocks the effects of other opioids. Naloxone can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. But, naloxone has no effect on someone who does not have opioids in their system, and it is not a treatment for opioid use disorder. Examples of opioids include heroin, fentanyl, oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, and morphine.”

“Naloxone should be given to any person who shows signs of an opioid overdose or when an overdose is suspected. Naloxone can be given as a nasal spray or it can be injected into the muscle, under the skin, or into the veins.” 

 Narcan is given as a nasal spray. When would someone be given the Narcan? How would a caregiver know when a person is in distress? 

“An opioid overdose occurs when someone takes more opioids than their body can safely process.”

“Overdose symptoms include respiratory depression (slow, weak breathing) and loss of consciousness. Opioid overdose is a medical emergency because it can sometimes be fatal.”

“Each single-dose container of Narcan nasal spray holds 4 mg of naloxone. Narcan is given as a spray into one nostril. It’s meant to be given by caregivers or other people who may see someone who has overdosed or possibly overdosed on opioids.”

“It’s important to know that Narcan is not a substitute for medical treatment. After giving Narcan to someone, you should call 911 right away, even if the person wakes up after getting Narcan. Many opioids last longer in the body than Narcan lasts, so it’s possible that the person may return to an overdose condition after receiving Narcan. In any case, someone who receives Narcan should always be seen by a healthcare provider as soon as possible.”

“Narcan has been found effective in reversing opioid overdose.”

Most states have Good Samaritan Laws. Please do not be afraid to save a life. 

“Most states have policies, called Good Samaritan laws, in place to protect people who overdose on opioids and the people who seek medical help for those individuals. These policies vary by state and provide some protection against prosecution for possessing (having) illegal drugs.”

“If you witness someone who has overdosed or possibly overdosed on opioids, don’t hesitate to call 911. You can save a life by acting quickly to get medical help.”

Which pharmacies carry Narcan and is it over-the-counter? Can you pick it off the shelf the same way you pick your paper towels? It’s available in what is called “behind the counter”. You won’t find it next to your aspirin or epsom salt and I found per a phone call to my local CVS here in Beverly Hills, Ca. that is not available at all without a prescription. So what is the scoop? When I called my local Walgreens the answer was different: I could get it at the discretion of the pharmacist if I had an opioid prescription, or if I felt I or someone else was in danger.

Per the Drug Policy Alliance for naloxone access in California:

“Throughout the summer and fall of 2015, pharmacies across California will begin making the opiate overdose reversal drug naloxone available without a prior prescription. Thanks to a new law co-sponsored by Drug Policy Alliance, AB 1535, Californians are now able to purchase naloxone directly from a participating local pharmacist, either with cash or in some cases, private insurance.  Pharmacists who wish to dispense naloxone must complete an approved web-based training, and customers purchasing naloxone must also receive a brief in-store training on its use.”

According to the Narcan website the nasal spray is available quite readily or so it says.

“Anyone can purchase NARCAN® Nasal Spray directly from a pharmacist without a doctor’s prescription. All major pharmacy chains (such as CVS, Walgreens, and Rite Aid) stock NARCAN® Nasal Spray, so it’s convenient for you to obtain today. Download the Prescription Request Aid and present to your pharmacist to obtain NARCAN® Nasal Spray today.”

“In every state, residents can purchase NARCAN® Nasal Spray directly from a pharmacist under a Statewide Naloxone Standing Order or Collaborative Practice Agreement. State laws may vary.”

Perhaps it’s the state laws that may vary or the barriers to access but there are people in need who do not have access. 

“The opioid antidote naloxone (Narcan) is a safe, uncontrolled, prescription medication with proven morbidity and mortality benefits—if someone can obtain it and readily have it on hand. Despite policies such as co-prescribing mandates, increased insurance coverage, community outreach funding, and standing orders at pharmacies that permit “behind-the-counter” access, naloxone remains largely unreachable to those who need it the most, similar to Plan B prior to its over-the-counter switch.”

The reasons for the barriers to access for Narcan lie in stigma, bias, racism, cost, and lack of availability. 

“Professional organizations including the AMA and APhA have recognized this issue, releasing position statements (similar to ones on emergency contraceptives) that approve of over-the-counter naloxone. Bias, pharmacy availability, cost, and structural racism are all difficult barriers to naloxone acquisition. To achieve universal, equitable access to naloxone, we recommend instituting changes to establish an affordable, over-the-counter supply: “Plan N.””

“Dispenser and recipient biases impede naloxone receipt. In a study of 20 people who use opioids in New York City, bias was the main concern they had about accepting or carrying naloxone. Naloxone is “nearly synonymous with illicit substance use,” especially if the person is carrying the medication in the blue bags that the state of New York uses to distribute free naloxone. People do not want to be identified as drug users, and the connection between saving lives and naloxone is often obscured amongst the general public. On the dispensing side, some pharmacists are afraid of offending their patients if they offer them naloxone, while others feel uncomfortable or unsure on how to broach this difficult subject. Pharmacists have the knowledge of naloxone and opioid use disorder (OUD) but find it challenging to talk to their patients about these topics; some practitioners may even knowingly discriminate against patients with OUD, obviating the development of therapeutic relationships. This same bias may be held by providers as well, further alienating people with OUD from the health care system.”

“Naloxone availability is extremely variable; it has been found to be inadequately stocked in areas with high overdose rates, minority neighborhoods, and areas with a low average household income. One reason for this lack of availability may be the result of a phenomenon known as “medication deserts,” a term that describes areas where geographic access to pharmacies is severely limited and the stock at these locations may be insufficient to meet patients’ needs. In poorer districts, where people who are unlikely to own cars live, pharmacies have a greater chance of not having medications stocked in comparison to those in more affluent areas.”

“Many of those Black Americans may have been living in pharmacy deserts, where naloxone might not be as readily available. Longstanding racial differences in the response to substance use disorder also compounds this overdose issue.”

“The facets of structural racism perpetuate weaker OUD management practices for communities of color, disproportionately increasing the risks of overdose and death for people of color.”

“Cost is another large hurdle. While generic formulations can reduce the price of medications, expenditures are likely to remain high until adequate competition arises. The most-commonly prescribed Narcan nasal spray formulation has a list price of $150, and even after using drug coupons such as GoodRx, the cost still averages around $125.” 

 Naloxone is not reaching enough people. It needs to be moved to over-the-counter status and be as easily accessible as aspirin and paper towels. 

“Despite an annual recorded distribution of more than 20,000 naloxone kits since 2019, naloxone is just not saturating the needed areas in the most hard-hit communities.” 

“Reclassifying naloxone as over the counter would be one way to address this need in areas without pharmacies and would also attend to racial disparities that coexist among medication deserts.”

“While over-the-counter status would allow naloxone to be sold in locations such as convenience stores or grocery markets without any communication with pharmacists or health care providers, it would not preclude conversations at other points of access such as emergency departments, pharmacies, and provider offices. The sacred physician-patient relationship would not be altered by over-the-counter naloxone. In fact, if naloxone and discussions on OUD become more commonplace in society, it may even provide the impetus for doctors to talk to their patients about substance use, focusing on those with identified risk factors for opioid overdose.” 

The concerns of reclassifying naloxone to an over the counter medication should not outweigh the risks to saving lives. If there is a will there’s a way and there has been enough death already. 

“Before Plan B was changed to nonprescription status, opponents of the move claimed that increased availability of emergency contraceptives would cause women to engage in risky behaviors such as unprotected sex more often, potentially driving up abortion rates. However, this has not been true in cases where emergency contraceptive access increased. For instance, after Germany approved levonorgestrel and ulipristal emergency contraceptives for over-the-counter use, access increased; in areas with highest use, fewer abortions were actually performed. The moral hazard framework fails when applied to increased naloxone access as well.”

“Another concern is that moving naloxone over the counter would mean those who previously relied on insurance to cover the cost might now have to pay out of pocket. Yet, not all manufacturers will sell their products as nonprescription—consider how fluticasone propionate nasal spray (Flonase) can be paid for by some insurance plans as long as the over-the-counter packaging is not dispensed. Under the Affordable Care Act, most third-party payers, including Medicaid, provide coverage of Plan B and other emergency contraceptives when prescribed, even though levonorgestrel preparations are now over the counter. Similarly, certain states such as Rhode Island mandate insurance coverage of naloxone, which can easily be continued if the medication becomes nonprescription.”

“Part of the difficulty in achieving universal, low-barrier, over-the-counter access to naloxone lies in the price to consumers. Over-the-counter naloxone nasal spray will likely be costly, even if multiple generics become available to create market competition. While the federal government could contract with manufacturers under 28 USC section 1498 to produce inexpensive products in bulk, this does not entirely eliminate all payments and cost sharing, especially for people with limited financial means.” 

The bottom line is that Narcan meets all the criteria for an over the counter medication. How many more lives have to be lost? 

“The underlying rationale is that naloxone meets the four FDA criteria for over-the-counter status: (1) the drug’s benefits must outweigh its risks; (2) it must treat a condition that can be identified without the assistance of a medical professional; (3) it must have a low potential for misuse; and (4) its label must allow an individual to understand how to use it properly.” 

If you or anyone is in an emergency situation do not refrain from calling 9-1-1. Seconds count. 

Author: Sherri Margolin (Dark Matters)

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