“I will say that I have done many things I am proud of as a doctor, but one of the things that I am proudest of is just happening to be a person carrying Narcan when another person is literally dying on the sidewalk. I was able to give them Narcan, they survived it, and came back to life. It was not because I was a doctor, but because I was carrying Narcan.”
Dr Joe Wright, Boston Healthcare for the Homeless
On Wednesday, March 28th, the U.S. Food and Drug Administration (FDA) approved Narcan, an opioid overdose-reversal drug, for over-the-counter sales.
The FDA said in a statement, “Today’s action paves the way for the life-saving medication to reverse an opioid overdose to be sold directly to consumers in places like drug stores, convenience stores, grocery stores and gas stations, as well as online.”
Narcan is a naloxone nasal spray that can rapidly reverse the effect of opioid overdose. Approving the drug for over-the-counter (OTC) sale means that purchasers no longer need prescriptions to access the drug, a crucial step toward ending the national overdose crisis.
Overdose remains one of the most disruptive public health issues in the U.S. According to the FDA, the nationwide crisis has been linked to over 100,000 deaths each year, primarily driven by potent synthetic opioids such as fentanyl. It has been proven that Narcan is a safe and easy-to-use drug that can quickly restore normal breathing to a person if their breathing is slowed or stopped due to an opioid overdose. However, there has been a lack of accessibility to the drug due to its high cost and stigma around substance users. The most commonly prescribed two-dose package of Narcan nasal spray is usually sold for around $100 to $150 to customers without insurance. While with prescription in Massachusetts, some patients with insurance end up paying less than $10 for overdose-reversal drugs due to coverage by the state and insurance.companies, other populations in need of Narcan still need to pay mostly out-of-pocket due to health insurance plan limitations.
There has been a damaging stigma around using and dispensing naloxone. In a 2020 qualitative interview study called Reasons People Who Use Opioids Do Not Accept or Carry No-Cost Naloxone, researchers found that one of the barriers that impede the naloxone acceptance rate is the stigma related to substance use. According to the participants of the study, naloxone is “nearly synonymous with illicit substance use.” The fear of being identified as a drug user and the bias that drug users’ life should be devalued made people less willing to adopt naloxone. Some pharmacists also hold a bias against patients who needs naloxone. Researchers from North Dakota State University found that health professionals prefer to distance themselves from patients with opioid misuse, leading to poor quality of care given. Furthermore, independent pharmacies, particularly those in lower-income areas, do not stock the naloxone nasal spray regularly out of unwillingness to engage with drug users and the lack of demand due to the drug’s high cost.
The OTC approval of Narcan is essential as it may largely increase the accessibility to the drug and prevent cases of overdose from happening. “Making Narcan available over the counter across the country is smart public health policy that will save lives by improving access to a vital harm reduction resource and reducing the stigma associated with substance use disorders,” Boston Public Health Commission Executive Director, Bisola Ojikutu, said in a statement. “All Americans should know how to use and be able access this life-saving resource. It’s over the counter availability in Massachusetts has saved countless lives and I am glad that it will now be more accessible to the rest of the country. This is a major moment of hope for individuals, families, and communities that have experienced the trauma of the opioid epidemic.”
In the past, many states, including Massachusetts, had already done work to minimize the barriers through projects like “standing order prescription,” – which allows pharmacists to dispense the drug to people at risk without needing a doctor’s prescription. While the stigma around people with substance use disorders remains, OTC approval will lessen the existing barriers. “I think the move to make it over the counter will be helpful in a couple of different ways.” Dr. Joe Wright, Director of Addiction Treatment for Boston Health Care for the Homeless commented on the approval of Narcan in an interview with Sampan. He explained:
“One is it emphasizes to people that Narcan is a safe medication that they can use, and that it is fine to carry with you and use. I think sending this message of reassurance is helpful to the community and help to make the public comfortable with the medication. Certainly, the cost of the OTC is going to determine how accessible it is. But we will continue to benefit from programs we already have in Massachusetts and in some other states, to distribute Narcan for free, as well to cover it through health insurance, which currently covered by most if not all health insurance.”
While the approval is widely celebrated, some clinics and harm reduction groups are concerned that when Narcan is moved across the counter, people may face the full price of the drug as most public and private insurance programs usually do not cover over-the-counter medicines. So far, Emergent BioSolution has not disclosed the over-the-counter price of the drug and the discounted price of a box of Narcan is currently around $47.5. Health economists predict the new price for Narcan could place between $35 to $65 without retailer’s markup, a significant increase in cost for some consumers with insurance who have previously been paying less than $10 a box. This potential rise in charge or the additional out-of-pocket cost may become a new barrier that limits people in need from obtaining life-saving medicine. Not only so, the high price of the drug may increase its potential to be shoplifted, causing Narcan to be placed behind the counter or inside locked glass, which further continues the stigma.
It is uncertain how this change will affect Chinatown. In Massachusetts, the Department of Public Health made a standing order to have every pharmacy hold at least one can of naloxone in stock due to the opioid epidemic. However, the owner of Chinatown’s Tai Tung Pharmacy, Eva Chau, told Sampan that there is almost no demand for naloxone at her store. “I never get call for naloxone… It could be a cultural thing. Barely anyone comes in for pain killers, fentanyl or oxy either. But, I’m sure the increased accessibility to the drug will help with overdose death to a certain extent.” While no direct public health statistics point to the rate of opioid use in Chinatown, all neighborhoods and cities and towns in Massachusetts are struggling with the overdose crisis to a certain degree as clinics and hospitals constantly receive overdose or ambulance calls so everyone should learn how to access Norcan OTC
“However, many people say I’m not the sort of person who’s involved in that kind of thing,” Dr Wright told Sampan. But naloxone is often recommended along with opioid pain medications for patients with severe injuries, cancer, and other severe pain issues. In cases where patients unintentionally overdose from too many drugs, it is essential for the family of these patients to have and know how to use naloxone. Many medical professionals and harm reduction groups have also advocated that Narcan should be held in everyone’s household first aid kit and purses, not only for people who experience substance use disorder.
The public re-education of naloxone as a commonly used medicine will help people be prepared in cases of emergencies and may serve to counter thousands of preventable deaths each year. Many efforts have already been made to promote the use of naloxone. In 2022, Boston Public Health Commission distributed 14,803 doses of Narcan and reversed up to 5 opioid-related overdoses per day. About 10,000 individuals undergo training on administering naloxone each year in Boston. The city offers education and training to opioid users, their families, and community partners that work with or may encounter people at risk of overdosing. Whether increasing the accessibility of naloxone through OTC sales or distributing naloxone through governmental and social efforts, more awareness around overdose prevention needs to be raised.
