June 11, 2023

A shiny circular pin on my purse reads “I CARRY NALOXONE,” proclaiming that I am ready to respond to an opioid overdose—an event that kills over 180 people every day in this country. That means when someone stops breathing, turns blue and isn’t responsive after an overdose, I can administer naloxone to reverse another tragedy.

I am neither a medical professional nor a trained EMT. Anyone can reverse an overdose in an emergency, along with calling 911 and giving rescue breaths. We could all be carrying this miracle drug in our purses and back pockets.

The FDA made that easier last month by approving Emergent BioSolutions’ Narcan nasal spray for over-the-counter (OTC) sale. The first overdose-reversal drug approved for community use and now OTC, it delivers a spray of naloxone through the nose and works in minutes. This decision has been a long time coming; emergency medical personnel have used naloxone for decades, and it’s been prescribed for laypeople to carry since 1996. As an expert in harm reduction, I know that although finally authorizing one OTC naloxone product is a step in the right direction, it does not go far enough.

Every year we lose more Americans to drug overdoses than the total number of lives lost during the Vietnam war. In 2021, this was over 107,000 people. The drug overdose crisis lowered the life expectancy of the average American even before the COVID-19 pandemic, where isolation and economic struggle sent overdose deaths to an all-time high. In Maryland, like most of the country, we’ve seen the illicitly manufactured opioid fentanyl spur a rapid rise in overdose deaths. Fentanyl—100 times stronger than morphine—causes respiratory arrest even more quickly than heroin. And Maryland’s drug-checking program, in which used paraphernalia is tested at harm reduction programs statewide, shows that there is virtually no more heroin in the illicit drug market. It’s predominantly fentanyl. Naloxone is the most important tool available to respond to this high-risk environment, and we need aggressive action to reverse the devastating trend in deaths.

We can start with liberating naloxone, in all its formulations (including injections), from prescription requirements, not just in one, more costly, nasal spray. It has long deserved OTC designation in every form; it is safe and effective, has no potential for abuse, and can be used by anyone without training. Harm reduction programs, which are comprehensive care centers that without judgment help people who use drugs, have distributed it since 1996.  State laws that swept the country officially made naloxone accessible outside of medical settings, meanwhile, after 2001. Nonprofit and government organizations next started handing it out on street corners, in homeless encampments, barber shops and beyond. Research shows its widespread distribution to people who are most likely to witness an overdose—people who use drugs—reduces overall opioid overdose mortality rates.

The failed “War on Drugs,” which criminalized drugs and imprisoned people who use them, helps to explain the long-delayed federal response to the overdose crisis. We’ve overinvested in prison cells and underinvested in addiction treatment and harm reduction. Only in the last 10 years have we seen a shift to a more compassionate, humanizing approach that has elevated the importance of harm reduction, including naloxone.

Before then, harm reduction nonprofits and activists led a bottom-up revitalization of health care for people who use drugs by applying creative ways to distribute naloxone and other lifesaving supplies to them despite legal barriers. For example, Dan Bigg and the Chicago Recovery Alliance worked around naloxone’s prescription requirements in the 1990s by having doctors write prescriptions in the field alongside staff who provided training. While such nonprofit organizations are still best positioned to get naloxone to people who use drugs, they can’t distribute enough to stem the tidal waves of overdose deaths. The dearth of federal support has left them underfunded and understaffed, struggling to meet an ever-increasing demand for their services. The Biden administration only approved the first federal spending specifically for harm reduction, $30 million, in 2021.

Moreover, cost outweighs convenience with naloxone. While an OTC nasal spray is welcome, community distribution of all naloxone formulations to people most at risk of overdose—at no cost—remains essential to ensure it is on hand at every overdose. We do not know if Narcan will be affordable to all who need it. Also, product placement matters to avoid the stigma surrounding drug use. People may not want to be seen holding a Narcan box in the checkout line. Harm reduction programs that meet people where they are with free naloxone circumvent these barriers.

The federal government should remove all forms and dosages of naloxone from prescription requirement altogether. Federal funding should be directed to companies like Remedy Alliance, run by the country’s leading naloxone experts, which negotiates cheap naloxone prices with pharmaceutical companies and distributes it to harm reduction programs. State funds could then support organizations providing free naloxone to people who use drugs and their families in innovative ways. Without the limitations of prescription, naloxone could be more easily offered in key places like a homeless shelter, emergency department, opioid treatment program, or jail, as well as churches, hair salons and skate parks (why not?). Naloxone in vending machines increases the reach of harm reduction programs, as does doorstep delivery by mail. A whole new world of free naloxone distribution is critical to reversing overdose death trends and needs support.    

To go a step further, ending the opioid overdose crisis requires decriminalizing drugs and reinvesting in behavioral health. Oregon voters made this happen in 2020, influenced by European countries like Portugal where decriminalization and investment in harm reduction have kept drug use and related deaths well below European averages. From the field, I see this sea change in American drug policy as not only possible, but inevitable. We must keep people alive to benefit from this sweeping change, and that starts with the liberation of naloxone.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.

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