An overdose drug is finally over-the-counter. Is that enough to stop the death toll?
Earlier this month, drug stores and pharmacies nationwide began stocking and selling the country's first over-the-counter version of naloxone, a medication that can stop a potentially fatal overdose from opioids. It's sold as a nasal spray under the brand name Narcan.
Coming off a year with a record number of drug overdose deaths in the United States — nearly 110,000 in 2022, according to the CDC's National Center for Health Statistics – community health workers and addiction medicine experts were hopeful that the arrival of Narcan on retail shelves might make it easier for people to get the medication.
The urgent and ultimate goal is to prevent more fatal overdoses.
But it's unclear if the move will actually expand access to Narcan. Experts worry that its retail price, sporadic availability on store shelves, or general consumer confusion about potentially having to ask a pharmacist to retrieve it will mean that fewer people than expected will purchase Narcan and actually have it at the ready when an overdose occurs.
That means that more education and outreach will be needed to get this lifesaving medication into more hands. Those already engaged in the opioid epidemic – community health workers and nonprofits focused on harm reduction – will have to stay intensely involved. Over-the-counter Narcan will be an additional tool, alongside prescription and free versions of the drug.
"It's not by any means a game changer. I don't think it's a step in the wrong direction. I just think it's a tiny, tiny baby step that does not deserve a round of applause," says Shoshana Aronowitz, a family nurse practitioner and assistant professor at the University of Pennsylvania's School of Nursing in Philadelphia.
"We should not be under any illusion that this is going to meaningfully change things for a lot of people," she says. "But we need to be moving in this direction, we just need to be doing it faster and with an understanding that this is just way overdue."
Over-the-counter can mean behind the counter
The U.S. Food and Drug Administration approved over-the-counter marketing and sales of Narcan in March. It's manufactured by Emergent BioSolutions, and started arriving in stores in early September, with a suggested retail price of $44.99 for a two-dose package.
As an over-the-counter product, Narcan should ideally appear on store shelves in the same way as ibuprofen and cough medication.
But at several drugstore locations in Philadelphia, "over-the-counter" means it is stocked and sold from behind the pharmacy counter. That requires people to wait in line and ask a pharmacist to buy Narcan.
"Having to go talk to the pharmacist who may or may not know you, it's not comfortable for people and that's a barrier that this is supposed to eliminate," Aronowitz says. "It's counterintuitive. It needs to just be on the shelf and someone can take it."
Keeping Narcan behind the counter will especially deter people who use drugs, says Dr. Lewis Nelson, chair of the Department of Emergency Medicine and director of the Division of Medical Toxicology at Rutgers New Jersey Medical School.
"For those who don't have substance use concerns, they might go in and just ask for the product and not be concerned about what the other person's thinking," he says. "But that's a mental state that's very hard for most of us to put ourselves into if we don't live the life of somebody with the stigma and the marginalization that is so associated with substance use."
Will a price of $45 (or even more) be too much?
Another potential barrier is related to affordability. Although the suggested price for a two-dose pack is $44.99, there's nothing that stops individual pharmacies and other retailers from charging more.
At least one drugstore in Philadelphia was selling it from behind the pharmacy counter for $72 per box.
"The higher the price, the fewer people who are going to splurge to have this with them in case somebody else needs it," Nelson says.
That's especially true for people with low incomes who are facing other daily financial challenges, Aronowitz says. Even $44.99 may be too steep for many consumers.
"That's a lot of money to be spending on something if you need food today, if you have a headache and need ibuprofen today," she says. "You think you'll probably need naloxone, but it's not a guarantee that you'll need today, so why spend the money."
Prescription versions will still be needed
For some people, generic brands of naloxone, already available at many pharmacies, could be a more affordable option than brand-name Narcan. But generic naloxone still requires a prescription, and may involve significant out-of-pocket costs, particularly for uninsured customers.
To deal with the prescription requirement, most states have instituted a standing order for naloxone, which authorizes pharmacists to dispense naloxone immediately to someone, even when they don't have a doctor's prescription.
Many private health insurers — and public programs like Medicaid and Medicare — cover the cost of these prescription sales.
Will insurance plans help pay?
State officials in Pennsylvania, New Jersey and Delaware confirmed to NPR that their Medicaid programs, which offer health insurance to people with low incomes, will cover the cost of the new Narcan spray as long as a pharmacist puts the order through as a prescription.
In California, a bill is headed to Governor Gavin Newsom's desk that would require health insurers - both public and private - to cover most of the cost of naloxone, and other FDA-approved opioid-overdose reversal drugs, in the nation's most populous state. The bill allows insurance plans to charge a maximum co-pay of $10 per package, and would sunset in five years.
Aronowitz predicts that if cost deters people from buying over-the-counter Narcan, it will fall upon nonprofit organizations and harm reduction programs, which already distribute naloxone for free, to continue efforts to distribute it to a larger population of people.
Why LA is giving out free Narcan to immigrant communities
In Los Angeles County, health officials have launched a unique push to get Narcan into the hands of an overlooked demographic when it comes to the overdose epidemic — Latino immigrants.
The rate of fentanyl deaths among Latinos in L.A. County jumped by 721% in just seven years, according to the county Department of Public Health.
In 2016, 25 Latinos died of fentanyl overdoses. By 2021, 550 Latinos had died. It's unknown how many of those people were immigrants, because country of origin isn't a required data point in overdose reported data. Still, county health officials are proactively reaching out to immigrant communities with their harm reduction efforts.
While Mexico doesn't have an opioid use epidemic as severe and deadly as the one in the U.S., overdoses in that country are increasing — particularly in border communities— and there's a growing need for Narcan, the nasal spray that reverses opioid overdoses.
A captive audience for overdose awareness
In Los Angeles, Martha Hernandez, a county community health worker, makes frequent visits to local consulates for Spanish-speaking nations, where she gives short, sharp demonstrations tailored to her audience, instructing them on how to effectively use Narcan.
"I go to five Latin consulates," Hernandez explained during a recent visit to the city's Mexican consulate near MacArthur Park. "I use myself as an example. A lot of us go to our hometown, Tijuana is the closest one, and we go and get medication, especially pain killers. [I tell them] 'a lot of them have fentanyl in the medications' and you'll see their wide open eyes, like 'Woah, that is true.'"
Narcan is highly restricted in Mexico, so immigrants are unlikely to know much about it. But in the U.S., Narcan's new availability without a prescription, along with the ongoing surge in overdoses, made consulates a new priority for enhanced outreach and training.
One common misconception Hernandez runs into surrounds Narcan's packaging, which says nasal spray in large letters on the box.
"People do mistake the fact that it's nasal [spray], they think it's for allergies," she says. "That's where you see the necessity of educating our community because a lot of people will say 'oh I need it, I have allergies."
The main room of the Mexican consulate in L.A. feels like the lobby of a DMV, with long waits amid rows of hard plastic chairs. On a recent morning, about 30 people sat waiting for their new Mexican passports or ID cards.
This is the captive audience Hernandez takes advantage of, walking in front of the assembled people, holding brightly colored public health brochures above her head.
"Simple words, colorful brochures, nice and easy. The way you approach them is the key to getting your message across," she says.
How and when to use Narcan — and what to do after
Today, she tells the captive audience, they'll learn how to save someone from dying of an opioid overdose.
Hernandez tells them Narcan is not a substitute for medical care, but it can quickly prevent an overdose from becoming fatal. And it's so easy to use that the training can take as little as 10 minutes.
It's not always clear if someone is experiencing an overdose, but Hernandez tells the group that they should still call 911 and administer Narcan.
"I tell them, if I saw my mom on the floor I would administer Narcan," Hernandez says. "Why? Because my mom will go to her sister's house and say 'my neck or my knee hurts' and her sister will pop out a pain medicine [that she has.] A lot of us, being Latinos, will pop it into our mouth. How do I know what she put in her mouth?"
Fake prescription pills are partially fueling the country's opioid crisis, especially in western states. The share of overdose deaths involving counterfeit pills more than doubled between 2019 and 2021, and the percentage more than tripled in western states, according to a new report from the Centers for Disease Control and Prevention.
The report found those who died from overdoses with evidence of counterfeit pill use, compared to those without it, were more often younger, Hispanic or Latino and had misused prescription drugs in the past.
Younger Latinos are aware of the overdose threat
Jose Magaña Lozano, 67, works in cement construction in L.A. and has lived in the U.S. for 30 years.
"I've only seen opioid overdoses on TV," he says. "Hopefully I never have to witness an overdose happen, but if in case I do see it happen, at least you know what to do, and at the very least you can help a little."
But for younger generations who went to high school in the U.S., and who grew up in the midst of the raging opioid epidemic, the problem is all too familiar.
"I've actually learned it [Narcan] in high school because you'd be surprised, lots of people were doing drugs and overdosing," says Luis Armas Ramirez.
"Latinos, we don't really take it seriously like that, especially because it's something very private," he says.
Armas was excited to receive a free box of Narcan while waiting for his travel documents.
"[Narcan] is like, crazy expensive. I believe that things happen for a reason, so if I'm seeing it [Narcan] now, God's timing is never wrong, I may see an overdose next week, you never know," he says.
Hernandez gave three demonstrations at the Mexican consulate, and gave out a total of 45 boxes of Narcan. The following day, she headed over to the Guatemalan consulate to teach more immigrants about the increased danger of opioid overdoses in America, and how they might help.
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