You shouldn’t need a prescription
to stop a deadly overdose
Naloxone is a lifesaving antidote that reverses overdoses from opioids like heroin, OxyContin and Vicodin. It won’t get you “high” or make you “trip.” It can be administered easily, immediately bringing a person back from the brink of death. So why isn't it available over-the-counter? Why do pharmacies refuse to stock it? We talked to health advocates, community leaders and pharmacists about New York's fight against the opioid epidemic.
Additional reporting, photography:
“My life came to a screeching halt when I found out my son was on heroin,” Missy Forsyth told a Staten Island hotel room full of strangers at a Community Health Action conference. Forsyth's son had overdosed four times before. The last time, about three years ago, Forsyth was barely able to get him to the hospital in time to save his life. There, hospital staff administered naloxone.
Forsyth is now part of a New York statewide initiative to train both first responders and ordinary community members on how to identify an overdose and administer the antidote.
Led by Kevin Keeley of Community Health Action, this training session was one of over 200 taking place this year. Keeley held up a blue bag containing an intranasal naloxone kit, a small plastic injector resembling a syringe with a mushroom-shaped tip that fits the nostril. Administration is simple: just squirt the liquid into the nose.
Heroin and prescription painkiller overdoses have reached epidemic levels according to the Centers for Disease Control and Prevention (CDC). In New York, drug overdose rates rose 41% from 2010 to 2013. More than 75% of these deaths involved opioid drugs according to the NYC Department of Health. Narcotic abuse use has been an especially grim problem in Staten Island, with the borough trailing only the Bronx for the highest rate of heroin overdose deaths.
Overprescription of painkillers such as OxyContin hit the borough especially hard, particularly its large middle class population, firefighters and school teachers, public sector workers with jobs that afford them decent health insurance, Karen Varriale, Chief of Narcotics Bureau for the Staten Island District Attorney’s Office, tells Hopes&Fears. Prescriptions were written so freely that the State Attorney General’s office led a thorough investigation that ultimately discovered that Purdue, the pharmaceutical company that manufactures OxyContin, had aggressively encouraged healthcare providers to prescribe the drug. Though the investigation led to providers clamping down on dispensing prescription pills, the damage had already been done.
Drug overdose rates in New York, 2010 to 2013
involved opioid drugs
Earlier this month, CVS pharmacies in New Jersey announced that it would provide naloxone without prescriptions across the state.
Hopes&Fears called CVS locations in five different New Jersey counties and found that none had the overdose reversal medication on their shelves.
Not a “drug”
Opioid drugs like heroin and prescription painkillers cause respiratory depression, the slowing down of the body’s breathing. Opioid overdoses become fatal when the respiratory depression becomes so great that not enough oxygen gets to the brain.
Naloxone is a competitive antagonist to the mu-opioid receptors that opioid drugs bind to. It immediately reverses the overdose and prevents death.
Naloxone is unique as a drug antidote. It is essentially a pure antagonist; unless you have opioids in your body, it generally has no effects. There is no “high” if you take naloxone sans opioids, so there is no danger of naloxone being used as a substitute drug.
“If you’re already addicted or dependent, and you have the experience of naloxone reversing an overdose, it’s an extremely unpleasant state,” Sharon Stancliff of the Harm Reduction Coalition tells Hopes&Fears. “They go into immediate withdrawals.”
Naloxone won't make addicts "push the limits" of their highs
Naloxone by itself has absolutely no potential for abuse. It has no activity in the body whatsoever unless the patient has been using opioids.
There is absolutely no evidence to show that an addict will do that. No one would intentionally use more medication thinking that they are going to be administered naloxone and be put into immediate withdrawal. Because it’s a horrible feeling.
Pharmacist Sarah T. Melton to Richmond Times Dispatch
A matter of access
In 2014, New York began equipping EMTs and police officers all over the state with the drug, expanding the initiative to fire departments this summer. The New York Department of Health has recently loosened regulations on naloxone kits to allow anyone to obtain one from registered providers, with or without a prescription.
Yet you can’t just stop into a pharmacy to buy a naloxone kit. “Naloxone remains a prescription product,” Stancliff explains. While there’s currently an effort to make it available similar to how flu shots are available at pharmacies, you would currently need to find a registered Opioid Overdose Prevention Program in New York State to get a kit.
While CVS pharmacies in New York can’t yet sell naloxone without a prescription, pharmacies in New Jersey can. Drug overdose is now the leading cause of accidental death in NJ, even exceeding car accidents. The Overdose Prevention Act allows pharmacists to dispense naloxone to those capable of administering it in an emergency.
We called five CVS locations in Hoboken, Union City, Newark, Atlantic City, and Orange. When asked if they were selling naloxone with a prescription, a Hoboken pharmacist said they were not selling it over the counter, and that the antidote would have to be approved by the FDA. A pharmacist from CVS in Atlantic City said they were not selling it without a prescription, and had not gotten any word that policy would be changing. Newark’s CVS said they also were not selling it, but would be changing that policy in the next couple of months. The CVS locations in Union City and Orange both said definitively that yes, they were selling it without a prescription, but that someone would have to come in and order it because it was currently out of stock.
Consistent availability, price, and lack of knowledge are significant barriers to getting naloxone out to the public and save lives. “Pharmacies need to be sure there’s a way they have stock without it going to waste,” Stancliff explains. “Naloxone has a short shelf life.”
As naloxone increases in demand, injection naloxone went from less than a dollar to $23. Intranasal naloxone has doubled in price. Just last fall, Amphastar, the pharmaceutical company which manufactures naloxone, increased its wholesale price from $13 to $30, and more in various parts of the country. State representatives across the country—including current presidential candidate Bernie Sanders—have been probing the company about its decision, and earlier this year New York State Attorney General Eric Schneiderman reached a deal with Amphastar to cut and cap naloxone prices for all state agencies. Kaléo, who manufactures Evzio, a talking naloxone autoinjector that uses an encouraging voice to talk caregivers through the process of giving the antidote, costs more than $500.
New York has joined 26 other states in passing 911 Good Samaritan laws, which protect people from prosecution for possession of a controlled substance or drug paraphernalia when calling 911 in good faith. Keeley emphasized the importance of calling 911 immediately after giving naloxone even if there are controlled substances still in the area. Naloxone, while highly effective at reversing overdoses, is short lived. Most opioid drugs last longer than naloxone, and naloxone can wear off before the body can escape overdose, putting the victim back into danger.
Keeley stressed this with a story about a group of people who administered naloxone to someone who was overdosing. They stopped watching him when he regained consciousness and appeared to be fine. “The man went to sleep and never woke up,” Keeley told Hopes&Fears.
Prison inmates are also potential good samaritans on the frontlines of opioid abuse. This past February, the Department of Health launched a pilot program to train soon-to-be released inmates at the Queensboro Correctional Facility, citing that drug-related overdose remains the leading cause of death among former inmates, especially in their first two weeks out of prison. “It’s been known for a while that people, when they are released, are really prone to having an overdose,” Stancliff says. Because heroin is both less available and less clean in prison than on the street, people may lose their tolerance to drugs while serving time, which can cause them to take doses their bodies can no longer handle once back in public. Once the pilot program is complete, the DOH hopes to spread training to all 54 correctional facilities across the state.
While many states have passed Good Samaritan laws and expanded naloxone access, many have not. Part of it is just the general paucity of motivation on the part of state legislatures to pass these laws. “They just don’t get around to it,” Stancliff said. “It took West Virginia a couple of tries to get it to actually reach the place where people can vote on it.”
The state Department of Health offers instructional booklets on how to use the injectable and intranasal versions. Intranasal naloxone isn’t yet approved by the FDA, however it can still be legally prescribed by a physician or approved pharmacists. Find a registered Opioid Overdose Prevention Program near you and see where naloxone is available without prescription.
A deadly argument
Criminalizing addiction has failed to prevent opioid abuse. New York hospitals saw nearly 20,000 opioid abuse-related admittances in 2013, costing state Medicare and Medicaid over $130 million.
Critics argue that making naloxone more available will make heroin and painkiller abuse more popular or more attractive by making it less dangerous.
“That’s like saying we shouldn’t have airbags because people might drive faster,” Stancliff says. This cruel argument is similar to those used against other harm reduction programs like clean needle exchanges. To stand against making naloxone available on the basis of misinformed moralizing disregards a growing public health crisis.
To put it simply, a dead person cannot choose to become clean.