A few months ago, my wife, who is pregnant, was told by her pharmacist that her prenatal vitamins were no longer covered by her insurance. She would now have to pay $150 out of pocket for a month’s supply. When I called our insurance company to inquire, I was informed that because the medication was available over the counter, it would no longer be covered.
At the end of March, the Food and Drug Administration made naloxone, the medication that reverses opioid-related overdoses, over the counter. This is a significant step toward making naloxone more widely accessible in our communities.
Just as EpiPens save the lives of people with severe allergic reactions, naloxone saves the lives of people who overdose on opioids. The magic of watching someone who is unconscious, not breathing and on death’s doorstep wake up and start talking, will never get old.
As fentanyl increasingly dominates the Chicago opioid supply, using opioids is riskier than ever, even for those who have been doing it for decades. Naloxone is used frequently by paramedics, emergency doctors, and other medical providers. But it has also been shown to be safe and effective at saving lives in the hands of lay persons. In 2018, then-Surgeon General Jerome Adams issued an advisory notice encouraging its use and availability. Making naloxone available in the homes, cars, purses and backpacks of as many people as possible will help us save lives. It should be found in public spaces anywhere you see an AED.
Out-of-pocket cost: $50?
But what does last month’s landmark step by the FDA really mean for people whose lives are in the balance? Will insurance companies who currently cover naloxone, including Illinois Medicare and Medicaid, start charging consumers huge prices like they did for my wife’s prenatal vitamins? Or will they make an exception for this critical medication given its role in the current public health crisis?
Emergent, the company that makes Narcan, which is the version of naloxone that will be supplied over-the-counter, released a statement last week acknowledging the importance of affordability and suggesting the out-of-pocket price for retailers would be in the range of $50.
The ultimate retailer price will be determined by individual retailers. Many people who use opioids may not be able to afford much, if any out of pocket payment. For comparison, some Canadian provinces offer naloxone for free without a prescription.
Will pharmacies consistently stock naloxone as they do other OTC medications? In a recent study that is under review, we found that of all the pharmacies in Illinois that had gone through the trouble of formally registering to distribute naloxone under the Illinois Naloxone Standing Order, just over half of them actually had naloxone available for patients without a prescription. Is this poor availability driven by stigmatizing attitudes toward people who use drugs? Or perhaps the customer demand isn’t there to incentivize pharmacies to stock naloxone regularly. These questions remain unanswered.
Continue the advocacy work
But most importantly, we need to consider the needs and preferences of those at highest risk — people who use drugs. Do they want to walk into their local pharmacy to pick up naloxone? Is that a safe space for them to risk revealing their drug use to staff or other customers? Or would they prefer to get naloxone and other harm reduction supplies from places like syringe service programs, emergency departments, or addiction providers?
For decades, the Chicago Recovery Alliance, a harm reduction non-profit, has been distributing naloxone, supplying clean syringes, testing drugs for dangerous substances like fentanyl or xylazine, providing education on safe drug use, and generally offering a supportive and non-judgmental space to people who use drugs. They use mobile vans and outreach workers to offer services in the areas that are most at risk. They employ staff that are specially trained to engage with people who use drugs, many of them with lived experience that informs their ability to provide compassionate care.
Naloxone becoming available over-the-counter can be celebrated as a step toward a more comprehensive approach toward the treatment of opioid use disorder. But we must monitor how it affects access for those who are most in need, and continue to advocate for widespread availability of free naloxone, particularly in spaces that feel safe for our neighbors who are most vulnerable.
P. Quincy Moore, MD, is an assistant professor of emergency medicine at the University of Chicago. He is dual-board certified in emergency medicine and addiction medicine and has published studies on opioid use disorder and naloxone.
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