A new state law is expanding access to naloxone — an often lifesaving overdose-reversing medication — but raises concerns over local ability to provide it free of charge.
The change in access is part of a new statewide order issued by Dr. Howard Haft, deputy secretary of public health services for the Maryland Department of Health and Mental Hygiene.
The order allows licensed state pharmacists to provide naloxone — also known by the brand name Narcan — to anyone who requests it, replacing a 2015 order that allowed pharmacists to supply the medication to anyone who completed a naloxone training program.
The rationale behind the new order was to make naloxone even more accessible, reducing a barrier that could prevent people from carrying it, said Katie Kuehn, the communications director for the state Opioid Operational Command Center.
“As the [opioid] epidemic has evolved, so has the state’s response,” Kuehn said in an email statement. “The updated order is yet another tool to fight this crisis and to provide immediate assistance to overdose victims.”
But on a local level, increasing ease of access to the medication could also lead to a reduction in funding for the Frederick County Health Department’s naloxone training program, said Dr. Barbara Brookmyer, the county’s health officer.
Under the previous standing order, residents who wanted naloxone could receive training online through the website getnaloxonenow.org or complete a class offered through the Frederick County Health Department. Residents who completed the class also received a free Narcan kit and were instructed to notify the Maryland Poison Center if they administered the medication.
Now that naloxone training is no longer required, Brookmyer worries that residents will be even less likely to notify the Poison Center after Narcan use, reducing the amount of data available to health officials. Not only does that make it harder to analyze naloxone use around the state — including patterns of usage and geographic concentration — but it also makes it more difficult for the Health Department to defend their practice of distributing Narcan kits free of charge.
“I anticipate that making it more widely available generally would make it more difficult for our funders to justify the expense,” Brookmyer said. “I think there will be less funding ... though we’ll do our best to remind people of the resources we do have available.”
The Health Department receives funding through the state to supply Narcan kits, but the grants extend only through June 2018, Brookmyer said. Though the Health Department continues to offer training classes and provide Narcan kits, it’s unclear if the medication will still be available free of charge after that period.
Despite Brookmyer’s concern, data shows that local residents rarely report naloxone use to the Maryland Poison Center. The agency received zero reports from Frederick County in 2015 and only two in 2016. So far, there has been one report of naloxone use from Frederick County in 2017, according to Bruce Anderson, executive director of the center.
A better indication of the county’s current need for naloxone are numbers from public safety agencies. In 2016, Frederick police officers and county sheriff’s officers reversed 78 overdoses using Narcan. Rescue personnel from the county’s Division of Fire and Rescue Services administered 426 doses.
Reducing the stigma
For pharmacies, the new standing order does little to change the status quo, besides affecting how pharmacists interact with customers who request Narcan.
“Now the training component can be a pharmacist taking the time to talk to a customer and explain the risks and how to use it,” said Anne Marie Merritt, director of community outreach and relations for Whitesell Pharmacy in Frederick. “It’s never been an over-the-counter medication, but every pharmacy can request a copy of the new standing order from the state of Maryland to act as the prescription.”
For Merritt, who regularly carries Narcan in her purse, the new standing order was just one way to reduce the stigma surrounding the use of naloxone in the community. She said at least two to three residents come into the pharmacy to request Narcan every month, and she’s noticed an increase as the opioid epidemic continues to affect the county.
“It’s a push to decrease the stigma and get it into the hands of people who need it,” Merritt said. “The easier that it is and the more comfortable it is for people to carry this product, the better.”
Whitesell also has plenty of experience with naloxone in the community. The pharmacy provides Narcan to the Frederick County Sheriff’s Office and the Thurmont Police Department, and previously supplied the Frederick Police Department. The city police developed its own contract with Adapt Pharma, the manufacturer of Narcan, in November 2016.
Narcan isn’t free, but pharmacies do bill insurance companies to cover the cost, Merritt said. With state health insurance, the cost is just a $3 copay. Some private insurance companies cover the entire cost of the drug, though the cost of a box of Narcan — two doses — is $125 without coverage.
“We’ve had a couple of customers whose insurance didn’t cover it, and of course, some people don’t have insurance,” Merritt said. “In those cases, we generally refer people to the Health Department. The bottom line is that we want to see this getting into the community, so if payment is a barrier, there are plenty of options available.”
Both Merritt and Brookmyer also emphasized the importance of Narcan as a means of harm reduction — or mitigating the often deadly impact of overdose and addiction. Though Brookmyer worried that residents may receive less knowledge on how best to handle an overdose without training — including how to safely roll a victim onto their side — improving access to the drug is one way of preventing fatal overdoses, she said.
Keeping opioid users alive also increases their chances of receiving treatment in the future.
“If someone overdoses and it’s not fatal, there’s always a possibility of recovery,” Merritt said. “For those who aren’t necessarily ready to enter that recovery environment, at least they’re staying safe and staying alive.”