Naloxone, also known as Narcan, may not be needed at every street corner, but how about every city bus stop?
Lt. Zakariya Reed, EMS bureau supervisor for the Toledo Fire & Rescue Department, is all in when it comes to helping drug users recover from an opiate overdose, especially when products as ubiquitous as marijuana may be laced with fentanyl, unbeknownst to those who are aficionados of Mary Jane.
One result of Lieutenant Reed’s initiatives is that emergency personnel with the Toledo Fire & Rescue Department may offer naloxone kits for free, along with information on recovery services, whenever called to a home with an overdose situation.
Now, pharmacies, such as CVS, Walgreens, Rite Aid, Walmart and Kroger, are offering kits, with two 4-milligram doses, for about $45 over the counter. The move follows approval in March of 2023 by the U.S. Food & Drug Administration, when it also acknowledged in a news release that drug overdose continues to persist as a major public health issue, with more than 101,750 reported fatal overdoses occurring in the 12-month period ending in October of 2022.
"We are really glad to see the over-the-counter approval of Narcan," said Joseph Wood, integrated naloxone coordinator for the Toledo-Lucas County Health Department.
He said that such distribution is important to communities that are not able to easily access naloxone. However, Lucas County and the Ohio Department of Health, which administers Project DAWN (Deaths Avoided With Naloxone), a network of distribution programs, have dedicated a lot of resources to combating the opioid epidemic.
Local experts agree use of Narcan, one of a number of marketed naloxone products, is an effective method for reducing opioid overdose deaths. However, the cost of a two-dose kit places it out of reach by about 20 percent of uninsured adults who might need it, according to a study published by RAND, a nonprofit and nonpartisan organization focusing on research and analysis.
“Increasing access to naloxone at both the individual as well as the community level continues to be a critical factor in reducing opioid overdose deaths,” Lauren Maziarz, an associate professor in the Department of Public and Allied Health at Bowling Green State University, said. “Of course, cost is an issue when it comes to over-the-counter availability.”
Or it may not be.
The Toledo-Lucas County Health Department offers naloxone kits for free. Residents from 16 northwest Ohio counties can ask for a kit to be mailed to them.
In 2022, the Toledo-Lucas County Health Department distributed 10,187 naloxone kits and trained 3,829 community members to use them, according to Mr. Wood, who noted that the department recorded 712 successful overdose reversals as a result of that distribution.
In 2023, 15,505 kits were distributed and 4,584 community members trained to use them, he said, adding that the department recorded 1,231 successful overdose reversals that year.
That data does not include kits given to community members by local police and fire departments.
“I'd seriously encourage everyone to have naloxone on hand,” Mrs. Maziarz said.
New approach
Increased availability of naloxone followed a 2018 advisory by the U.S. Surgeon General urging that expanding the awareness and availability of naloxone was key to any public health response to the opioid epidemic.
However, it was the pandemic, when city and county offices were shut down, that catapulted Lieutenant Reed into action. Services, including community access to naloxone, were severely curtailed or non-existent, so the Leave It Behind program was started to give EMS personnel the option to offer free kits of naloxone after responding to an overdose call.
“In 2020, we had an unreal number of overdoses and overdose deaths. Since then, our numbers have stabilized,” Lieutenant Reed said.
To date, 800 kits have been delivered by the fire department and Lieutenant Reed says there is documented evidence that at least 80 have been put to use in saving lives by the general public.
“It is a lifeline,” Lieutenant Reed said. “But you are not going to end an addiction by having naloxone in the home.”
However, each dose of naloxone administered buys someone a bit more time.
“Harm reduction interventions, like naloxone, are effective at reducing overdose deaths, are cost-effective, and can be an important strategy for keeping people alive long enough to seek treatment when they are ready,” Mrs. Maziarz said.
Narcan nasal spray was first approved by the FDA in 2015 as a prescription drug. The application to approve Narcan nasal spray for use over the counter was granted priority status by the FDA, and an advisory committee voted unanimously to recommend it be approved for marketing without a prescription in February of 2023. In July of 2023, the FDA approved RiVive, a second naloxone nasal spray, to be sold over the counter as well.
Walgreens, which launched its over-the-counter availability in September, has partnered with End Overdose, a nonprofit organization, in its efforts to educate the public on how to use the nasal spray.
“This community-first effort with Walgreens will hopefully empower everyone to feel comfortable carrying and administering naloxone nasal spray,” said Theo Krzywicki, CEO and founder of End Overdose. “Just as you might carry other first aid items, this can and should be something that is accessible to all.”
Kamara Turner, a senior specialist in retail communications for Walgreens, said naloxone is located at the front register and pharmacy counter.
“The intent is to make this life-saving drug easily accessible for customers,” she said. "For those purchasing from the pharmacy counter, this helps facilitate conversation between Walgreens’ pharmacists and customers, allowing them to address questions in real time around the new product.”
A fentanyl surprise
In some cases, drug users' marijuana or cocaine is laced with fentanyl, which has become increasingly stronger than even five years ago, according to Lieutenant Reed.
“There is so much fentanyl and it is easy to get,” he said. “A lot of times they don't know they're taking fentanyl. They think they are smoking pot or on cocaine and it is laced with fentanyl. They are not prepared for that.”
The nasal spray and the inoculation are both effective and safe, according to Lieutenant Reed. EMS personnel administer it in 2 milligram doses, while general kits provide 4 milligram doses. In extreme cases, 12 doses or more may be required to revive someone, but usually it takes no more than one or two.
The nasal spray is a fast-acting, fine mist. It is absorbed in the nasal cavity, where there are many capillaries, and moves into the bloodstream very quickly. The overdosed person does not have to be breathing for it to work.
The mechanics work similar to a wooden cup with stringed ball game, popularized in the 1800s, which challenged children to catch the roped ball with the cup. If the cup represents nerve receptors, then the ball is the opiates, which fit into the receptors. When naloxone is introduced, it fills the receptor cups and the opiates no longer have a place to go and aimlessly bounce around until they wear off. It takes two to three minutes to take effect.
“Naloxone is not cheap. It is an expense,” said Lieutenant Reed, noting that opiates can cause so much relaxation that the body forgets to breathe. “You can only go so long without breathing without going into cardiac arrest.”
If death does not occur, brain damage can and a person might have to rely upon costly long-term care, if incapacitated, he said.
Regardless, a patient who has received naloxone will likely see a bit of a blood pressure drop and feel nauseous or may vomit.
Lieutenant Reed assures that patients are going to feel lousy immediately afterward, but they will be alive no matter where they are – perhaps even a local bus stop.
First Published February 4, 2024, 5:00 a.m.
