Last month, drugstores 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 opioid-related overdose deaths in the United States — nearly 83,000 in 2022, according to the Centers for Disease Control and Prevention’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.
And, ultimately, prevent more fatal overdoses.
But it’s unclear whether the move will actually expand access to Narcan. Experts worry that its unpredictable 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 to have it at the ready when an overdose occurs.
“It’s not by any means a game changer,” said Shoshana Aronowitz, a family nurse practitioner and assistant professor at the University of Pennsylvania’s School of Nursing in Philadelphia. “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.”
“We should not be under any illusion that this is going to meaningfully change things for a lot of people,” she said. “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.”
The FDA approved over-the-counter marketing and sales of Narcan in March. Manufactured by Emergent BioSolutions, it started arriving in stores in early September, with a suggested retail price of $44.99 for a two-dose package with a three-year shelf life.
Enduring Barriers to Access
As an over-the-counter product, Narcan ideally would 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 said. “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, said 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 said. “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.”
Another potential barrier is related to affordability. Despite the suggested price of $44.99 for a two-dose pack, nothing is stopping individual pharmacies and other retailers from charging more. At least one drugstore in Philadelphia was selling it from behind the pharmacy counter for $72 a 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 said.
That’s especially true for people with low incomes who are facing other daily financial challenges, Aronowitz said. 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 said. “You think you’ll probably need naloxone, but it’s not a guarantee that you’ll need today, so why spend the money?”
Generic brands of naloxone are also available at most pharmacy stores, but consumers need a prescription from a medical professional.
Most states have also adopted some kind of standing order, which authorizes pharmacists to dispense naloxone immediately to someone even without an individual prescription.
For some consumers, purchasing naloxone via prescription could remain cheaper than buying it over the counter. Many private health insurers — and public programs like Medicaid and Medicare — cover the cost of these prescription sales.
State officials in Pennsylvania, New Jersey, and Delaware confirmed to NPR and KFF Health News that their Medicaid programs, which offer health insurance to people with low incomes, will cover the cost of the new Narcan spray if a pharmacist puts the order through as a prescription.
In California, a bill is headed to Democratic Gov. 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 would allow insurance plans to charge a maximum copay of $10 per package, and it would sunset in five years.
Aronowitz predicted that if cost deters people from buying over-the-counter Narcan, it will fall upon nonprofit organizations and so-called harm reduction programs, which already distribute naloxone for free, to continue efforts to distribute it to a larger population of people.
Health Departments Try to Do More
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 748% in four years, according to the county Department of Public Health.
In 2016, 25 Latino residents died of fentanyl overdoses. By 2021, 551 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 report 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.
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 painkillers. [I tell them] ‘a lot of them have fentanyl in the medications’ and you’ll see their wide-open eyes, like ‘Whoa, 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, has 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 said. “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.’”
A Captive Audience
The main room of the Mexican consulate in L.A. feels like the lobby of a department of motor vehicles, 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.
Hernandez walked in front of the assembled group, 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 said.
She told the captive audience they’ll learn how to save someone from dying of an opioid overdose.
Hernandez told 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, she said.
It’s not always clear if someone is experiencing an overdose, but Hernandez told 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 said. “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 comparing a three-month period in 2019 to the last quarter of 2021, and the percentage more than tripled in Western states, according to a new report from the CDC.
The report found those who died from overdoses with evidence of counterfeit pill use, compared with those without it, were more often younger, Hispanic, and had misused prescription drugs in the past.
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 said in Spanish. “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 during 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,” said Luis Armas Ramirez, who was part of the group at the Mexican consulate in L.A.
“Latinos, we don’t really take it seriously like that, especially because it’s something very private,” he said.
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 said.
Hernandez gave three demonstrations at the Mexican consulate and gave out a total of 45 boxes of Narcan. The next 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.
Gillian Moran-Pérez contributed Spanish translation assistance to this report.