Sagar Chokshi, MD

More needs to be done to ensure that steps are taken to decrease the risk of opiate-related deaths. Even if a prescription is written, a barrier to receiving this prescription is often cost. In my opinion, naloxone needs to be made available and affordable to any patient who is identified as high risk. A high copay expense or sometimes a total lack of insurance coverage cannot be justified — it is putting a price on a life-saving medication. Thousands of lives have been saved by this medication and it will likely save thousands more in the future.

This administration seems to have identified that rural areas are not receiving as many naloxone prescriptions; however a more detailed study needs to be done. Is it because the medication is not being prescribed? Or is it because it is being prescribed and not filled? Why is the prescription not filled? Is it because patients are not educated well enough about it or is it because of the cost? These are the few things that will help improve availability of the medication and will hopefully decrease the number of opiate overdose deaths. One reason it may not be being prescribed in rural areas may be because of the lack of availability of this medication at pharmacies in these areas. In fact, it is even more vital that the rural areas readily have access to naloxone as these patients are often the furthest away from receiving any care from a first responder who may be carrying naloxone.

William Eggleston, PharmD, DABAT

The findings of this recent study on naloxone prescribing in the United States demonstrate that efforts to increase access to naloxone are moving in the right direction. However, the findings also suggest that a significant number of patients at risk for harm from opioids still do not have access to this life-saving antidote. I agree that pharmacists and other health care professionals must play a key role in efforts to increase naloxone access and improve patient safety. Research has shown that many pharmacies still do not stock naloxone or have it available for patients. As the most accessible health care professionals, pharmacists need to ensure that naloxone is available for their patients, that they are familiar with local resources to assist patients who cannot afford naloxone, and that they work closely with patients at risk for opioid toxicity (patients prescribed an opioid with: a high dose, concomitant benzodiazepines, a history of COPD) to ensure they understand the importance of having naloxone.

Although this study primarily evaluated naloxone access for patients prescribed opioids, it is also important to recognize the need for increased naloxone access among patients with opioid use disorder, who may or may not be prescribed opioids. Often these patients face significant stigma and may be uncomfortable discussing naloxone with health care professionals. We must approach all of our patients with empathy and compassion so that people who need these resources the most don’t think of health care professionals as another barrier to naloxone access. Lastly, I agree with the HHS and Surgeon General that more resources are needed to increase naloxone access, but these efforts need to go beyond pharmacies. As this study notes, rural areas had the lowest naloxone prescribing rates. It can be difficult for patients in rural communities to access their local pharmacy due to limited hours, travel distance, and lack of public transportation. Alternative distribution models, such as using other local resources, retail locations, or online-based programs, are necessary to address the needs of patients in rural communities.

Brad Lander, PhD, LICDC-CS

Many clinicians and patients are aware of how naloxone could curb the opioid epidemic.

But there are many patients who may not be aware of how to get their hands on the antidote, and there are still some clinicians who refuse to prescribe naloxone because they see it as giving patients with opioid use disorder a license to use opioids and fentanyl; therefore, the recent CDC Vital Signs report is very indicative of the current state of naloxone prescribing here in the United States.

Here at The Ohio State University Wexner Medical Center, our entire medical team — physicians, pharmacists, social workers and others — have been thoroughly trained regarding the risks and warning signs of opioid use disorder and opioid overdose, and most of our patients have responded positively. Statewide, we have Project DAWN, which provides participants with a take-home naloxone kit and instructions on how to use it. These are just two examples of how part of CDC’s approach to reverse the trends — (1) health care providers participating in virtual mentoring, academic detailing and other training on naloxone prescribing and dispensing to teach patients about overdose risk and (2) governments expanding naloxone access — can be applied in the real world.

The real challenge will come from another facet of CDC’s approach: health insurers lowering out-of-pocket costs for patients. Many drug companies intentionally raised the price of naloxone as the opioid epidemic grew. One company even raising their price from $600 to $4,000. There must be legislative action taken to prevent drug companies from playing an unfair game of supply and demand with patients’ lives in the future.

Robin A. Pollini, PhD MPH

Last year the U.S. Surgeon General recommended that all persons at risk of opioid overdose and those who care about them get naloxone and know how to use it. Expanding naloxone access is a cornerstone of our efforts to reduce opioid overdose deaths. Given that the majority of these deaths involve illicit opioids like fentanyl and heroin, programs designed to serve people who use illicit opioids (eg, harm reduction programs) should be prioritized for naloxone distribution. However, for people who use prescribed opioids, others likely to respond to overdose, and communities where harm reduction services are limited, pharmacies can play a critical role in improving naloxone access.

The recent Vital Signs report suggests we have a long way to go in achieving broad naloxone coverage. Despite laws in all 50 states allowing nonprescription naloxone dispensing, national recommendations for naloxone co-prescribing, and laws in some states mandating co-prescribing, pharmacy-based naloxone distribution rates remain discouragingly low. Improving these rates will require efforts on both sides of the pharmacy counter.

On the pharmacy side, dispensing nonprescription naloxone is generally not required by law. Pharmacies must therefore voluntarily commit themselves to training staff, stocking naloxone, and integrating mandated naloxone counseling into the pharmacy workflow. Even where this commitment exists, pharmacists cite both time constraints and lack of privacy as challenges to naloxone counseling. In addition, given the stigma surrounding opioid use disorders, many pharmacists express concern that offering naloxone with opioid prescriptions could make patients uncomfortable.

On the patient side, even where naloxone is available, a number of barriers remain. Family members may mistakenly believe that their loved one is not at risk of overdose. Individuals may not know what naloxone is or be aware that it is available without a prescription. Some may feel uncomfortable accessing naloxone due to fear of being stigmatized as a person who uses opioids or cares about someone who does. Cost can be a factor, as naloxone is expensive without insurance and even public and private insurance requires copays that can be unaffordable. Finally, confidentiality is a concern — especially in rural communities where maintaining anonymity is a challenge.

Expanding pharmacy-based naloxone distribution requires more than changing laws to facilitate dispensing. It requires targeted implementation efforts on both sides of the counter to maximize access and increase the ability and willingness of individuals to obtain this lifesaving drug.