United States / Opioid Epidemic

How (Much) to Save a Life? The Costs of Naloxone Access in Maine

Last spring, in a three-part series, Allison Rutz assessed the scope of the opioid crisis in America.  The series also analyzed the long-term policies in place to combat the failure of America’s health system to provide treatment to addicts. While long-term problems and proposed solutions will be critical to addressing the opioid epidemic, there are other policies directly tied to the short-term, immediate treatment of heroin abuse that demand attention. One of them is the availability of the drug Naloxone.

Naloxone, commonly known by its brand name Narcan, is an opioid antagonist. Binding to opioid receptors in the brain, Narcan resuscitates a person suffering from an overdose within one to two minutes. With hardly any side effects, Naloxone is essentially a miracle drug with a clear potential to prevent hundreds of deaths.

In the critical minutes following a heroin overdose, a single dose of Naloxone can be used to save a life. In a state like Maine, where 313 of the 376 drug-induced fatalities in 2016 were caused by opioid overdoses, Naloxone has the power to save hundreds. In places like Quincy, Massachusetts, where Narcan is required to be carried by every police officer, the drug has a ninety-five percent success rate; it is proven to save lives.

However, more recent discussion around Narcan has focused on expanding its availability beyond law enforcement. Simply having police officers carry Narcan is not enough; all too often, the police are never called. Statistically speaking, 911 is the last resort in many overdose cases. The reason for not calling stems from fear of getting charged with possession, or even manslaughter, for providing drugs to the person who overdosed. In cases where 911 is not called immediately, witnesses have been reported to try to revive victims themselves, injecting them with anything from milk to salt, and even cocaine. Meanwhile, Narcan offers other users a safe way to bring their friends back—according to the Centers for Disease Control, in eighty-three percent of cases where Narcan was administered, it was done so by other users at the scene.

For these reasons, lawmakers in Augusta passed an amendment to a bill last June that would allow the drug to be sold over the counter without a prescription. The rules for the amended law, written by the Maine Board of Pharmacy, also ensure training for both pharmacists and customers. Today, their efforts have resulted in a market for the heroine antagonist with stores such as Walgreens and CVS providing over-the-counter options.

Arguably, these actions by lawmakers and private corporations could be seen as the first step in a comprehensive solution to the opioid epidemic. The idea is simple: increased access to Naloxone would lower the overdose death toll, in turn, giving more people a second chance to seek actual treatment for their addiction. Once they get treatment they can eventually lead normal lives. Ideally, over the long term, this would lower the demand for the drug and reduce the amount of people in jail for possession or dealing. Currently, however, there is no conclusive evidence that this will happen; all we can be certain of for now is that Naloxone reverses the effects opioids have on the brain and respiratory system in order to prevent death. The connection between a lower death toll and curbing other problems associated with the epidemic have yet to be observed or studied.

Many do not believe that Narcan should become readily available over the counter as the new law would allow, arguing that Naloxone perpetuates a cycle where users return to heroin after being revived, because they know they will easily be saved. Several politicians hold this view, including Maine Governor Paul LePage who, in a widely criticised move, vetoed the proposed amendment to the bill.

While LePage’s veto was ultimately overturned in the Senate and the House, other drug policies spearheaded by LePage have been successful. They demonstrate the pro-law enforcement politician’s belief that drug addiction is a crime rather than an affliction and his reluctance to treat it as such. Instead, he seems to pay most of his attention to the law enforcement side of the issue.

Last year, LePage passed a bill that added two hundred hospital beds to the Maine Correctional Center for incarcerated addicts, the most ever added for drug treatment. In the same bill, LePage appropriated 1.2 million dollars to fund ten new positions for drug investigators in Maine’s Drug Enforcement Agency, planned an expansion for the correctional facility as a whole, and raised wages for law enforcement officials. In the same year he also took a vocal stance on Naloxone, proposing a bill that would charge Mainers for each dose of Narcan after the first use.

Although in 2014 alone Naloxone saved over eight hundred lives in the state, LePage wants to make it harder for people to get repeated doses. His logic rests on the notion that Naloxone creates “a situation where an addict has a heroin needle in one hand and a shot of naloxone in the other produces a sense of normalcy and security around heroin use that serves only to perpetuate the cycle of addiction.”

LePage’s opinion is an insensitive oversimplification of a complicated issue. Nonetheless, his stance is one shared by many officials from Congress to law enforcement. Their critique of Narcan stems from the belief that it only serves to enable heroin addicts. While Narcan itself does not perpetuate addiction, the side-effects of withdrawal are so insufferable that they lead many to seek heroin as soon as they can after a Narcan injection. At one needle exchange in Ohio, one woman is said to have been revived three times in one day.

While these cases are only anecdotal evidence, this issue of repeated use of Narcan by individuals stands at the core of an ethical dilemma. For some people it seems that second, third, and fourth chances are not enough to get clean. Kelly Bruner, a twenty-year-old woman from Ohio, reports to have been revived from a heroin overdose ten times. In an article published by the Journal of Emergency Medical Services, another woman is reported to have been revived fifteen times with Narcan.

It is these examples that have people like Governor LePage demanding that users pay for each additional dose of Narcan they need after the first. This cost varies depending on the brand of Naloxone and method of injection. While generic Naloxone made by the company Amphastar goes for only sixteen dollars, the brand-name form, depending on the method of injection, can cost a whopping two thousand dollars per dose and prices are only rising.

With such staggering costs for the drug, it is easy to imagine some users may not be able to pay. Paramedics will not just let people who overdose die. Thus, the cost will then fall on law enforcement agencies and ultimately taxpayers. While LePage’s efforts to curb reliance on the drug have failed, there are other people in positions of power whose efforts to limit the use of Narcan because of cost-related reasons have been met with success, including one Ohio sheriff who has banned officers from carrying the drug because “it is sucking the taxpayers dry.”

This hostility toward Narcan demonstrates just one of the many incredible difficulties the opioid epidemic has created for users and the communities that surround them. As tempting as it may be to see Narcan as a solution to America’s overdose problem, it is important to realize that, like many other small issues within the larger crisis, Narcan raises its own set of not only political and economic considerations, but also ethical questions as well.