We Don't 'Do' Narcan Here

When lawmakers in California were looking for solutions to the growing number of prescription painkiller overdoses, broadening access to the antidote, naloxone hydrochloride (Narcan, Evzio, and others), seemed like the obvious answer. Treat naloxone as an over-the-counter drug, activists claimed, and it would become as commonplace in medicine cabinets as cold medicine.

In January 2015, California pharmacy law did change. The state assembly passed AB 1535 and naloxone hydrochloride was given the same special legal status as the flu shot or emergency contraception. This change enabled pharmacists to dispense naloxone widely – not only to those at risk of an overdose, but to their family, their friends, and to anyone who might be at the scene when somebody overdoses on painkillers.

Expanding access and enlisting pharmacists to help made sense considering studies finding prescription opioids — not heroin — as a culprit in most overdoses and conclusive evidence showing naloxone is effective and safe. However, two years later, many pharmacies refuse to face the problem that they had a hand in causing. I spent months researching the consequences of AB 1535, during which I encountered a baffling trend: at the large chain pharmacies, the pharmacists refused to take seriously the law meant to expand access to naloxone. In those major drug stores, it is simply not available.

To me, this refusal is not some abstract problem. Ten years ago, while struggling to overcome my addiction to prescription painkillers, I unintentionally overdosed while in the company of two friends. The OD left me prostrate and comatose, slowing my breathing reflex until my skin started to turn blue. One of the friends called 911, and one of the responding paramedics injected me with Narcan and adrenaline. Administered intravenously, naloxone sobers you up just as quickly as an opioid would get you high.

I “came to" lucid and shivering as they strapped me onto a stretcher. After I arrived at the hospital, I experienced the antidote's single drawback: its effects, while powerful, are short-lived. Less than an hour after the paramedics revived me, I experienced the unique terror of "air hunger"; the residual opioids in my bloodstream, no longer displaced by the naloxone, were causing respiratory depression all over again. I gasped for air but couldn’t catch my breath. Panicked, I yelled to the nurses for more naloxone. I am alive today because of Narcan and because my two friends risked arrest* to called 911 instead of panicking and leaving me to die.

I encountered Narcan again in my twenties as an anthropology student in the liberal northern California city of Santa Cruz, which ran one the country’s first pilot programs to make naloxone available outside of hospitals and first responders. The program, associated with a long-running needle exchange, empowered a doctor to prescribe a kit containing a 10 ml ampule of naloxone to anyone who took a 30-minute training course detailing how to use the medication safely. I attended the training to write about it for my medical anthropology class, and I kept the vial with me for several years, not expecting to use it. In fact, if I had used it to revive someone, I could have been prosecuted for the act, since technically the medicine was in my name.

Five years later, when a panicked roommate barged into my room to tell me his girlfriend had stopped breathing, I was prepared. I grabbed the ampule of naloxone and made him empty a heroin-filled syringe to inject the opioid antagonist into the muscle of her arm. Although she was not heavy, we struggled to steady her dead weight and took turns straining to count her respirations. Neither of us could hear her breathing. I injected the naloxone and we took turns administering rescue breathing as the heroin in her bloodstream was slowly rendered inert. It was the second time in my life that I had witnessed naloxone bring someone back from the brink.

In January 2016, a year after the law was passed, I focused my research on AB 1535. With my firsthand appreciation of the antidote and the historical importance of the new attitude toward naloxone, I was eager to document the positive impact the drug was making in my community.

I learned that pharmacists could dispense naloxone hydrochloride to anyone who asks. A prescription from a physician is no longer necessary, provided the dispensing pharmacist: completes an hour of professional training; agrees to train the recipient in the antidote's use; briefly mentions drug treatment options offered in the community; and notifies the recipient’s primary care physician.

The media departments of large pharmacy chains issued enthusiastic PR releases, pledging to make Narcan easy to get for those who needed it. They would not have to look far; it’s no secret that these pharmacies supply the medications used in most overdoses, and they fill the prescriptions that start many more Californians (either directly or through diversion of the drugs) on the road to dependence.

To learn about the law, I started looking for naloxone, and I documented my visits to a broad cross-sample representative of every chain pharmacy in two California counties.

I discovered that I would not be able to write that positive article I had envisioned. The results of my fieldwork baffled me: the new law had made virtually no meaningful difference. Even now, at the time of this article's publication, a Californian will, more likely than not, struggle or fail to find naloxone.

When the pharmacy technician at the first location I surveyed admitted she had never heard of naloxone hydrochloride, the new law, or the press campaign, I shrugged it off as an anomaly. I waited for the pharmacist, only to learn that she was only vaguely aware of the change in the law.

Furthermore, although thousands of doses of potent painkillers waited in drug lockers to be dispensed, she told me that naloxone was not even among the medications commonly ordered. She offered to talk to her boss and call me back, so I left my number and left the pharmacy empty-handed. This was not a tiny pharmacy in an isolated town; I was within five miles of one of the best known medical teaching universities on the West Coast. There were two overdose deaths in the county that day; what if one had tried but failed to get Narcan?

My fieldwork continued throughout 2016. Pharmacy staff met my respectful requests for Narcan with puzzlement or annoyance. Still worse, more than half the pharmacists reported never dispensing the medication or receiving the requisite training. They had no naloxone hydrochloride in stock and, absurdly, had no plans to order any. One pharmacist scoffed, "We don't 'do' Narcan here."

Frequently I was directed to try my luck at a competing pharmacy nearby, only to be directed back to the original store. The first outcome from my research was my new ability to conceal rising anger. The second is the observation that every major retail pharmacy chain operating displayed implacable disinterest in supplying this essential medication to the communities from which they profit through massive sales of prescription opioids.

Compounding the problem is the rapid escalation of the price of Narcan, while insurers refuse to pay for it. At the time of publication, the least expensive naloxone hydrochloride product costs about $50, even though I found the drug for half that price not twelve months ago. One pharmacy had the kit priced at $380 on December 8th of this year.

The law makes it very clear that pharmacists must complete 60 minutes of training before they can prescribe naloxone hydrochloride. Coordinating special training might not be straightforward, but it isn’t without precedent. In 2009, two major chain pharmacies lobbied the California State Assembly to change pharmacy law to give pharmacists the ability to administer flu shots. Their efforts were successful. Anyone can walk into one of those stores and get the shot.

I don’t know what needs to happen within a company for it to begin the wide-scale dispensing of a drug like naloxone, but we can look to the immunization programs to identify what elements encourage companies to move quickly. I have a source within one profitable corporation who told me about the tremendous pressure exerted by managers on pharmacists to exceed flu shot targets to increase revenues. No such pressure exists for naloxone hydrochloride. Another difference between these two items is how they are ultimately paid for: a dose of the flu vaccine costs about the same as a dose of naloxone, but private healthcare insurers along with Medi-Cal and Medicare (among the state’s largest healthcare insurers) cover the full cost of immunizations. If a connection exists and these companies are motivated solely by profit, then Californians will continue to leave with painkillers to misuse in one hand, but nothing to undo the imminent overdose in the other.

*Progressive attitudes and the Good Samaritan laws that embody them were not prevalent at the time, and all three of us were cited and had to appear later in criminal court.