The case for expanding access to the anti-overdose drug is gaining steam around the country. Here's how it works, where it’s available and what comes next

The last thing I remember is the sensation of sliding down against a wall. I woke up lying on my back in the emergency room, looking up at the faces of the doctors and nurses surrounding me. They had introduced naloxone into my IV. – Tim, Marin County, California

The death of actor Philip Seymour Hoffman from a heroin overdose in February cast a spotlight on America’s steadily rising overdose rate. Since then, there’s been a lot of reporting on how state governments are trying to address the problem. One popular move: making naloxone, a drug that can reverse opioid overdose, more widely available to the public.

Laws that expand access to naloxone have been passed by 23 states so far, 15 of which did so over the last two years. Seven more states have similar bills under consideration as of April 2014. As naloxone legislation moves from state to state, we take a look at the drug itself to better understand how it works and why it’s up for debate.

Throughout the article, Guardian readers who responded for an earlier feature on heroin addiction recount their own experiences with the anti-overdose drug.

Back from the edge: how naloxone works

We warned her to be careful of doing too much but she shot up anyway. Seconds later she was trembling and unresponsive. I held her up, hit her face, and everyone frantically looked for the [naloxone]. Finally they found it and gave it to her. She came-to. – Elly, Minneapolis, Minnesota

For starters, forget everything Pulp Fiction has taught you about reversing an overdose. A shot of adrenaline to the heart is not the standard treatment.



An overdose means you’ve taken too much of a drug – that much is obvious. In the case of opioid drugs like heroin and many prescription painkillers (Vicodin, Percocet and OxyContin to name a few), taking too much will cause your body basically to forget to breathe. That’s because these drugs depress the central nervous system, so, aside from causing euphoria and dulling pain, they slow down respiration, heart rate and many other critical bodily functions, too. The more of opioid drugs you take, the slower your breathing becomes, until it cuts out altogether. Without prompt medical attention, an overdose can cause brain damage, coma or death.

Naloxone, which is also commonly known by the brand name Narcan, is administered either by injection or nasal spray. It reverses respiratory depression by blocking off the brain’s opiate receptors. Like this:

An overdose occurs when too much of any opiod, like heroin or Oxycontin, fits in too many receptors, slowing and then stopping the breathing. Naloxone knocks the opiods off the receptors for a short time, allowing the person to breathe again. Photograph: courtesy of the Harm Reduction Coalition / Graphics by Maya Doe-Simkins

Naloxone isn’t a permanent fix. It only lasts for 30-90 minutes in the brain. Essentially, it buys an overdosing patient some time, either for first responders to show up with further assistance or for the body to metabolise some of the opioid drugs floating around.



There are few major risks or side effects involved. According to the Harm Reduction Coalition, naloxone is non-addictive and it won’t hurt a non-overdosing patient if mistakenly administered. The drug has been used by emergency rooms staff since the 1970s, but, more recently, advocates have been looking to get naloxone into wider circulation.

The Nalxone debate: who gets to carry it?

I have never had the luxury of being given naloxone when overdosing. During my many overdoses in the years past, friends were intimidated … intimidated that they’d get in trouble for getting a friend help. I am a believer that naloxone can start to help break stereotypes and stigmatism around people who suffer . – Richard, Wyomissing, Pennsylvania

Naloxone is a prescription drug like any other – it’s not a controlled substance. “Anyone who can prescribe drugs – doctors, some nurses, physician’s assistants – can prescribe Naloxone to their own patients,” explains Corey Davis of the Network for Public Health Law. But prescribing Naloxone hasn’t been very common, he says.

Doctors have been hesitant to prescribe the drug because overdoses were long associated with illicit drug use. Many doctors feared they could be prosecuted for abetting criminal activity, says Davis. In any case, direct prescription isn’t necessarily the most useful scenario when it comes to naloxone. The anti-overdose drug isn’t of much use if you’re the one overdosing, since you can’t exactly administer it to yourself.

But what if doctors could be guaranteed immunity for prescribing the drug? And what if you could get naloxone into the hands of bystanders – friends and family of those at risk for overdose – EMTs, and even police? That’s exactly what some states have been trying to do.

In 2001 New Mexico became the first state to pass a law addressing naloxone access. It guaranteed criminal and civil immunity to prescribers of naloxone and allowed for “third-party prescription.” (The third “third party” being a concerned parent, partner, caregiver, or any other person who might administer it in case of overdose.)

Since New Mexico set the precedent, 22 other states have passed legislation addressing naloxone access, though the characteristics of each law vary. This state-by-state adoption has not moved at an even pace, but has picked up significantly over the past two years. Four months into 2014, five states have passed laws expanding naloxone access and seven more are considering similar bills in local legislature.

“The main thing these bills do is expand that circle of people to whom the prescriber can get the drug to,” Davis says. “One way the do that is by allowing for third-party prescription. But the newer laws go even a step further: they also permit doctors (which I’m using as shorthand for anybody who can prescribe) to write non-patient-specific orders – or what are known as ‘standing orders.’”

In this model, a physician could write a “standing order” that gives blanket authorization for trained non-medical personnel – like social workers, harm-reduction center staff and others – to distribute naloxone and train members of the public to use it.

Hover over the map below to see where your state stands (if you’re reading on mobile, access the map via the drop-down menu).

It’s been around for a while, so why is naloxone getting so much attention now?

As more and more state governments embrace naloxone (with the notable exception of Maine, whose governor is poised to veto any naloxone legislation) – you might ask yourself, what caused this recent shift in attitude? Why now?

“The foundation for all this media attention and for [the state and federal government push for naloxone] has really been provided by more than a decade of activism,” says Maya Doe-Simkins, long-time naloxone advocate and manager of the Boston Hope & Recovery Center’s national naloxone program locator. “We were having the same conversations five years ago and today, but the tone is just a little different. Today you have a focus on prescription abuse, you have high-profile fatalities that garner a lot of media attention – you didn’t see this level of attention paid to the issue when Heath Ledger died of an opioid overdose.” But, she says, the main driver of the recent increase in attention around naloxone access is “the numbers”.

“If you look at an epidemiological graph, the number [of opiate-related deaths] just keeps rising. So maybe we’re at some sort of tipping point,” she says.

The latest CDC report on overdose, along with various state data, supports that idea. Drug overdose deaths have risen 102% from 1999 to 2010, according to the CDC, and three-fourths of those deaths can be attributed to prescription opioids. While, more recently, resurgent heroin use has made its mark in municipalities across America.

Heroin and prescription drug use are “absolutely related”, says Doe-Simkins. “Even if we see a drop in prescription opioid abuse, we see an increase in heroin. When your prescription opioid source gets cut off, unless they’re offered accessible, affordable and acceptable treatments, the transition to heroin is very intuitive,” she says.

“To treat these as separate issues is probably a bad idea.”

What’s next for naloxone?

The state-by-state push for naloxone access has gotten a recent boost from the federal government. Earlier this month, attorney general Eric Holder voiced support for all emergency responders to carry the drug, calling the current rate of overdose deaths an “urgent public health crisis”. Just last week, the FDA approved a new auto-injection device for administering the drug.

Both Davis and Doe-Simkins identify a slow but significant change in the way drug use and treatment are talked about at the federal and state levels. “We were sized by this anti-drug frenzy for a while, and I think that in some areas we are seeing a bit of a pullback from this,” says Davis, adding that, in some ways, naloxone is just the easiest piece of the puzzle to address.

“Naloxone is sort of low hanging fruit. It’s a relatively straightforward legal change, it’s relatively uncontroversial, it’s relatively easy to accomplish. Don’t get me wrong, it’s important, but it’s a lot easier [to propose] than some other things that states and the federal government might take on, like reforming drug sentencing,” he says.

But while the dialogue on issues like naloxone access may be shifting, a corresponding shift in funding priorities is lagging. Getting the money to make naloxone distribution programs work on the ground-level is “hugely problematic”, says Doe-Simkins.

“The biggest influencer of existing community-based naloxone distribution and overdose prevention programs is cost. There’s very little support. There are very few if any federal grants. There’s not very much support from the philanthropic community, not very much support from the state level,” she says.

“There’s lots of excitement about the possibilities, but the work to operationalize from the legislation is daunting … especially, when there’s no budget.”

Having federal and state governments acknowledge the overdose problem and look for public health-based solutions, like expanded naloxone access, is “the first step in the right direction” for advocates, but it won’t mean much for the people most affected unless money can be found to back naloxone access and doctors can be convinced to write more prescriptions.

This story was amended on April 30, 2014, to update the number of states that have passed naloxone access laws to date.