Harm Reduction programs distribute one million doses of naloxone in 2019
by Eliza Wheeler and Maya Doe-Simkins
2019 marks the close of a decade of unimaginable loss to our communities. Likely an underestimate, we lost half a million of our friends in these last ten years to the War on Drugs-fueled overdose crisis. With deep reverence for this painful truth, we want to take a moment to uplift and reflect upon the power of one small group of Harm Reduction programs who were responsible for distributing an enormous portion of the nation’s naloxone directly to people who use drugs and those who love them this past year.
For the first time, the OSNN Naloxone Buyer’s Club, comprised of 110 Harm Reduction programs in 39 US states and DC, surpassed one million doses of injectable naloxone purchased for distribution in 2019.
1,012,700 doses to be exact.
Our hope with this piece is to celebrate the largely unrecognized work of the Harm Reduction programs who shoulder the lion’s share of naloxone distribution to people who use drugs in the US. This is also a call to action to locate the distribution of this powerful medicine back into its radical social justice framework. Distributing naloxone was originally an act of liberating a material resource crucial to survival from the control of the health care and criminal justice systems and putting it into the hands of people who use drugs. Despite recent developments where naloxone has been largely re-located back into these systems, there are still hundreds of programs that continue to operate from this ethos. In the years to come, our hope is for more attention and resources to be directed towards the programs that are working to embody the radical practice of naloxone distribution.
History of naloxone access in the US:
Naloxone hydrochloride was approved in 1971 by the FDA to treat opioid toxicity (“overdose”) by blocking the effects of opioids in the brain, restoring respiratory functioning and “reversing” an overdose. For twenty-five years, it was used exclusively by emergency medical personnel and in hospital settings to reverse the effects of opioid-related overdose and to manage opioid-involved anesthesia. Over the years there were whispers of the diversion of naloxone to people who use drugs for the treatment of overdoses among their peers, sometimes moved off of ambulances quietly by sympathetic EMTs and paramedics who recognized that people who use drugs were witnessing the majority of overdoses, and that naloxone was extremely easy to use.
In 1996, 25 years after the approval of naloxone, the Chicago Recovery Alliance (CRA) lost a co-founder and beloved colleague to overdose and decided something more needed to be done. Under the leadership of Dan Bigg, co-founder and director of CRA, and Dr. Sarz Maxwell, they made the decision to start distributing naloxone to the people who used syringe exchange services. For CRA, this act was based on the recognition of several important concepts:
· people who use drugs are the primary witnesses to overdoses
· people who use drugs have many legitimate reasons to not engage EMS/911 and in fact did so very infrequently
· people who use drugs already employed a whole array of creative methods of reviving their peers that had been passed down through many generations via word of mouth
· there was an easy to use, very safe, and extremely inexpensive “pure antidote” to an opioid overdose
CRA worked with Dr. Maxwell to order a supply of the drug and began giving it out. Sure enough, almost immediately, people returned to say that they had used the naloxone to revive a friend, peer, partner, stranger, roommate, neighbor, family member — and the first coordinated naloxone distribution program was born.
CRA’s actions pre-date any naloxone access laws, any endorsement or political support, or funding from the public health establishment. Buttressed by an ethical imperative, they operated without any litigious concern for liability. It was an act of defiance to liberate naloxone from its historical medical placement, a power shift, and an embodiment of the belief that people who use drugs have the right to their own life and survival.
As we look back on the history of Harm Reduction in the United States and internationally, this was a pivotal moment in the development of an intervention that has changed the way we think about overdose. This revolutionary act by CRA has sparked a movement that is now more than two decades old, one that has increasingly been absorbed into mainstream public health, health care and even the criminal justice system — from the Surgeon General’s announcement, to SAMHSA including naloxone distribution as an approved intervention, to law enforcement carrying it in departments across the country, to pharmaceutical companies vying for market share for their naloxone products.
We now have many years of public health evidence that distributing naloxone to people who use drugs results in reversals — that if you give naloxone to the people who witness overdoses, they use it and people survive. But we also have evidence of a different, more meaningful kind — that at the hundreds of Harm Reduction programs across the country distributing the vast majority of naloxone to people who use drugs in the US — radical, unconditional love is practiced every day, and power is being built up among people to take control of their own lives.
State of naloxone access at the close of the decade:
On April 5, 2018, the US Surgeon General Jerome Adams made a widely publicized statement on naloxone (emphasis ours):
In most states, people who are or who know someone at risk for opioid overdose can go to a pharmacy or community-based program, to get trained on naloxone administration, and receive naloxone by “standing order,” i.e., without a patient-specific prescription. Naloxone is increasingly being used by police officers, emergency medical technicians, and non-emergency first responders to reverse opioid overdoses. There are two FDA-approved naloxone products for community use that are available by prescription, but too few community members are aware of the important role they can play to save lives.
Dr. Adams’ statement was celebrated as an emphatic endorsement of naloxone as an important tool in preventing overdose death. However, it contains several misleading statements that can serve as a case-study of how the medical, public health and criminal justice systems have changed the narrative about naloxone.
First, it gives the impression that there is substantial infrastructure for access to naloxone via pharmacies or community-based programs in this country.
There are still significant barriers for community-based naloxone distribution. According to a recent paper published on the gaps to implementing community-based naloxone distribution, only 8% of all US counties had community-based naloxone programs and 13% of counties with the highest overdose mortality rates had these programs. What’s more, several states’ largest volume naloxone distribution programs do so without any state, federal, or local funding support, highlighting concerns for the sustainability of some of the most important sources of community-based naloxone.
There are also considerable barriers to prescription and pharmacy naloxone access. For example, in one study of patients given a prescription for naloxone in an emergency department, less than 20% of the cohort actually visited a pharmacy and obtained the naloxone. A slightly higher proportion of primary care patients receiving a naloxone co-prescription filled their prescription in a North Carolina study. People in need of naloxone continue to face stigma and concerns about being publicly identified in pharmacy settings. There is no uniform education of pharmacists and many continue to have difficulty providing low barrier access to customers who need naloxone. Co-pays and other insurance barriers are myriad.
Second, the statement mentions “police officers, emergency medical technicians, and non-emergency first responders”, yet fails to directly mention the tens of thousands of overdoses that are reversed by people who use drugs and their community every day in the US using naloxone provided free of charge through Harm Reduction programs. Indeed, approximately 90% of naloxone utilizations in the community are by people who use drugs.
Finally, it states that there are “two FDA-approved naloxone products for community use” — a misleading statement referring to two branded products, Evzio® and Narcan® — while the majority of naloxone distributed in the community is still generic injectable naloxone (vial and syringe), a product that has been FDA approved since 1971. The FDA released a clarifying statement including generic injectable as an acceptable product for community use, but it was less widely circulated than the Surgeon General’s statement.
It is important to identify this type of misleading messages because of the ways that they contribute to the dangerous diversion of resources away from the most effective life-saving models for community-based naloxone distribution, based on years of evidence: ample naloxone distribution targeted directly to people who use drugs.
With the influx of federal dollars to states to address the “opioid epidemic,” (a term to which we object, for one of several great discussions about why, check out Carl Hart’s Vice piece here) we have more state health departments using federal dollars to purchase naloxone. However, with only a handful of exceptions, these dollars have been used to purchase Narcan® Nasal Spray, which can be purchased by states for the community price of $75 per two-dose box. The company that manufactures Narcan®, Adapt/Emergent BioSolutions, has established relationships with the state government agencies who are responsible for the administration of funds, and have positioned their product as the only viable and acceptable naloxone product for community use. They have contributed to the erroneous narrative that (vastly more affordable) injectable naloxone is inappropriate, dangerous and an undesirable option for community use (see NIDA’s page on naloxone for an example of multiple incorrect statements).
What we know to be true, however, is that community-based programs distributed over a million doses of injectable naloxone just this year, to the very population most likely to use it and have been doing so for nearly 25 years.
In many states, Harm Reduction programs (including organizations led by people who use drugs, syringe services programs (SSPs) and other programs distributing naloxone directly to people who use drugs) have been excluded from accessing these federal funds or the supplies of naloxone. Community-based programs receive regular reports of naloxone kits purchased with this first wave of funding sitting on shelves expiring, in many cases having been distributed to agencies and community members unlikely to have the opportunity to use them.
Moving forward into 2020 and beyond, it is critical that we learn from these mistakes and make certain that funding and naloxone product is channeled into the hands of organizations and individuals who are using naloxone to save lives daily.
Towards a sustainable, affordable source of naloxone for Harm Reduction programs: the role of the OSNN Naloxone Buyer’s Club
Despite the challenges facing Harm Reduction programs, they have collectively purchased and distributed over one million doses of injectable naloxone to people who use drugs and their friends, family and communities in 2019 through the OSNN Naloxone Buyer’s Club.
The Opioid Safety and Naloxone Network (OSNN) was formed to address issues related to naloxone access in the United States following the Summit on Opioid Overdose organized by Temple University School of Law in 2008. OSNN now has nearly 800 hundred members, including legal and policy experts, representatives from naloxone distribution programs, advocates, public health officials, researchers, medical professionals, and others involved in varying aspects of expanding access to naloxone. OSNN is an association of programs and individuals that are working to expand access to naloxone who provide inter-organizational mutual aid and technical assistance to each other. It is an unincorporated entity that receives no funding to support its activities.
In 2012, OSNN members — led by Dan Bigg-– negotiated with a major manufacturer of naloxone to allow expanded access to affordable product for Harm Reduction programs, and the OSNN Naloxone Buyer’s Club was born. The Buyer’s Club is now comprised of 110 programs in the US who are distributing generic injectable naloxone directly to people who use drugs in 39 states and the District of Columbia. Dan Bigg passed away on August 21, 2018 and the work of the Buyer’s Club continues in his name and memory.
The OSNN Naloxone Buyer’s Club is the only mechanism for purchasing affordable injectable naloxone in the US. The aim of the Buyer’s Club is to provide Harm Reduction programs with a sustainable, affordable option for scaling up distribution to people who use drugs with the goal of community saturation. With the one million doses that have gone out the doors of Harm Reduction programs in 2019, we are a little closer to that goal.
The programs that make up the OSNN Naloxone Buyer’s Club vary in size and scope. There are large-sized programs like the Chicago Recovery Alliance, Sonoran Prevention Works in Arizona, and the DOPE Project in San Francisco, who maximize the impact of their funding by purchasing the least expensive form of naloxone in order to distribute in the tens of thousands of doses to their communities. There are also many smaller programs who do not receive any resources (or insufficient resources to meet the need in their communities) from their state funding streams and rely on fundraisers, crowdsourcing, selling merchandise or receiving foundation grants to support their naloxone distribution, like the indomitable folks at Quad Cities Harm Reduction in Iowa, Trystereo in New Orleans, or the Central Arkansas Harm Reduction Project. OSNN Naloxone Buyer’s Club programs are located in rural and urban areas, some are covering one city or region, others are providing distribution services for their whole state. What unites them is their prioritization of people who use drugs as the primary focus of naloxone distribution efforts.
At the close of this decade when so many of us have lost friends, colleagues, beloveds, and community members, it is crucial that we uplift the work of under-recognized and often under-resourced Harm Reduction programs who are doing the hard work. You distribute massive amounts of naloxone, often on shoestring budgets. You have succeeded for the first time in getting one million doses of injectable naloxone into the hands of the people who need it most this year. Your work may feel invisiblized and marginalized, just as people who use drugs are invisiblized and marginalized, but we see you. Thank you for your tireless, life-saving, radical, unconditional love.
If you are a non-profit Harm Reduction program distributing naloxone directly to people who use drugs and are interested in joining the OSNN Naloxone Buyer’s Club, please contact Maya Doe Simkins or Eliza Wheeler.