In November 2014, Pennsylvania’s Act 139 went into effect. Designed to prevent overdose deaths, it focused primarily on increasing access to naloxone, a medication that reverses overdose caused by prescription opioid pain relievers and heroin. In simple terms, Act 139 does three things:
Allows first responders (not just paramedics) to carry naloxone
Allows naloxone to be prescribed to family members and friends, instead of only the opioid user herself
Provides a certain amount of immunity to anyone who calls 9-1-1 in case of an overdose (this is also known as a Good Samaritan law)
Increasing access to naloxone and implementing Good Samaritan laws are two evidence-based overdose prevention strategies. In 2013, Pennsylvania scored 4 out of a possible 10 points for the use of effective strategies to curb opioid overdoses, putting us in the bottom 20% of all states. So the passage of Act 139 was major progress.
In 2013, Pennsylvania scored 4 out of a possible ten points for the use of effective strategies to curb opioid overdoses, putting us in the bottom 20% of all states.
Standing orders have also changed naloxone access. Two physician/policymakers–Pennsylvania’s physician general, Rachel Levine, and the Allegheny County Health Department Director, Karen Hacker–have issued standing orders that allow Pennsylvania pharmacies to dispense naloxone without a prescription. Other municipalities and states (such as Massachusetts) have found standing orders an effective way to widen naloxone access.
In the old days in Pennsylvania, you had to have a prescription from a physician and you had to be the opiate user yourself to get that prescription. Now anyone is entitled to naloxone and they aren’t even required to have a prescription.
To my imagination, these two policy changes should have radically changed the situation in Pennsylvania. All municipal and state police, firefighters, and EMTs should be equipped with naloxone. Regular citizens should carry intranasal naloxone along with their cell phones. Pharmacists should hand it out with every opioid prescription. Why not? It’s harmless, non-addictive, saves lives, and research tells us it doesn’t increase substance use or high-risk behavior.
But the devil is always in the details, more so in this case than I could have imagined. That was my primary takeaway from the 2015 Allegheny County Overdose Prevention Coalition conference in July: recent policy changes have opened up certain possibilities, but that’s a far cry from making them happen. You’ve really got to appreciate the folks who are hacking around in the weeds on this issue. Think crabgrass, think morning glory.
For First Responders: You’ve Got to Secure Buy-in
Despite their now being permitted to, most police officers in Pennsylvania are not carrying naloxone.
“You can’t force an optional program.”
Just last month, the Center for Rural Pennsylvania published a survey of municipal police departments showing that although 84% of police departments have responded to an overdose call in the last year, 82% of police departments are not currently carrying naloxone. What’s more, 70% of the time, police are the first on the scene of an overdose before EMTs or fire departments.
Why not? Most responded that they rely on other emergency responders (73%) or that the cost of naloxone was a barrier (51%).
In short: just because police departments can carry naloxone, doesn’t mean it magically appears in their pockets.
“You’ve got to secure buy-in,” explained Dan Schwartz, MD, the Emergency Medical Services medical director at Forbes Regional Hospital in Monroeville, PA. “You can’t force an optional program.”
In turns out, Act 139 doesn’t mandate anything. Paramedics carry naloxone, but that’s nothing new. Neither police, firefighters, or EMTs who are considered “Basic Life Support” (BLS) (as opposed to Advanced Life Support–ALS–which is used to describe a paramedic) are required to carry naloxone. So you’ve got to secure buy-in. And there’s the matter of logistics.
As Schwartz explained, to successfully implement a naloxone program among police and fire departments requires buy-in from the top down, which includes the individual police officers and firefighters. For professionals who have trained to enforce the law, reversing an overdose caused by an illegal drug (and perhaps giving a pass to another illegal drug user who called for help) requires a conceptual shift.
And for all first responders affected by Act 139–that’s police officers, firefighters, and EMTs who are considered BLS–there are a number of logistical questions that need answers before a naloxone program can be established.
For example, a physician is required to sign off on the department’s use of naloxone. The medical director of an EMS program, like Schwartz, is an ideal candidate because first responders can more closely relate to that physician. Finding that physician and securing her buy-in, then, is one hurdle.
Furthermore, training is required before any first responder can carry naloxone. The source of this training varies, but according to Act 139, all first responders have specific training requirements before authorized to administer naloxone.
And finally, the medication supply should be secured. Most first reponders purchase naloxone from hospitals, but this requires collaboration between the departments and local hospitals. And who pays for the naloxone? This is particularly important because BLS EMTs are only permitted to use the intranasal naloxone (as opposed to the intramuscular injection), which is more expensive. The question of where to find the dollars for a naloxone program is left unanswered by Act 139.
Pharmacies: Most Don’t Currently Stock Naloxone
Although they may dispense naloxone (with and without a prescription) most pharmacies in Pennsylvania don’t. As with first responders and the passage of Act 139, in order to dispense naloxone and help prevent overdose deaths, pharmacies need to decide to participate and work through the details themselves.
The pharmacy needs to stock naloxone kits. They need to choose which type of naloxone kit to dispense (intramuscular, intranasal, or auto-injector). Chain pharmacies need to secure approval and establish polices and procedures from higher-ups. As a result, independent pharmacies have moved more quickly on this issue; however, Walgreens, Rite Aid, and Giant Eagle are planning to participate in the near future.
Although friends and families of opiate users are legally permitted to obtain naloxone and all pharmacies in Allegheny County are permitted to dispense naloxone, any individual seeking naloxone should call the pharmacy in advance to see if they stock it. Here is a list created by Prevention Point Pittsburgh (which will probably be outdated soon!) of participating pharmacies.
The cost of naloxone has grown significantly in the last year. Pharmaceutical companies have raised prices in response to demand and this year, many organizations are paying double what they paid last year for naloxone. Cost hikes serves as a barrier to the first responder departments and individuals who now have the right to access naloxone under Act 139.
We called several local pharmacies and found that the price for various formulations of naloxone ranged considerably. Most kits contained two doses (recommended because sometimes the first dose isn’t enough). The cost of the injectable intramuscular formulation (typically the cheapest one) was $50-60, whereas the intranasal formulation cost ranged from $45-$87. This price variation, explained Aaron Arnold of Prevention Point Pittsburgh, is because the pharmacies themselves buy naloxone at different prices. Larger chains might be able to buy in bulk, whereas independent pharmacies may buy small quantities at higher prices.
Not only does the cost vary; insurance coverage does, too. The intramuscular injection is covered by Medicaid, but the intranasal formulation isn’t. Some private insurers cover some or all of different formulations, but there’s so much variation that a consumer would do best to inquire with a participating pharmacy to see what their insurance covers and whether the pharmacy carries that formulation.
We called several local pharmacies and found that the price for various formulations of naloxone ranged considerably.
Phew. From an individual consumer’s perspective, then, the out-of-pocket cost for various formulations of naloxone might range from $40-$90. To see if the naloxone is covered by insurance, have the pharmacist run your insurance information. Medicaid covers the intramuscular injection. But not all pharmacies carry the intramuscular injection.
Allegheny County Overdose Coalition Conference 2015 (all slideshows are available for download)
OverdoseFreePA, which has updated information on overdose deaths and naloxone availability across the Commonwealth
Prescribe to Prevent, a fantastic reference for a prescriber or dispenser interested in overdose prevention with naloxone
Pennsylvania Municipal Police Departments and Naloxone, results of a survey conducted by the Center for Rural Pennsylvania in 2015 (response rate was just over half)