The pandemic has been associated with increasing rates of drug overdoses in the United States, with the New York Times relaying an overall increase of 29% in 2020 over the year prior. Public health professionals point to disrupted healthcare and crisis services, increased drug potency, worsening mental health, and isolation, but what about access to naloxone, a drug that rapidly reverses opioid overdose? While the available answers aren't as conclusive as one might like, it seems the upstream supply chain—the manufacturing part—hasn't seemed to waver for harm reduction centers.
Even before the pandemic temporarily shut down some substance disorder centers, people who could benefit from naloxone could be stymied by the regulations that vary state by state. Some allow clergy to provide naloxone; others don't. Some have more encouraging pharmacies or a greater wealth of harm reduction services.
"Naloxone is complicated [to track] because many states allow it to be distributed with means larger than just a pharmacy, which is great, it really improves access, but getting data on that information isn't as simple," says Ashley L. O'Donoghue, PhD, an economist at Beth Israel Deaconess Medical Center in Boston.
O'Donoghue recently noted a drop in naloxone pharmacy fills for naloxone, and she says that take-home naloxone has also declined because of COVID-related disruptions to organizations that would normally distribute naloxone in person.
Changes to in-person, mail-order naloxone needs
Emergency departments (EDs) can be a great access point to give naloxone to at-risk people, says Alexander Walley, MD, MSc, of Boston University's Addiction Medicine Fellowship Program. "Where do we find people that are high risk but who don't go to harm reduction or don't go to treatment? Well, the greatest factor for a fatal overdose is a nonfatal overdose, so the emergency department makes a lot of sense."
He believes, however, that only about half of overdose patients are prescribed or offered naloxone during discharge.
He's not the only one who sees this as a missed opportunity. Last month, the Associated Press spotlighted the Colorado Naloxone Project, which aims to make take-home naloxone standard of care for at-risk ED patients.
San Diego County is also increasing naloxone access to at-risk or at-risk adjacent populations. County officials recently announced that community organizations can distribute the drug without prescriptions and that anyone who needs to administer it to someone at risk of an overdose is free of liability.
Besides these in-person distribution expansions, mail-order naloxone has seen a surge in demand during the pandemic, according to Jamie Favoro, founder of the nonprofit NEXT Distro, a mail-order syringe and naloxone service. In 2020, NEXT and its partner affiliates distributed more than 58,000 free doses of naloxone solely through donations, small grants, and a free supply from the nonprofit Direct Relief. That tallied up to about a tripling in demand compared with 2019.
"For the Distro program, the summer was terrible. The Louis DeJoy USPS [US Postal Service] was very real, and we had some people who didn't receive packages for weeks, or they'd get lost in the system and wouldn't show up for tracking," Favoro says. "It was challenging for a period, but it resolve in August. It was very time-specific. We haven't had a problem since."
Manufacturing supply appeared strong
Favoro's brief issues were a transportation problem, not a supply problem, and similarly, Direct Relief and the OSNN Buyers Club—two organizations that provide naloxone to community organizations—said they had no supply issues despite increased orders.
Direct Relief went from shipping about 450,000 naloxone doses to 700,000 from 2019 to 2020, according to its vice president of global programs, Damon Taugher. Some doses were allocated to new providers, and others went to organizations that had connected with the network when it started distributing free naloxone in 2017. Approved entities such as community health centers are allowed to place an order once a month, but Taugher says that Direct Relief can send emergency supplies, as well.
Most of the naloxone supply comes from a no-cost, multi-year agreement with Pfizer, but other companies also help with naloxone donations or the just as necessary syringes and alcohol swabs.
"We didn't experience significant delays, but we did have to manage and increase our resources to do COVID relief effort," Taugher says, adding that at times they were filling orders more frequently for larger volumes. Additionally, Direct Relief asked Pfizer for more doses than in years past and needed Pfizer to send them supplementary supplies outside of Direct Relief's normal quarterly shipments.
Similarly, the OSNN Buyers Club was able to supply about 30% more naloxone doses in 2020 to meet increased demand from the year prior. According to Maya Doe-Simkins, MPH, co-founder of Harm Reduction Michigan and part of the Buyers Club, each year for the past 4 years, she has seen a 20% or 30% increase, so this year is not necessarily an outlier.
OSNN Buyers Club subsidizes naloxone purchases for about 100 organizations and nonprofits that provide free naloxone. (Pharmacies, hospitals, and EMS often acquire their medications, including naloxone, from third party distribution companies such as McKesson, Cardinal, and AmeriSource Bergen, according to Doe-Simkins.)
"The supply disruption from organizations to participants were things like staff getting sick, staff dying, staff needing to take time off because they're too traumatized to walk," Doe-Simkins says. "In fact, the suppliers, they speeded it up during COVID time" from a week or 10 days' shipping time to less than a week.
Overall, though, O'Donoghue, of Beth Israel, says naloxone access still needs to increase. "During the pandemic, there has been increased knowledge of and support of mail-order and delivery of naloxone because of the reduced access to take-home naloxone and naloxone from pharmacies and other sources," she says.
"But even after the pandemic, expanding funding and reducing legal barriers to the delivery of harm reduction supplies would help to make naloxone much more accessible to people who use drugs as well as their loved ones."