Why Was Narcan So Hard to Get for So Long?
Reading Time: 9 minutesNarcan Is Just a Band-Aid on the Opioid Crisis, Narcan over the counter: Naloxone will now be available at drugstores. Is it enough?
A couple of weeks back, when the Food and Drug Administration decided to make a nasal spray that has the power to reverse an overdose available over the counter, Nancy Campbell thought about her own supply of this drug. It’s called Narcan. She keeps it on her pretty much all the time.
‘I carry my Narcan with me in my backpack,’ she said.
Campbell is a historian of science and technology at Rensselaer Polytechnic Institute in New York. She studies drug use and abuse. She says that she can’t quite tell how big of a deal this Narcan news is going to be. Naloxone, the drug Narcan dispenses, has been available without a prescription in other countries for years. But here in the U.S., there have been real barriers to getting your hands on this stuff.
Until now, the rules around overdose drugs have been really variable. Here in New York, the Department of Health will hand you an overdose prevention kit if you ask. In Arlington, Virginia, you can grab it from a public library. But in other places? It’s not that easy.
‘I’m really hoping that over-the-counter naloxone will prevent deaths and allow us to bring down that exponential curve that we’ve seen for the past 40 years. We’ve seen overdose deaths grow at about a rate of 9 percent every single year since 1979,’ Campbell said. ‘And now we’re at the top. Hopefully this is a crest and we are going to come down in our overdose death rate.’
Campbell continued: ‘I am hopeful about over-the-counter naloxone. I just don’t think it’s enough. And I think it comes very late in the process.’
On Wednesday’s episode of What Next, I spoke with Campbell about how activists forced the U.S. government to make this lifesaving drug more widely available. It took decades, and their fight isn’t done. Our conversation has been condensed and edited for clarity.
Mary Harris: Narcan is the brand name for the nasal spray version of naloxone, which is a drug that can reverse overdoses, right?
Nancy Campbell: Yes. Naloxone was synthesized in 1960. It was FDA approved for opioid overdose reversal in 1971. And it’s been available since then, largely within emergency medicine. You would find naloxone on your basic life-support trucks.
How does it work?
Everyone’s brain has opioid receptors in it. And those opioid receptors, if you imagine them as golf tees, when an opioid drug comes on—those are called agonists, things like heroin or morphine or fentanyl—the opioid grabs on to the golf tee as if it’s a golf ball.
That can have the effect of depressing respiration. Naloxone is a very powerful opioid antagonist. It will knock the opioid right off the receptor, and it will occupy that receptor for a very short time. That will very rapidly allow people to breathe again. And sometimes that will happen very sharply, and it will throw people very quickly into withdrawal from the opioid.
Part of why I wanted to talk to you is that you’ve researched the long history of overdose reversal drugs like naloxone. And I was surprised to learn how old they are. When were these kinds of drugs discovered and how?
They are quite old. There were a lot of users of opioids in the United States in the 19th and early 20th centuries when we criminalized morphine and heroin and other opiates. Along the way, in the 1940s or so, there was the discovery of the first narcotic antagonists, nalorphine or Nalline, which will reverse opioid overdose but not quite as dramatically as naloxone will. It was used also by police to identify who exactly was or was not an opiate addict.
Can you go back to that? I want to focus on the police just a little bit, because I think the way police used it is so surprising. We knew that this drug, nalorphine, could reduce overdoses, but that’s not the way cops were using it. How did they use it?
Law enforcement in California and other states used Nalline, the brand name for nalorphine, to detect whether someone’s pupil size changed. And if it did, if they injected nalorphine and someone’s pupils changed, they were confirmed as an opiate addict.
The Nalline programs were used to fight particular opioid epidemics in, say, East L.A. or Northern California. And what that meant was that people came in to the police precinct for this kind of early version of drug testing. This was before there was urine-based drug testing. The police would indeed administer nalorphine and make sure that people were not using opioids. The problem, of course, is that people might be using opioids, and in that case they would feel extremely ill. And then, of course, the police would know that they had violated the conditions of their parole.
You said naloxone was developed in the 1960s, so a little bit after these Nalline tests entered the scene. How was naloxone’s development different?
Pharmacologists were trying to figure out this business of the opiate receptors in your brain. They’re trying to figure out how they work. They’re trying to figure out if there’s any way that they could create a drug that could actually treat or block drug addiction. And so there was an idea that we could use the narcotic antagonists to make it impossible for people to get high, impossible for people to feel the effects of an opioid. And so the pharmaceutical company Endo Pharmaceuticals that took naloxone through the FDA approval process in the 1970s did not see a big market for it. They were really thinking that naloxone was going to be a specialty drug confined largely to the operating room.
Did they think, Oh, maybe it’ll be used in the ER in an emergency in case someone’s OD’d?
There were clinical reports of people being brought into emergency rooms and naloxone being used in cases of known opioid overdose. They were certainly thinking about that. But my point is they were thinking about a medical market. They were not thinking about a consumer market. And in fact, even the idea of having naloxone out in the hands of the people who need it most—drug users—that was never conceived of. That was never thought of until the activists in the harm-reduction organizations of the 1990s began to see opioid overdose in their friends and began to realize that if they had had naloxone, they could have prevented a death.
Tell me about how the use of naloxone spread. Because originally it was an injectable. And then that changed. So how did the whole way that naloxone was used shift?
By the mid-1980s, naloxone was off patent and it was an injectable solution that came in little tiny glass vials that you had to load into a syringe. So in the 1990s, at the Chicago Recovery Alliance, a guy named Dan Bigg, who had lost a friend from overdose in 1996, began to realize drug users are good at getting solutions into syringes. So he began to experiment with obtaining naloxone. And then CRA became, in a sense, a national clearinghouse for that product. Dan and his cronies would negotiate with manufacturers of naloxone, and they would be supplied these little glass vials. And that is how the distribution of naloxone beyond the medical use began.
But simultaneously, wasn’t naloxone also being criminalized in some places?
Yes. There are many accounts of activists being arrested. Now, they may have had opioids on their person as well, but also they were not supposed to exactly have naloxone. Needles were also criminalized. Paraphernalia was criminalized by the ‘parents movement’ of the 1980s—the Reagan-era ‘Just Say No’ movement. And so naloxone was, in a sense, thought of as part of the paraphernalia that would indict a person as a drug user. And certainly giving it out to people was seen as a violation because it was a prescription-only drug. And so what the harm-reduction activists, notably Chicago Recovery Alliance, did was to create legal pharmaceutical prescriptions called ‘standing orders’ that allowed you to prescribe to a member of a group rather than to an individual.
It’s funny because it really does seem like this neck wrench: Naloxone comes out. Harm reductionists start distributing it to people. Laws start to criminalize naloxone, and then the harm-reductionist community pushes back again and opens up access. It’s this back and forth and back and forth. And the final back and forth is making naloxone available as a nasal spray. So it’s not an injection. It’s not something you need expertise in. You can just squirt in someone’s nose and that makes it even more available, right?
Yes. I think about this process as like the game of Whac-A-Mole. Every time harm reduction activists thought that they were going to be able to get naloxone and overdose-prevention education out to people, a new barrier appeared that they had to overcome. The intranasal version of naloxone came about as a result of innovation by paramedics.
Hold it. They came up with a way to make it a nasal spray on their own? The EMTs?
Exactly! They had other solutions that could be administered intranasally, and so when they figured out that this could happen, pharmaceutical companies began to innovate in this sort of nasal spray market. And so this does make naloxone much more possible for the consumer market. You don’t have to have that much education. The first overdose-prevention educations were hourslong. When I went to pick up the naloxone kit that I have right now, at my public health department, the education was five minutes. So the nasal spray has reduced the knowledge necessary for navigating an overdose situation to almost nothing because we have this technology, Narcan.
I’ve had this question on my mind since I learned that Narcan would be available over the counter: If overdose rates weren’t what they are today—last year it was about 100,000 people a year who died from an overdose—do you think if those numbers were a little lower, would this approval have happened at all?
I’m not sure that we would have seen any innovation in this sector. The federal agencies have been so lagging behind in terms of seeing overdose as the public issue that it is. So, I would say no. Unfortunately, our federal agencies have been very slow to see this 40-year epidemic as a public problem. The CDC did not keep track of overdose deaths until the activists started showing up and drawing attention to them.
Who does this decision to make Narcan available over the counter help the most? I live in New York City. I know of high schools where kids are just trained to administer it and given Narcan and sent on their way. So how big of a difference is it going to be to have this drug available over the counter at the local pharmacy?
I’m hoping it will make a difference. In my heart of hearts, I am not sure what difference it will make. And we haven’t, by the way, yet heard what the price will be to the consumer. I also wonder about what public health departments will decide to do. In other words, will they still decide to put their budgets toward naloxone when now consumers are supposedly able to go into a pharmacy and purchase it?
I wonder if you think the real change is the normalization of this drug. I say that because you’ve written really compellingly about how naloxone is a technology of solidarity, because it requires there to be another person there who can revive you with this drug. You can’t do it to yourself. So what it really requires is not just a drug, but someone else there to help you. And if we’re all very familiar with Narcan from walking up and down the aisles of Rite Aid or whatever, maybe it makes that solidarity more possible.
I am hoping that that is true. The harm-reduction activists, their first tenet is never use alone. That’s not possible for everybody. Many people who use opioids do use alone, despite all of the education. I do think that this change, this normalization, this democratization of naloxone does mean a change in people’s attitudes and beliefs, their emotional support for drug users in their midst, and also the openness that people will hopefully have about their drug use, because typically it is hidden until it’s too late. I teach students in a course called Drugs in History every year at Rensselaer Polytechnic Institute, and I am often surprised at the low level of knowledge concerning opioids, opioid overdose, and drugs more generally. These are not mundane technologies. These technologies can kill you, and you should know as a consumer, you need to be educated about opioids, in particular opioid overdose. And if you have a prescription for opioids, you should be co-prescribed naloxone. And if you’re prescribed an opioid and not prescribed naloxone, you should be asking for naloxone at your pharmacy.
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We’ve talked about how the U.S. is late to the party when it comes to making a drug like Narcan more widely available. And I’ve been thinking about that as we talk, because naloxone is a drug that simply keeps people alive for a little bit of time. It gives them just a couple more minutes, hours, days, whatever. It doesn’t get them healthier in any kind of wider way. There are drugs that could help people struggling with addiction live a more normal life if they want to. Drugs like Suboxone and methadone and buprenorphine. They allow people to stabilize their relationship with narcotics. How available are those drugs?
If there’s anything that should be over the counter, I would like to see much wider availability of treatment drugs.
And the fear with drugs like methadone, Suboxone, buprenorphine is that they contain opioids. And so you’re maintaining your use of opioids, even though these drugs may allow you to live a more steady life.
They don’t just contain opioids. They are opioids. This is a form of medication-assisted treatment. And yet those drugs are not nearly as widely available as they should be. And that is what we should be focusing on. In a lot of ways, naloxone is a Band-Aid. And we stigmatize people who need to be on addiction-treatment drugs in long-term ways to support their not using drugs that are unsafe.
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