This June, Pat McCrory, governor of North Carolina, signed a bill into law that allowed pharmacies across the state to provide naloxone, a drug that reverses an opioid overdose, to the public without a prescription. North Carolina is only the third state to pass such a law, following Maryland and Pennsylvania. This most recent law is part of a series of bills that North Carolina has enacted regarding harm reduction from opioid use. While harm reduction policies comprise only part of a comprehensive solution to substance abuse disorders, they represent a much needed change from the more punitive approaches of the past.
Opioids, as a class, act by binding to opioid receptors, which regulate sensations of pain, as well as processes critical to life, such as breathing. When individuals consume excess opioids, the body loses its ability to control heart rate and respiration; individuals may progress to respiratory arrest and subsequent death. Naloxone can reverse an opioid overdose by binding tightly the opioid receptor to block the effects of opioids. Death from an opioid overdose is typically not rapid; the time from initial ingestion to death may leave a 1- to 3-hour interval for potential intervention. Naloxone is a very safe medication; it does not produce any dependence or tolerance, it has been used extensively to reverse overdose and its side effects are rare.
The opioid class of drugs includes illicit drugs, such as heroin, but also comprises many commonly prescribed painkillers, such as oxycodone. Nationally, fatal overdoses have increased significantly since the 1990s, driven by growth in non-medical use of prescription opioid analgesics. According to the CDC, North Carolina had 1,358 deaths from opioid overdoses in 2014.
In response to rising rate of opioid overdoses, community programs have been distributing naloxone directly to “lay rescuers” in the United States since 1999. Typically, distribution of naloxone is conducted in conjunction with training regarding overdose identification, rescue breathing, and the necessity of EMS activation. Naloxone can be administered as an injection in muscle or, more popularly, as a nasal spray. Large-scale naloxone distribution programs exist in New York City, Chicago, Baltimore and Massachusetts. A 2012 Morbidity and Mortality Weekly Report from the CDC identified 48 naloxone distribution programs in the US, which had trained 53,032 individuals, resulting in 10,171 reported overdose reversals. In North Carolina, in 2015, the number of opioid overdose reversals from the use of naloxone exceeded the number of overdose deaths.
Often, one dose of naloxone is not sufficient to reverse an overdose. Additionally, the rapid onset of withdrawal may cause confusion, headache, and nausea or vomiting. Very rarely, more serious adverse effects, such as seizures and tachycardia, occur. Activation of EMS responders is critical, as these providers can give additional doses of naloxone and are prepared to provide medical support to patients who experience withdrawal symptoms.
Fear of prosecution or arrest can be a barrier to bystander activation of the EMS system. This is particularly significant in situations in which multiple people are using drugs together and one experiences an overdose. In response, North Carolina signed a Good Samaritan law in 2013 that protected those seeking help for an overdose victim. These bystanders cannot be prosecuted for possession of drug paraphernalia, possession of small amounts of drugs, or underage drinking. A further clarification of the law in 2015 also protected those on probation, parole and post-release. While expanded public access to naloxone is critical, the medical importance of the Good Samaritan law is also significant.
North Carolina’s legislation regarding naloxone represents good public health policy and common sense. It focuses on providing lifesaving medical care those with substance abuse disorders. Both the law lifting the prescription requirement and the Good Samaritan law meaningfully increase the availability of a critical medication.
However, this legislation is not comprehensive. Access to more definitive substance abuse treatment, including access to medication-assisted treatment, still remains a challenge for many residents of North Carolina. Similarly, when considering the ultimate efficacy of this legislation, it is important to consider possible cost barriers that may prevent the most vulnerable populations from accessing naloxone. While Medicaid and many insurers will cover the medication, the drug, in retail, costs between $70 and $110. North Carolina’s policies regarding harm reduction are laudable, but substance abuse is by no means a novel health problem, and years of punitive policies towards those suffering from addiction have caused serious harm. It truly a shame that policies of harm reduction did not receive widespread acceptance from state and national policy makers at an earlier date. Nevertheless, it is promising that this mentality is being formally codified in legislation.
Lauren Groskaufmanis is a graduate student in the school of medicine.
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