The Daily - What if You Could Save Someone From an Overdose?

Episode Date: May 4, 2023

In the face of an escalating opioid epidemic, the F.D.A. recently approved over-the-counter sales for Narcan — a lifesaving nasal spray that can reverse an opioid overdose. Jan Hoffman, who covers health law for The Times, explains why the new availability of Narcan could change the trajectory of the epidemic.Guest: Jan Hoffman, a health law correspondent for The New York Times.Background reading: Narcan can reverse opioid overdoses and public health officials hope that making the nasal spray more widely available could save lives and reduce America’s high rate of drug fatalities.Here are answers to 10 questions about Narcan.For more information on today’s episode, visit nytimes.com/thedaily. Transcripts of each episode will be made available by the next workday.

From The New York Times, I'm Sabrina Tavernisi, and this is The Daily. In the face of an escalating opioid epidemic, federal authorities recently took a bold step. They approved a life-saving medicine to be on drugstore shelves all over the country starting this summer. Today, my colleague Jen Hoffman on the new availability of Narcan and how it could change the trajectory of the epidemic. It's Thursday, May 4th. So first question, what is Narcan, for those who don't know?

Narcan is a nasal spray that can reverse an opioid overdose. You basically put the nozzle up the nostril of someone who appears to be overdosing, and you push the plunger once, and within a few minutes of injecting the nasal spray, someone can actually wake up from an overdose and their life can be safe. It is something of a miracle drug. Okay, so this miracle drug is now going to be available over the counter without a prescription,

which is a big deal because opioids are taking something like 80,000 lives a year. That's exactly right. And what's remarkable about it is that we've come so far in our view of a drug that can reverse an opioid overdose. And that's really more about how we view opioids and how we view people who use opioids. That's what's really astonishing about the history of Narcan. Okay, so tell me more about that, Jan. What does Narcan and its adoption, more broadly, tell us about how we view opioids in this country? What's the history there?

Let me take you back to the turn of the century. Perhaps you heard the word laudanum from your 19th century novels. Perhaps I had not. Tell me more. Laudanum is a mixture of opium and alcohol, and it was actually available by prescription, as was morphine. They were both used to address all kinds of aches, pains, nervous conditions, and even diarrhea in kids. Both of them, morphine and laudanum, were among the most popular medications around the turn of the century. But doctors began to notice that people who could become inordinately fond of laudanum, they could overdose, they could lose respiratory ability, blood pressure would drop. And so they began to discuss, how do you get the benefits of laudanum, which was very soothing,

it took away pain without it killing you. And how could you save somebody from a drug that was otherwise doing good things for you? So the conversation around how to reverse overdoses began. And by 1961, a drug called naloxone was patented. And by 1971, the FDA approved an injectable form of naloxone for the purpose of reversing an opioid overdose, but restricted its use to hospital settings and ambulances. According to the latest Newsweek poll, about a quarter of registered voters sense heroin use rising at least somewhat in their own communities. But by the late 1990s...

You know, a lot of you have experienced in your communities the increasing allure of heroin among young people. IV drug use on the streets was becoming a serious problem in many communities. 75% of heroin users seeking treatment use needles with all their risk of AIDS and other diseases. At the same time, we were still dealing with the ravages of the HIV epidemic. Around the country, small underground groups that were very worried about the transmission of HIV focused on the fact that IV drug users were using opioids. And there was already grassroots programs to give them clean syringes to help save their lives. One of the leaders of the movement, a guy named Dan Bigg of the Chicago Recovery Alliance, had the idea to also give them naloxone to help reverse overdoses.

And slowly, the harm reduction movement of handing out naloxone on the streets began. And then by the 2000s... When it comes to the highly popular and addictive painkiller, OxyContin, are we dying by prescription? The surge of what we now know as the opioid crisis. Throughout the Northeast, we face what can only be described as an opioid abuse epidemic. It's beginning in poor rural communities in the Northeast. Since the year 2000, Vermont has seen nearly an 800% increase

in opiate drug abuse. At the same time, you have the harm reduction group people who are trying to disperse clean syringes, and they are messing around with little atomizers on the top of the naloxone syringes, gerrymining them to be able to actually use them as nasal sprays.

And then by 2015... Today, I want to talk about a medicine that some people say could help stop this epidemic. The FDA approves a formal nasal spray version of naloxone called Narcan. The beauty of Narcan nasal spray is even individuals like you and I can administer without oversight of a medical personnel. just like you and I can administer without oversight of medical personnel. That means it's now available to many of the people who are most likely to encounter someone overdosing, first responders like police and firefighters, EMTs,

and it's a much easier way for them to use it. That's huge, right? Like, into this worsening epidemic walks a miracle drug. In theory, but that's not what happened. True, there were some firefighting departments and police departments and, of course, the harm reduction groups who glommed on to Narcan and hit the streets. the streets. But it was not taken up broadly across the country by law enforcement. And one reason that resistance was so vigorous is that many firefighters and police felt it just wasn't their job to keep reviving the same people over and over again. They would say, are these lives worth saving? Why are we wasting our time if they're just going to keep using? Brutal.

Yeah, that's extremely harsh. You know, I would remember hearing debates among cops at the time, you know, do you have your Narcan? Nah, I don't need it. Nah, you know, I don't use it. I was reading about the lack of supplies because police and firefighter chiefs didn't believe in it. They felt that the job was to fight crime and to save lives, you know, pull them out of burning buildings. Not understanding or not believing truly that the opioid crisis was its own kind of burning building. So what changed? What changed was the opioid crisis itself.

So what changed? What changed was the opioid crisis itself. The crisis, which began largely as a phenomenon of poor white rural communities in Maine, New Hampshire, Vermont, West Virginia, began to head south, Florida, Georgia, Tennessee, and then go west and into the major cities. Well, the drug OxyContin is supposed to take away the pain, but some families say it's doing the exact opposite. It goes into every kind of household. It includes kids on the football team, you know, the kid who has the ACL injury who was prescribed opioids and then became addicted. The number of kids and teens dying from overdoses is spiking.

It includes people who had wisdom teeth pulled, who were prescribed opioids and became addicted. Every family demographic that you can imagine. After years of decline, teen deaths from drug overdoses are now on the rise. And you can hear throughout the country this outcry of pain and anguish and agony as this terrible swath of death touches everyone. So basically what you're saying is the opioid problem spreads, and it spreads far beyond just rural pockets in certain parts of America,

out to the broader country, everywhere, to every kind of community in America. Yeah, it's everywhere. And what that meant for Narcan was, I wouldn't say 180 degree shift in how people viewed it, but it became part of the conversation. Police officers that carry guns, wear bulletproof vests, but more and more Bay Area police officers are adding another critical tool to their arsenal. It's Narcan. And now, crucially, you start to see cities investing in naloxone for all first responders. Police officers carrying anti-opioid drug Narcan may have saved lives. And those first responders are beginning to embrace it. They gave the two people Narcan, started CPR, and they survived.

In fact, Narcan becomes a verb. In the way that Google becomes a verb, you gotta Narcan them. It's at this point that the FDA essentially lays out a roadmap by which companies could find a way to make Narcan over the counter. So this is a huge breakthrough, potentially, in how we treat opioid overdoses. So what's the response from the companies? Crickets. Why? Why crickets?

Well, from the point of view of the company, Emergent Biosolutions, the manufacturer, they're able to charge a high price, top dollar for a two-dose kit. And they're mostly selling to institutions who weren't paying full price. Cops, firefighters, hospitals, harm reduction groups, they were paying less because Narcan was subsidized by the government for insurance but if you're going to sell it over the counter you're not going to be able to charge that much because over-the-counter medications are largely not covered by insurance so that money has to come straight out of someone's pocket so to make it work financially you have to be confident that there's a market out there that's going to make up the difference. Right. The demand from the lay audience has to be big

enough in order to be able to charge less and still make as much or more money as they had been doing. Right. So even though the opioid crisis itself isn't going away, you know, like on the contrary, it's actually getting worse. And even though Narcan is very well accepted for first responders, Emergent doesn't rush to apply for over-the-counter status because there doesn't seem to be a big enough layperson market for it yet. But obviously now, a few years on, they changed their calculation. Yes. And I think that's because of at least two powerful forces. Remember, we have just been through a soul stifling and deadly pandemic during which people were isolated,

they were lonely, and many were craving opioids more than ever. Overdoses and deaths from overdoses only continued to grow. So you had demand and need. And from the company's point of view, I mean, I interviewed them. They said they recognized the need and they had a product that they could respond with. But also at the same time, I mean, let's just be honest, there was also new competition. Other companies were getting into the naloxone world. There were other versions of naloxone coming up with different strengths, different modes of delivery. And some companies were getting into the naloxone world. There were other versions of naloxone coming up with different strengths, different modes of delivery, and some companies were even making their own naloxone nasal sprays.

So between the competition and the growing need, it was a very good time to apply for Narcan to go over the counter. We'll be right back. Okay, so Narcan is going to be over the counter soon, but how is it going to actually work? And is it going to be a big game changer for opioid deaths? The answer to those questions really turn on what the price is going to be and who will be able to get access to Narcan. Okay, so talk about the price. What will it cost?

Emergent has said that the cost will be below $50. My best guess is it's probably going to be in the mid to high 40s. Again, that's for a two-dose kit. So mid to high 40s is actually kind of a lot for something that you're going into the drugstore and buying over the counter, right? Oh, it absolutely is. And particularly for people who use drugs, who want to have Narcan around to save their friends, they're not necessarily going to be able to cough up $40, $50 for a two-dose kit. But maybe another question is, will parents of teenagers and young adults start to think they should stock Narcan in the household first aid kit, you know?

So basically, you're saying that at this price point, it feels like the target audience is really the worried moms, less the drug users. Well, yes, worried moms. Hello, I'm one of them. And think more broadly. Think about restaurants that worry about accidental overdoses in their bathrooms. Think about hotels that worry about something happening to a guest. Think about an airline that worries about something happening to a passenger. When you begin to think in those broad strokes, you begin to see the market expanding. Right. And what about access? How exactly will that change? Right now, the main ways that people can get Narcan are through EMTs, firefighters, police, public clinics. They can get them from harm reduction groups, which are across the country.

But frankly, if you're an individual right now, strictly speaking, you could go to your pharmacist and say, I'd like to buy some Narcan. Pharmacists are legally allowed to do that under something known as a standing order, which exists in almost all states. I actually tried to do that when I was researching an article on Narcan that I wrote recently. And let me tell you, it's difficult for lots of reasons. I went to pharmacies in three different locations, two different states. And I've been writing about addiction and the opioid litigation for many years. And even as I went out to a pharmacist and said, hi, I'd like to buy Narcan. And I got a long stare. I got the eye blink and the pharmacist said to me, why? And I found myself talking

really rapidly, which I always do when I'm nervous. And I said, oh, well, you know, I have these young adults in the house and I want to make sure they're safe. And, you know, mom never knows. And I was trying to sort of say, oh, it's not me. I don't have a problem. It's not me. It's not me. It's not my kids. I just want to, you know, you never know who they're around. You felt it, the stigma. I was embarrassed that with all of my so-called knowledge about the situation, I didn't have the nerve to say, because I need it and you don't need to know why. Yeah. I should have, I'm embarrassed and mortified that I didn't say that. But I didn't. One of the reasons behind the move to make Narcan over-the-counter is to have people avoid that face-to-face, potentially embarrassing conversation with the pharmacist. Right. That feeling that you had, theoretically, it goes away, right, if it's over-the-counter.

You just put it in your basket, check out, and leave. Theoretically, yes. But if you imagine a $40 to $50 item in a pharmacy, under what circumstances do you usually see it? You don't necessarily see it on a shelf. That would make it highly susceptible for shoplifting because it's so valuable. And it's most likely then behind a locked glass case. That means that you'd have to still go to somebody in the pharmacy and say, hi, I want to buy some Narcan. Could you please unlock the case for me?

Right. And that doesn't feel great. Yeah. Again, the stigma. Absolutely the stigma. But we have been saying over the counter and we visualize your local pharmacy. But maybe we need to think differently. Think about online retailers.

That's possibly a more likely scenario. It would eliminate that stigma problem altogether. But, you know, I think it could have its own challenges. What if someone didn't have an address for the Narcan to be sent to? In that case, walking into a store and buying it is, in theory, simpler. Okay, the whole point of this was to make this wonder drug more widely available, right? To get it in more hands and save more lives. But from everything that you're saying, Jan, like, it sounds like it's really an open question whether it will be because of these

issues with price and access that you're talking about. I do keep wondering who's going to use it. I mean, the harm reduction people, the nonprofits are definitely going to keep using it. But will you go get it, Sabrina? Will you carry it on yourself? Will I continue to buy it? Will the squads of worried moms buy it? I don't know. Yeah. I mean, you know, you say, will I buy it? I was thinking myself like, okay, would I use this?

I mean, if I'm on the subway, I'm seeing someone who's kind of nodding out, maybe they're overdosing. Am I going to go up to that person and give them Narcan, this nasal spray, like with a stranger? I'm not so sure. Well, let me make it an even more difficult question for you. So Narcan, particularly in someone who has taken a particularly strong dose of an opioid, you know, fentanyl mixed in, can provoke and often does provoke signs of withdrawal. That can mean that someone who is being jolted alert can, at the very least, be extraordinarily irritable. They will have headaches. They could vomit. They could have diarrhea, they'll be alive, but they are going to be sick. Knowing that, will bystanders be willing to invade that person's space and stick a nasal spray up a stranger's

nostril? I don't know. I find myself now walking through Port Authority and around Times Square, and at the same time that I see so many people who in theory could be nodding out, I think, do I have the psychological strength to invade that person's space and risk their wrath, particularly if they're just sleeping and they're not nodding out? If you give Narcan to someone who is fact, not overdosing, you won't harm them. But I don't know. I test myself every day that I see something that looks questionable. And I think, could I do this?

Yeah, because you may be setting yourself up for a very intense interaction, right? With a stranger. Yes. I will say, though, that the culture, particularly for younger people, I do think is beginning to shift a lot. For example, there are a kachillion, that's my fine understanding of numbers, there are at least a kachillion TikTok videos, you name it, with kids showing how to use Narcan. You know, somebody said to me, it's a kind of virtue signaling, you know, I go out, I carry my Narcan, what are you doing? But I think that's great, frankly. When I had the kit of Narcan that I bought while doing my research, I turned to my daughter, who's college

age, and I said, I think you should carry this with you. And she said, absolutely. And she's actually already used it. Oh, wow. She told me that she was rushing to class and she saw a commotion on the street. People were shrieking and it looked like somebody was slumped over. And she reached into her bag and said, do you want Narcan? Oh, wow. Yeah. The person who was leaning over the person who was collapsed said, thank you so much. And they took it. And I don't know what happened afterwards. I mean, my daughter was already late to class, but at least she had a really good excuse. But to me, that underscores the value of just carrying Narcan with you. I mean,

the rapidity with which she responded and the fact that she had it, to me, just illustrates what a game changer this could be. So in the same way that the use of Narcan and the way we think about this opioid problem as a culture has changed, the uptake of Narcan over the counter could reflect how we feel about it, right? How it's changing overall. could reflect how we feel about it, right? How it's changing overall. Well, I think it's not only Narcan itself, it's how we feel about people who take drugs. I mean, my kid is certainly of an age where she's hearing about a lot of people overdosing. In fact,

two weeks before I gave her the Narcan, a kid she went to high school with, she found out, accidentally overdosed and died in his college dorm. And so I think that is driving her to want to see something like that prevented again. And I think, you know, ultimately as a culture, it really asks the bystander question, will you get involved? How much involvement will you take on into your heart? Will you be willing to save someone's life? Will you get that up close and personal with them and put something up their nose, risking the fact that you have made a gross error? Will you do that? I don't know. Right. And the question of whether we actually buy this over the counter depends on the answer to that question. Do we ultimately feel a responsibility as bystanders?

Will we actually do this? a first aid kit on an airplane, at a restaurant, in your house, I think it just becomes normalized. And you know what I think is going to make a huge change? The first time someone files a lawsuit against an airline, a restaurant, or an office building because they didn't carry Narcan and could have saved someone's life. Right. Like the attitude shifts to being negligent if Narcan isn't there on the premises. Exactly. That it's your job to carry it. And that's seen as normal due diligence care to your community. Which would be a huge shift. It absolutely would,

especially given how far we've come. Jan, thank you. Oh, thank you, Sabrina. We'll be right back. Here's what else you should know today. The Federal Reserve raised interest rates by a quarter point on Wednesday, the 10th straight increase in an aggressive campaign to tame rapid inflation. Central bankers lifted rates to a range of 5% to 5.25%, a level they have not reached since the summer of 2007.

The move capped the fastest series of rate increases since the 1980s, as central bankers attempt to cool price increases by slowing growth. And Russia accused Ukraine of trying to assassinate President Vladimir Putin in a drone attack after a pair of explosions went off above the Kremlin early on Wednesday. Video footage verified by The New York Times showed what appeared to be two drones detonating 15 minutes apart. Russia called it an unsuccessful, quote, attempt on the life of the president, although it said Putin was not in

the Kremlin at the time. Kyiv, for its part, denied any involvement. Today's episode was produced by Alex Stern, Eric Krupke, Luke Van Der Ploeg, and Carlos Prieto. It was edited by Paige Cowett and Devin Taylor, with help from Michael Benoit. Contains original music by Marian Lozano and Dan Powell, and was engineered by Chris Wood. Our theme music is by Jim Brunberg and Ben Lansford of Wonderly. Our theme music is by Jim Brunberg and Ben Lansford of Wonderly. That's it for The Daily. I'm Serena Tavernisi.

See you tomorrow.