Some background: there are programs the give away free narcan (generic name naloxone) to the public. Naloxone is a drug which temporarily reverses the effects of an opioid overdose. 

This seems like a good thing right? Get a life saving drug into the hands of people who need? Wrong. There has been near constant debate about this issue for years now. Some people (I hope merely a vocal minority) hate this idea. Lest you think I’m straw-manning you, here are some real Facebook statuses I found about narcan (excuse the spelling- these are copied verbatim) 

  • Giving away free narcan so where do I pick up my free epi-pen that Ineed to save my life…. such BS
  • As a retired police officer I’m appalled at the use of tax dollars to supply narcan to drug users…
  • Yep, let’s shoot up, I got the free Narcan….tax payers footing the bill for people who have a blatant disregard for their own lives…
  • This is a JOKE to me! Free Narcan and I’m struggling to figure out how to get insulin cause I’m type1 diabetic!!!!!! I kno I’m goin to catch flack for this but ppl CHOOSE to do drugs, I didnt CHOOSE to be a diabetic!!!!

I have been involved in several arguments about naloxone now. I think people who are criticizing these programs are incredibly wrong headed about the whole issue. What follows is my answers to the most common objections to giving away naloxone. 

“We should implement a three-strikes system: three narcans then you die”

There is no practical way to implement a ‘3-strikes’ policy or any strikes policy. There’s no central database of such things, and even if there was, it wouldn’t be set up for anyone to quickly query “how many doses of naloxone has John Smith had in the past 12 months?”. Even if there were- most narcan administrations (including by PD or EMS) will happen before they even know the patient’s name- let alone DOB and social and input it into the MDT. In the case of an overdose, most of the initial care will be done prior to even knowing who the patient is. When you roll up to an unresponsive the first priority is not getting the patients social and typing it into the computer.

The transition to electronic medical records started over a decade ago and there’s still no reliable way to transmit records between different hospital systems, ems agencies, etc in a single county let alone a state. When you move a patient between healthcare facilities the most common way of moving the records is sending them with a folder full of paper copies. Further police records are on an entirely different system than any medical records.

“But I don’t think it’s fair that addicts are getting free Narcan”

Naloxone is not and was never “free” if it’s administered in a hospital or by EMS. The cost of naloxone is billed to the patient’s insurance the same as any other medicine or treatment. The “free” naloxone is either naloxone that’s being given away to the public as part of a public outreach program or sometimes naloxone that’s administered by a police officer.

“Why don’t we give away epi pens for free? Or insulin for diabetics? Or Chemo?”

First, people with epi pens and people who are insulin dependent self-administer. This means that the only person who needs to have an epi-pen or insulin syringe is them. Narcan is different. It can’t be self-administered because someone who is having an OD is by definition not going to be able to administer Narcan on themselves. So an effective public access Narcan program needs to saturate society with people who have Narcan, in hopes that during and overdose somebody near or the first first responder on scene will have naloxone and will act.

Second, Narcan is more or less harmless. If you administered it to me now, it wouldn’t do anything. You can however hurt or even kill someone with insulin or epinephrine. So you can’t just hand out epi-pens willy-nilly. It makes more sense to think of Narcan as like an AED for overdoses, as opposed to like insulin.

But cost cost cost the refrain continues. Can we really afford to save all these people? As it happens, the answer is yes. Naloxone as a drug is so cheap it’s basically free. Below is a table comparing the cost of naloxone to Humalog (a common insulin brand) and Epi-Pens.

Humalog Pen$34/mlMedicaid (NADAC)
Naloxone Syringe$15/mlMedicaid (NADAC)
Epi-Pen$143/eaMedicaid (NADAC)
Naloxone Nasal Spray$63/eaMedicaid (NADAC)

So why not epi-pens? (a) Epi is 2x-3x more expensive than narcan. (b) there also isn’t an epidemic of people with severe allergies dying because they don’t have epi pens. (c) epinephrine incorrectly administered can hurt or kill people. (d) epi-pen users can self-administer. (d) Many police officers also carry epi pens in their cruisers (and all ambulances do).

Why not insulin? (a) insulin is 2x as expensive as Narcan. (b) there isn’t an epidemic of diabetics dying from lack of insulin. (c) the dosage on insulin is important, so you can’t just hand out standard doses to people. (d) insulin users can self-administer. (e) insulin is not an emergency medication. People who are dependent on insulin need multiple doses on a regular basis in perpetuity.

And why not chemo? Well that’s such a dumb comparison I’m not even going to address it. But you could start by googling “average cost of chemo” and then comparing that number to the prices above.

“Yeah but still. Narcan is expensive, and these addicts did this to themselves”

The option you seem to be suggesting as an alternative to narcan administration is “everyone stands around and watches the overdose victim die then calls the coroner.” This is just never going to happen, not least of all it would be illegal for EMS providers to do that, and grossly immoral for anyone to do that. You could I suppose refuse to give police or the public narcan, but you don’t technically need naloxone to treat an overdose. Overdoses can often be treated by breathing for the victim for several hours until the drugs they took wear off. The killer during overdoses is respiratory arrest followed by cardiac arrest followed by death.

Since most police officers and bystanders are neither equipped nor trained to deliver effective rescue breaths, in many (most?) cases the victim will have stopped breathing, their heart will have stopped, and their brain will be being slowly choked of oxygen by the time the ambulance arrives. This means that the paramedics and EMTs will be walking into a full blown code.

So, what does working a code mean? Upon arrival, the EMS team will start doing CPR. While CPR is happening one of the members of the team will attach a set of EKG leads ($20) and a pair of defibrillation pads ($60-100). They will establish a line using an I/O needle ($90). At the very least push epinephrine ($40) and normal saline ($30). This will all be done whether the patient lives or dies.

And, if they live, what then? This would likely mean that upon arriving at the hospital the they would need to be placed on a mechanical ventilator (retailing for $5,000-10,000+) and be sent to the ICU ($600-1,500/day ). In 2015 the average total cost of an overdose admitted to the ICU was $92,408 .

This could have all been prevented by a police officer or member of the public administering a $60 dose of narcan before they went into full arrest. Some quick math tells me that for everyone OD narcan prevents from being sent to the ICU, we could buy about 1,600 more doses of naloxone. Seems like a stupid good deal for the taxpayers and the healthcare system to me.

Narcan is also the cheapest option for dealing with an overdose. Well, not the cheapest. The strictly cheapest option would be to let the victim die on the ground while everyone watched. But in limiting ourselves to options which are not grossly immoral and callous, Narcan is the most cost effective option. The cost of the pre-hospital supplies alone $230. This is 1500% more expensive than delivering a single syringe of naloxone, or 380% more expensive than delivering on nasal spray of naloxone. That’s the costs before the patient is even admitted to the hospital.

“But a lot of addicts don’t have insurance and won’t pay their bills.”

Correct, many victims of overdoses are people who do not have any kind of insurance or the money to pay out of pocket for expensive medical treatment. So a large portion of the cost of treating overdoses is going to be eaten by the agencies/hospitals who provide that care. We, society as a whole, are at the end of the day eating the cost of treating many overdoses.

From a purely economic perspective, would you rather pay for:

  1. A single syringe of naloxone that costs $15 which will likely save a person’s life and give them the opportunity to fight their addiction or
  2. Thousands of dollars of pre-hospital care and tens of thousands of dollars of in-hospital care, where the patient may come out with brain damage or not come out at all.

“But I heard my police department is having trouble paying for Narcan.”

Yes. To the extent the there is a legitimate cost problem, it’s at the police department level. Police departments, especially small departments, may have trouble paying for naloxone kits & training for their officers. Across a small department serving a jurisdiction with a lot of overdose cases, the costs can certainly add up very quickly. Since police generally cannot bill (charge insurers) for medical care they provide, the town or city government has to pay all the costs of the naloxone.

But this is not a reason to not give police and the public naloxone. This is a reason to develop some mechanism by which police agencies and non-profits can share in the immense society benefits of police having naloxone. If police administering a $60 nasal spray when they arrive at an overdose is potentially preventing nearly $100,000 in hospital and pre-hospital medical costs per patient and hundreds or thousands of deaths, then it would seem to be in everyone’s interest to make sure all police officers have as much naloxone as the need. By ‘everyone’ I mean- hospitals, EMS agencies, insurance companies, Medicare, Medicaid, and then just all of us in the public.

If the hurdle is getting the necessary money to police departments and non-profits to purchase naloxone, then we can undoubtedly find a way to get either the naloxone or the money for naloxone to them. Maybe this means hospitals purchase naloxone in bulk and donate it to the police department(s) which serve the area they’re in. Maybe it means some cost sharing agreement where EMS agencies and hospitals will reimburse police agencies for doses that their officers deliver on scene. Maybe it means city governments move money from a public health, homeless assistance, or EMS agency fund to purchase naloxone for police officers, because police officers having naloxone will serve the purpose of those other funds.
But the “problem” is not being able to afford to get naloxone to police officer, the “problem” is connecting the wires across a complex society so that enough of the million of dollars in cost savings from naloxone end up getting naloxone to the people who need it.

“Yeah but even if they’re saved- there are still other costs at the hospital, and the success rates on resuscitation attempts on ODs is so low.”

Yes. The success rate on all resuscitation attempts are very low (though improving)- but the expenditure of EMS resources is going to happen in the process of the attempt. If they make it to the hospital, there will be more costs, and admitted to the ICU more costs, all regardless of what the outcome is. The total cost to the healthcare system will always be cheaper if there was an early narcan administration, just like the cost is always cheaper on a cardiac arrest if there was early CPR & defibrillation.

If there’s early administration and they’re conscious: they spend the night on a naloxone drip and can be discharged. Unless the victim is cold; there’s almost always going to be a resuscitation attempt on-scene- which is still more expensive than naloxone.

“Right, Drug abusers are already very expensive for society- the cost of incarcerating, the cost of crime- even without the medical costs should we really be paying for Narcan when addicts already cost so much money?”

A good first step if you’re worried about cost would be not incarcerating them in the first place. That’d save a lot of money right there. But that’s controversial. There are also options which would eliminate the need for addicts to commit crimes to either get their drugs or get money for their drugs, but those, likewise, are controversial, since they involve giving drugs or money for drugs to addicts. Starting with something cheap and non-controversial is a good place to start.

“Okay, but what we really need are treatment programs- people to come out of the shadows and get help- giving away free Narcan is just enabling them.”

About 85% of opioid addicts will relapse at least once in the process of getting clean . Due to the fact that a user’s opioid tolerance is a moving target (especially if you’re trying to kick it- your tolerance will change significantly) and the strength of available street drugs is likewise a moving target, the people who are most at risk for ODs are those who are trying to get clean and relapse. Daily users will be much more familiar with their tolerance and the strength of whatever they’re buying on the street than someone who was clean for eight months than slipped. So, there’s no practical or pragmatic justification for being opposed to narcan access programs. You’re going to end up letting a lot of people who are trying to get clean die.

If you want to stick with the “they made their choices” line you are going to be doing that at:

  • Great financial cost to society,
  • The cost of less people getting clean and surviving their addiction, and finally
  • The great moral cost of the tens of thousands of dead who could have been saved with a $60 medication (which in terms of medications, is so cheap it’s basically free)

“Yeah but come on- if you OD three times, that’s your fault at that point, I mean three times? Come on.”

An overdose is often the impetus for someone to seek treatment in the first place. So if they don’t survive their first overdose, they’re not going to get treatment. If they don’t survive a second overdose when they relapse, then they’re never going to complete their treatment program.

And what if someone overdoses three, four, five, six, seven, ten times- but after the eleventh time they get clean for good? At which overdose have they used up their chances? Where do you draw that line, and why? How many doses of a $15 medication is their life worth? How many shots at rehab? If we can’t put a price on human life then why are we putting artificial limits on how many times someone can OD before they’re irredeemable?

ODs are usually freak accidents, your dealer gave you fentanyl which was cut incorrectly, or you pushed a little too much because you have the shakes and don’t know what you’re doing with a syringe.

There is no moral quality the differentiates someone who ODs because of an unhappy accident and someone popping oxy every day, only that the person popping oxy hasn’t OD’ed and they can afford oxy. If you use long enough it will happen to everyone.

“Yeah but Narcan isn’t a solution, at best it’s just a band-aid”

Nobody is saying it’s a solution. It’s the cheapest and most effective intervention to both save lives and contain the social costs of addition. It should be non-controversial. Cheap noncontroversial interventions are a good place to start.

Band-aid, but band-aid are good things. Especially when they prevent death. A multi-trillion dollar investment into residential treatment programs and research into addiction is a little bit harder to sell than spending a couple thousand dollars to give police Narcan.

“Yeah but…”

Look, I guess if you want to leave addicts out to dry that’s your prerogative. But there is no financial or pragmatic justification for this. In fact, your position is more expensive and less effective than naloxone programs. If your twisted moral worldview makes you think that addicts don’t deserve to live, then say that but stop trying to hide behind just trying to be ‘fiscally responsible’. Say that you don’t think someone who overdosed isn’t entitled to the same level of emergency care we offer every member of our society.

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