Posing as shoppers, a team of researchers from the University of Mississippi called nearly 600 pharmacies across the state and asked a simple, yes-or-no question, “Do you have naloxone that I can pick up today?”

Mississippi enacted a law authorizing pharmacists to sell the opioid overdose reversal drug naloxone— often sold under the brand name Narcan—in 2017. The drug, which can be administered via nasal spray or injection, can prevent death from overdose by blocking the effect of opioids in the body.

The results of the survey, conducted last year, were disheartening. Despite the Mississippi law, 41% of the pharmacies the researchers called refused to dispense naloxone. Only 37% had naloxone available for same-day pickup. Most of the pharmacies saying they could not immediately provide naloxone said it required a prescription, which was false.

“It seems like that refusal might have been driven by a lack of education about the state’s naloxone policy,” said Emily Gravlee, a pharmacist and a doctoral candidate at the University of Mississippi who conceived of and directed the secret-shopper study.

Earlier this year, the U.S. Food and Drug Administration approved Narcan to be sold over the counter. That means that residents in every state can buy it at their local pharmacy without a prescription—at least in theory.

In reality, access remains patchy.

As the Mississippi researchers and other studies have found, pharmacies don’t always keep the drug in stock. And naloxone spray can be pricey for people paying out of pocket; a two-dose pack of Narcan typically retails for about $45–$50. As an over-the-counter medicine, it may not be covered by insurance.

In the past year, more states and municipalities have launched programs to distribute hundreds of thousands of doses of naloxone for free in a myriad of ways: by mail, vending machines, community groups, telehealth, first responders and more.

“We need to normalize that it is not only the humane thing but the appropriate thing to treat people with substance use disorders just like we do people with other diseases,” said Dr. Steven Stack, Kentucky’s commissioner for public health and president of the Association of State and Territorial Health Officials.

“We don’t tell diabetics, “I can’t believe you need to have insulin every day,'” Stack said. “We need to recognize people [with substance use issues] as someone with a medical problem. And there are resources available.”

A changing adversary

Drug overdose deaths in the United States have risen fivefold over the past two decades, claiming nearly 107,000 lives from last June to this June, according to the most recent estimates from the federal Centers for Disease Control and Prevention.

Twenty years ago, overdose deaths involving opioids mostly were from prescription drugs such as oxycodone and hydrocodone. In 2010, a new version of the prescription painkiller OxyContin was introduced that was harder to misuse, leading to a rise in the use of illicit opioids such as heroin.

The opioid epidemic continues to mutate. Today, overdose deaths are overwhelmingly caused by fentanyl and other synthetic opioids. They accounted for nearly 88% of opioid overdose deaths in 2021, the latest year for which final CDC data is available.

“In years past, many people who were chronic users of things like heroin or morphine or hydrocodone were experienced and knew their limits, so they didn’t overdose as often,” Stack said. But over the past decade, illicit drugs have increasingly been mixed with fentanyl to make them cheaper and 50–100 times more potent.

“When you get a drug on the street that’s laced with fentanyl, for most people it doesn’t matter what their tolerance already is,” he said. “One experimentation could be deadly, because fentanyl is that powerful.”

Enlisting bystanders

Naloxone is highly effective at reversing overdoses. It typically restores breathing within two to three minutes, and it’s safe even if given to someone without opioids in their system. It’s also non-addictive and doesn’t create a high.

Experts now say it’s vital for family members, coaches, business owners and community members to have naloxone on hand so they can administer it quickly if they encounter someone experiencing overdose, which can cause difficulty breathing and a loss of consciousness. Studies have shown bystanders are present in about one-third of all overdoses, Stack said.

“If you are in the midst of an overdose, you don’t have the capacity to treat yourself,” said Stack. “That’s why we have to make sure it’s in the hands of bystanders or witnesses.”

Last year, the Biden administration directed $1.5 billion to states to help them address the opioid and overdose epidemic, including funding for health departments to buy and distribute naloxone. Through State Opioid Response grants, 6.6 million naloxone kits were distributed and nearly 400,000 overdose reversals reported, according to the National Association of State Alcohol and Drug Abuse Directors.

Most states direct federal and state funding to community groups, local health departments, first responders, needle exchanges and other organizations to help them offer free or low-cost naloxone.

Increasingly, states also are trying to get the overdose reversal drug to individuals. Last December, the Mississippi State Department of Health launched a service that mails free naloxone kits to residents who request them.

The naloxone mailing program is part of a larger statewide substance use program initiated a few years ago to tackle Mississippi’s overdose crisis. And the state’s overdose rates have shown improvement: Mississippi’s total number of suspected drug overdose deaths decreased by more than 35% from 2021 to 2022, and the number of opioid-related deaths decreased by more than 25%, according to the most recent data from the Mississippi Opioid and Heroin Data Collaborative.

Other states, including Delaware and Kentucky, also have embraced mail-based delivery programs, offering residents free naloxone through the mail. The nonprofit Harm Reduction Ohio, which mails free naloxone to Ohioans on request, reports having distributed 42,000 naloxone kits last year.

Iowa’s Naloxone Iowa initiative offers free naloxone from a pharmacy or by mail for individuals who set up a telehealth appointment with a pharmacist through the University of Iowa’s Tele-Naloxone program.

In Kentucky, Stack’s department is placing boxes filled with free naloxone near high-traffic areas such as shopping centers, sporting events and common areas on college campuses.

States, cities and districts including Kansas, Las Vegas, Michigan, New York City, Northern Idaho, Philadelphia and San Diego County also have launched vending machine programs in the past year that offer free naloxone kits.

Dr. Karen Scott, president of the Foundation for Opioid Response Efforts and a physician in preventive medicine, said the recent spike in youth overdose death rates means more middle and high schools should look at making naloxone easily available.

Experts have attributed the increase in the adolescent overdose death rate almost entirely to fentanyl, which is increasingly found in counterfeit pills.

“I appreciate that some school districts will be very hesitant and say, ‘This doesn’t happen here,'” Scott said, “but the data is telling us that we need to be paying more attention to this population and their risk of unintentional overdose.”

Most teens don’t have an opioid use disorder or a long history of drug use, she said. But that doesn’t mean they have no need for naloxone.

“Given the prevalence of [counterfeit] pills in schools, a kid might think they’re getting a valium off their friends or an attention-deficit medication and it’s really fentanyl,” she said. “You don’t have to have a long history of using opioids to be at risk of having an overdose.”

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