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In the Market For Harm Reduction

Image via Kyle Barr/TBR News Media

On March 29, the Food and Drug Administration approved over-the-counter sales of Narcan, making it the first opioid overdose treatment drug to gain such approval in the United States. This move has been hailed as incredibly impactful in expanding access to a key tool in combating the ongoing opioid epidemic. The drug is already carried by pharmacies across the United States, with recent state legislation making it available for sale without prescription. However, in the meantime, concerns over the price of naloxone continue to grow, as the drug becomes subject to market price fluctuations—now without coverage under umbrella insurance plans. If the United States wants to remain committed to reducing the harm of opioid addictions, coverage of naloxone under health insurance must be reestablished, and Congress must not be hesitant to introduce further programs for the subsidization and distribution of opioid overdose treatment medication.

Naloxone, more commonly known under the moniker of its leading brand, Narcan, has largely come to be seen as a symbolic “technology of solidarity.” The operative symbolism comes from the drug’s envisaged use—a bystander administering it to someone experiencing an opioid overdose. Within minutes, naloxone can reverse overdoses of heroin, fentanyl, and oxycodone without addictive side effects, and it is produced largely in the form of nasal spray or injection. First popularly used to combat addiction in response to a heroin epidemic in northern Italy in the early 1990s, the drug has become a staple of harm reduction efforts across Europe and the United States. Community groups across the United States champion naloxone as an indispensable tool in reducing deaths by overdose, with many distributing the nasal spray free of charge. 

Naloxone has been proven effective in reducing the mortality rate of drug users. According to the National Institute on Drug Abuse, the opioid overdose death rate is anywhere from 27 to 46 percent lower in communities with widespread naloxone distribution, particularly when paired with overdose education. Throughout the 2010s, its efficacy has prompted a massive increase in the number of local sites and organizations offering it for free and has galvanized the passing of legislation in nearly every state to facilitate its availability. 

However, despite both legal and grassroots efforts, access has remained a salient issue. Prior to its approval for over-the-counter sale, naloxone was only available for consumer sale in pharmacies, often at a prohibitive cost, ranging from $50-120 per two doses. For those experiencing addiction, entering a pharmacy to purchase such a visible marker of their dependence is daunting, particularly when considering the cost. Randy Anderson, a former addict and founder of Bold North Recovery, writes, “There was no way I would [walk into a pharmacy to] spend $10 for something to save my life when I needed that money to buy drugs.” Moreover, though every state allows for its sale sans prescription, pharmacists retained a right to not carry it, embroiled in long-standing stigmas surrounding drug use.

It is this concern that the move to over-the-counter sale hopes to remedy. In making naloxone available for sale at corner stores and supermarkets, its process of purchase becomes more casual, comparable to purchasing Advil or Tylenol. The move is thought to stimulate greater production as it becomes available in more locations. 

However, even as Narcan becomes available over the counter, there remain cost barriers that prevent it from reaching vulnerable populations. Most insurance plans do not cover over-the-counter medication, meaning that consumers must pay out of pocket for the drug. Even if it becomes widely available for sale, if a single dose runs a price tag of anywhere from $25 to $60, the fact that it can be bought at a corner store as opposed to a pharmacy is negligible. Communities in need will still struggle with accessibility, and opioid overdose deaths will continue to occur. 

The market for pharmaceutical drugs has a particularly tenuous relationship with equitable pricing. Reports from Human and Health Services demonstrate that over the last seven years, the increase in price of prescription drugs has wildly outstripped rates of inflation. In the United States specifically, consumers pay, on average, 2.56 times the amount for drugs than 32 other comparable countries. The causal mechanisms of such egregious prices are debated, with Adam Smith-esque free-market advocates and pharmaceutical giants alike agreeing that such burdens are a natural result of robust research and development programs. However, countless studies demonstrate that the introduction of new drugs prompts markups, increases in demand, and simple price hikes. The market for drugs is not dissimilar to other industries with foundational barriers to entry, where the pricey development of manufacturing infrastructure and brand marketing can prompt collusion and arbitrary price increases. However, the market for drugs is distinct in that any price fluctuations can have vital implications for the saving of lives. 

The market for EpiPens is remarkably similar to the conditions facing naloxone. Both serve as reactive measures, intended to be applied in the event of emergency. Since acquiring the EpiPen brand in 2007, Mylan—a subsidiary of pharmaceutical giant Pfizer—has repeatedly raised the price of the lifesaving device, up to $600 in 2016, a nearly 500 percent increase in the nine year span. The near-monopoly that Mylan enjoys in this market is due to a myriad of factors: a contract package with schools, complex patenting, and exhaustive lobbying. While an unperfect comparison to be sure, the prices of EpiPens remain restrictively high and pave a dangerous road that Narcan must not follow. 

Currently, Narcan is the only brand of naloxone available for over-the-counter sale. The potential for a dramatically larger market will most certainly prompt greater production by Emergent BioSolutions, and its over-the-counter price is currently unknown. The FDA must be quick to approve a greater volume of generic naloxone nasal sprays for over-the-counter sale in hopes of challenging Narcan’s dominance. Insurance coverage must be re-extended to Narcan, allowing for those with coverage to receive it in pharmacies with little to no copay. 

However, it cannot end there. Nearly one-fifth of adults with opioid use disorder are uninsured. The United States could draw inspiration from the price control system of France, where independent government agencies determine the value of drugs and negotiate five-year contracts with manufacturers. In Louisiana, one such model was implemented to rapidly distribute Hepatitis C treatment under a “subscription” model, where the state negotiated a flat-fee contract with manufacturers and was able to disseminate an unfettered quantity of the treatment free of charge for consumers. Though the plan largely served patients covered under Medicaid, the adoption of such a subscription mechanism could be effective in rapidly dispersing naloxone spray into the communities that need it. 

Naloxone is our technology of solidarity. It is a proven method of reducing overdose deaths while not showing signs of encouraging greater use. If the United States wants to commit itself to meaningful harm reduction, the work is not yet done.