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Surgeon general issues rare advisory: more people should carry opioid overdose antidote

It’s the first advisory from the office in 13 years. But it’s unclear just how much it will accomplish.

Surgeon General Jerome Adams during a reception at the White House.
Surgeon General Jerome Adams during a reception at the White House.
Alex Wong/Getty Images

The surgeon general issued the office’s first advisory in 13 years — calling on more people to carry the opioid overdose antidote naloxone.

Surgeon General Jerome Adams’s advisory emphasizes “the importance of the overdose-reversing drug naloxone. For patients currently taking high doses of opioids as prescribed for pain, individuals misusing prescription opioids, individuals using illicit opioids such as heroin or fentanyl, health care practitioners, family and friends of people who have an opioid use disorder, and community members who come into contact with people at risk for opioid overdose, knowing how to use naloxone and keeping it within reach can save a life.”

The last surgeon general’s advisory was issued in 2005, with a focus on drinking alcohol during pregnancy.

Public health experts and officials applauded the move, believing that greater access to naloxone could help reverse more overdoses and save lives.

Help is desperately needed: The opioid epidemic is now the deadliest drug overdose crisis in US history. Nearly 64,000 people died of drug overdoses in the US in 2016, and at least two-thirds of those deaths were linked to opioids such as fentanyl, heroin, and prescribed painkillers. The total drug overdose deaths were higher than the number of deaths linked to guns, car crashes, or HIV/AIDS during any single year in America. Based on preliminary data from the Centers for Disease Control and Prevention (CDC), 2017 was even worse.

At the same time, there’s a sense of skepticism over just how far an advisory like this one can go.

Dr. Leana Wen, the health commissioner of Baltimore, has seen some of this firsthand. In the past, naloxone has typically required a prescription. But in 2015, her office issued a standing order that effectively acted as a blanket prescription for the entire city of Baltimore.

That helped, but major hurdles remain — particularly, naloxone’s cost. “Unfortunately, we are having to ration naloxone because we simply don’t have the resources to purchase this life-saving antidote,” Wen said in a statement. “Every week, we count the doses we have left and make hard decisions about who will receive the medication and who will have to go without.”

This is why those involved in the response to the opioid epidemic have argued for federal action to make naloxone easier to access. What’s more, while naloxone is an important tool in addressing the crisis, it’s only one part of the broader puzzle.

Access to naloxone can be limited

There are essentially two major barriers to getting naloxone: It requires a prescription and it’s expensive.

State and local officials, like Wen, have been working to loosen the prescription part through standing orders and other policies that make naloxone available to first responders like police, friends and family of people with addiction, community groups, and so on. There has been progress, but more work remains to be done in this area — some advocates and experts would like to see a version of naloxone made available over the counter, for example.

But it’s the cost of naloxone that’s become increasingly prohibitive. Depending on the type of product, naloxone can run in the tens, hundreds, or even thousands of dollars, in part the result of cost increases over the years. This can make naloxone very expensive for individuals and organizations, including police departments and harm reduction groups, trying to obtain the drug. The drug’s manufacturers offer discounts and work with insurers to try to bring down the price, but, particularly for broader government organizations and community groups, the price is still a big problem.

The federal government could do more to bring down the cost. Wen argued that the feds “can either negotiate directly with the manufacturers of naloxone so that it’s available at a much-discounted rate, or they can provide direct, sustained funding to local jurisdictions like ours so that we can provide evidence-based, effective treatment. We are in the middle of a national epidemic. We should not be priced out of the ability to save lives.”

Congress has approved new funding to address the opioid crisis, but experts and activists generally agree it’s not enough. President Donald Trump’s administration, meanwhile, has done nothing significant on its end to bring down the price of naloxone.

That leaves those working in the opioid space with the surgeon general’s advisory. While it could be a helpful tool for raising awareness, it simply doesn’t address the core problems.

Naloxone is only part of the answer to the opioid crisis

To the extent the surgeon general’s advisory helps, naloxone itself can only go so far.

There’s no empirical consensus on just how many lives would be saved by naloxone if access were dramatically increased. But experts have generally told me that while it can help, it can only be part of a fuller response to the opioid crisis.

Thankfully, experts have a pretty good idea of what should be done: more treatment (particularly via medications like methadone and buprenorphine), more harm reduction (including better access to naloxone), fewer painkiller prescriptions (while ensuring the drugs are available to those who really need them), and policies that can help address the root cause of addiction (like mental health issues and socioeconomic despair).

Doing this will require a lot more resources — potentially tens of billions of dollars a year over several years, some experts have told me. And it will require Congress to really think big about the crisis and the gaps it has exposed in how America systematically deals with addiction.

For example, a 2016 surgeon general report found that about 10 percent of people in the US with a drug use disorder get specialty treatment — attributing the low rate to a lack of supply in care. And even when treatment is available, other federal data suggests that fewer than half of facilities offer opioid addiction medications like methadone and buprenorphine, which are considered the gold standard of treatment and, studies show, cut mortality among opioid addiction patients by half or more.

Consider the counterfactual: What if, like addiction, only 10 percent of people with diabetes or heart disease got treatment? It’d be widely considered a public health disaster — and it’d demand a huge revamp of America’s approach to health care.

Some states have confronted this crisis by essentially rebuilding their addiction treatment system. Vermont, for one, built a “hub and spoke” system that closely integrates addiction treatment with the rest of health care.

But Vermont has managed to do that in large part with federal dollars. And this is going to be true for other states, which are often dealing with multiple priorities and cash-strapped budgets. That’s why they need outside support — and that goes beyond naloxone.

Again, it’s not that naloxone can’t help. It’s widely considered part of the solution.

The surgeon general’s advisory, then, is a step forward. But a lot more is needed before America really starts wrapping its hands around the deadliest drug overdose epidemic in US history.

For more on the solutions to the opioid epidemic, read Vox’s explainer.

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