A new study in JAMA Internal Medicine suggests that expanding access to naloxone, the opioid overdose antidote, may result in fewer overdose deaths — a lifesaving outcome as America deals with an opioid epidemic that’s now the deadliest drug overdose crisis in US history.
The study, from researchers at William Paterson University and the RAND Corporation, compared the effects of three different policy changes: directly giving pharmacists explicit permission to distribute naloxone, indirectly giving pharmacists the ability to dispense naloxone, and providing other legal protections (besides the first two changes) for naloxone distribution. It then compared states that enacted the policy changes to those that didn’t.
The researchers found states that directly allowed pharmacists to distribute naloxone saw reductions in opioid deaths as high as 34 percent on average compared to states that didn’t enact such changes. But there weren’t significant reductions in opioid deaths in states that indirectly gave pharmacists the ability to dispense naloxone or in states that only provided other legal protections for naloxone use.
The researchers couldn’t definitively prove that expanded access to naloxone led to the reduction in overdose deaths. It’s possible some other underlying factor drove the changes. For example, perhaps the states that explicitly gave pharmacists permission to distribute naloxone were also likely to make other changes — like expanding access to addiction treatment — that impacted overdose deaths. The researchers tried to control for some of these factors, but not all of them can be ruled out in this kind of comparative analysis.
The study also found that policies giving pharmacists explicit permission to distribute naloxone were linked to more nonfatal overdoses in emergency room visits.
At first blush, this might suggest that expanded access to naloxone led to more nonfatal overdoses. This speaks to a “moral hazard” concern that’s commonly raised by opponents of harm reduction efforts: If you make drugs safer to use by expanding access to an overdose antidote (or by expanding access to sterile needles or opening safe injection sites), the thinking goes, more people might use drugs, or people using drugs will be disinclined to quit because they won’t see the drug use as risky anymore.
But there are more plausible explanations. For one, the increase in nonfatal overdoses could be a sign of the naloxone policy actually working: Once naloxone is used, people are advised to call 911 in case the medication doesn’t fully work. So if I save someone with naloxone, and follow this advice, the person I save might be taken to the emergency room and be listed in hospital records as a nonfatal overdose; without naloxone, however, that person may not have ended up in the ER at all, because they died before someone could help them.
Another possibility, noted by the researchers, is that states that expanded access to naloxone may have also expanded access to ER-based addiction treatment. If so, these states would likely see more overdose cases in ERs due to successful outreach to people addicted to opioids. But that’d be a good thing — it would show an increase in the number of people who feel comfortable getting treatment in the ER — even though it would look like an increase in nonfatal overdoses in the data.
Even if it is true that expanded access to naloxone led to more drug use, though, the study suggests naloxone is still a net good: A world in which there are fewer overdose deaths, even if there are more nonfatal overdoses, is an improvement.
As the study’s authors noted, its findings are backed by other research. One controversial study, which got a lot of attention from media and harm reduction activists, suggested that expanded access to naloxone was linked to an increase in opioid-related problems, including deaths in some places. But two other studies found that naloxone access laws led to fewer overdose deaths, and one study suggested that the policies had no effect.
With the publication of the JAMA Internal Medicine study, the majority of recent studies now suggest expanded access to naloxone saves lives, though this is still an early area of research that requires more study.
Naloxone is not the only solution to the opioid crisis. As experts have long said, there is no silver bullet that will solve the opioid epidemic overnight, but there are a mix of policies that would certainly help a great deal: increased access to treatment (particularly medications like methadone and buprenorphine), more harm reduction (such as needle exchanges), fewer painkiller prescriptions (while ensuring the drugs remain available to those who really need them), and policies that address the root causes of addiction (like mental health issues and socioeconomic despair).
The latest study, however, suggests that giving pharmacists explicit permission to give out naloxone is a worthy policy approach on the harm reduction side.
For more on the solutions to the opioid epidemic, read Vox’s explainer.