PainRelief.com: What are the main findings? Does Fentanyl in many opioids now limit the effectiveness of naloxone?
Response: While it is not the topic of our paper, the presence of fentanyl in many opioids means that a patient likely needs more than one dose of naloxone to counter the diminished respiratory effects caused by an overdose involving fentanyl. Naloxone is still effective, but the required dosing is higher.
What we do show is that there have been dramatic improvements in access to naloxone since 2015 (following, unsurprisingly, with the passage of many state naloxone access laws which began in 2014). However, access is not universal. By 2018, those with insurance accessed naloxone at a rate 5.2 times higher than those without insurance. And this disparity is, in part, related to out-of-pocket costs. In 2014, uninsured patients paid about $7 more for naloxone than insured patients. But, while the out-of-pocket costs of naloxone decreased for the insured between 2014 and 2018, the out-of-pocket costs increased by 506% among the uninsured, from $35 to $250. What’s more, while patients have limited or no control over the brand of drug offered to them by pharmacies, the brand of drug actually plays a big role in the out-of-pocket costs.
If a patient showed up at a pharmacy in need of naloxone but that pharmacy only carried Evzio (the auto-injector) they would end up having to pay between 14.8 and 16 times as much for naloxone than if the pharmacy offered Narcan or generic naloxone.
PainRelief.com: What should readers take away from your report?
Response: Naloxone is a critical tool in combatting the dire and often fatal consequences of the ongoing opioid crisis that our country is experiencing. And efforts to expand access to naloxone are critical. However, while many states have enacted and continue to pass laws that expand naloxone access by enabling pharmacists to directly dispense or by limiting legal liabilities for Good Samaritans, out-of-pocket costs remain a barrier to access – particularly for the uninsured. And the uninsured are a particularly vulnerable and critical population representing approximately 20% of adults with an opioid use disorder and about 30% of adults that end up dying as a result of opioid overdoses.
PainRelief.com: What recommendations do you have for future research as a result of this study?
Response: Because the opioid crisis continues, with overdose deaths reaching record highs in 2021, its clear that more needs to be done. Naloxone is a critical tool that we have in combatting the opioid crisis and policy makers continue to explore ways to increase access. For instance, a growing number of states are now exploring or passing laws that require naloxone to be co-prescribed with opioids to individuals at risk of overdoses. However, our work indicates that the effects of any recommendations or laws will be muted is patients cannot afford to pay for the drugs.
So, potential avenues to address the barrier of cost include: (
1) Requiring pharmacies to maintain a stock of generic, lower cost naloxone, particularly for uninsured patients;
(2) Providing direct funding to cover the out-of-pocket costs of naloxone distributed by pharmacies to uninsured patients;
(3) Adopting a model similar to the Ryan White HIV/AIDS program model which provides co-pay support to uninsured patients; and (
4) Regulating or negotiating naloxone prices more directly.
PainRelief.com: Is there anything else you would like to add? Any disclosures?
Response: No disclosures, but I would add that because the opioid crisis is ongoing and overdose deaths continue to increase, there remains more to do in policymaking and the research that informs policy to mitigate this crisis. As such, this study is part of a larger project and just one of multiple projects in which we are continuing to examine how to mitigate the devastating and ongoing opioid crisis we are experiencing with the tools available to us, including naloxone.
Citation: Peet ED, Powell D, Pacula RL. Trends in Out-of-Pocket Costs for Naloxone by Drug Brand and Payer in the US, 2010-2018. JAMA Health Forum. 2022;3(8):e222663. doi:10.1001/jamahealthforum.2022.2663
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