Using Policy and Innovation to Improve Lifesaving Access to Naloxone

However, another potential barrier to uptake has been overlooked when considering the effect of naloxone access laws: the complexity of administering naloxone. Until February 2016, naloxone was administered via injection. Someone interested in using naloxone had to be trained to transfer the proper dose from a vial into a clean needle syringe, identify the correct part of the body to inject the needle, and ensure that all the medication was extracted from the syringe in a single shot. Given the preparation and skill required, naloxone administration was typically reserved for first responders, medical personnel, and trained bystanders. However, in November 2015, Narcan nasal spray became the first naloxone product approved for intranasal administration by the Food and Drug Administration (FDA). This medical device was a landmark innovation because it was the first formulation requiring no assembly, training, or needle. Thus, it broadened naloxone’s potential use to untrained laypeople. Following FDA approval, prescription Narcan became available in the first quarter of 2016. Generic versions became available in 2021, and the FDA allowed Narcan to be sold without a prescription beginning in March 2023.

Our research considers how Narcan interacted with dispensing naloxone access laws (DNALs), which allow pharmacists to dispense naloxone without a doctor’s prescription. We focused on three time periods when states adopted DNALs but with differing availability of Narcan: 2010–2015, when states adopted DNALs prior to Narcan’s introduction; 2015, when Narcan was introduced, and thus we could analyze its impact in states with and without preexisting DNALs; and 2016–2019, when states adopted DNALs after Narcan’s introduction. States adopted DNALs at different times, and once Narcan was approved, its distribution varied substantially across states due to variations in state legal infrastructures related to prescribing and dispensing. Our research uses these variations to make comparisons that reveal the effects of adopting DNALs and introducing Narcan and how these effects vary across demographic groups.

Using data from Symphony Health on pharmacies, our findings show that adopting DNALs increased naloxone dispensing by 1.4 claims per 100,000 state residents. Additionally, naloxone dispensing in states with DNALs increased even more after Narcan was introduced—to 9.2 claims per 100,000 residents. The difference between these effects demonstrates the importance of Narcan’s pharmaceutical innovation. Narcan quickly became the most dispensed naloxone brand, and by the end of 2016, naloxone distribution was 2.5 times higher in states that had previously implemented a DNAL. Furthermore, DNALs enacted in states after Narcan’s introduction expanded naloxone dispensing even further to 12.3 claims per 100,000 residents, substantially more than DNALs adopted prior to Narcan. Thus, the innovation of Narcan made DNALs more effective.

Our research also studies the effect of DNALs and Narcan on overdose deaths. Specifically, our research focuses on nonsynthetic opioid-related mortality, which includes oxycodone hydrochloride (OxyContin) and heroin but excludes fentanyl because prior research has found that a single dose of naloxone is less effective at reversing fentanyl overdoses. Our findings reveal no evidence that adopting DNALs significantly altered nonsynthetic opioid mortality before Narcan’s introduction. However, once Narcan was introduced in early 2016, nonsynthetic opioid mortality significantly decreased in states that adopted DNALs between 2010 and 2015. Moreover, states that adopted DNALs after Narcan’s introduction experienced even larger reductions in nonsynthetic opioid mortality.

Importantly, our study reveals that DNALs and the introduction of Narcan had differing effects across demographic groups. Narcan in states with a DNAL decreased nonsynthetic opioid mortality more for men than women and more for those between ages 25 and 64 than those younger than 25 or older than 64. Among racial and ethnic groups, Narcan’s introduction only reduced nonsynthetic opioid mortality for non-Hispanic white people.

Our research explores possible explanations for why DNALs and Narcan affected demographic groups differently. First, our findings reveal that counties with high black and Hispanic populations experienced smaller increases in naloxone dispensing following the adoption of DNALs and the introduction of Narcan. Similarly, rural counties and counties in the top quartile of poverty experienced smaller effects in naloxone dispensing.

Prior research has shown that chain pharmacies, such as CVS and Walgreens, are much more likely to stock naloxone than independent pharmacies. Consistent with that research, our findings show that the adoption of DNALs and the introduction of Narcan produced substantially larger increases in naloxone dispensing in counties with chain pharmacies.

Additionally, our research considers cost as a barrier to distribution. In March 2023, the FDA began allowing Narcan to be sold over the counter. While this may broaden access to the medication, many insurance companies do not cover drugs sold over the counter, so the decision could change the price consumers pay for Narcan. Our research finds that the increase in naloxone distribution caused by DNALs and Narcan was concentrated among Medicaid and Medicare beneficiaries, who had the lowest out-of-pocket costs for naloxone during the period we studied. Our findings do not suggest that Narcan’s introduction lowered the monetary costs associated with naloxone but rather that its use increased most among those with lower out-of-pocket expenses.

Finally, our research evaluates the effects of DNALs and Narcan on instances of opioid use disorder (OUD) treatment. Beyond saving lives, improved naloxone access is intended to enable affected individuals to seek treatment and avoid a future overdose. Our findings suggest that DNALs enacted before Narcan’s introduction did not increase OUD treatments. However, once Narcan was introduced, OUD treatments increased in states that had adopted DNALs. These findings suggest that greater access to naloxone contributed to the rise in OUD treatments.

NOTE
This research brief is based on Evan D. Peet et al., “Using Policy and Innovation to Improve Life-Saving Access to Naloxone,” National Bureau of Economic Research Working Paper no. 33105, November 2024.