My name is Jeffrey A. Singer. I am a Senior Fellow in Health Policy Studies at the Cato Institute. I am also a medical doctor specializing in general surgery and have been practicing that specialty in Phoenix, Arizona, for over 40 years. The Cato Institute is a 501(c)(3) non-partisan, non-profit, tax-exempt educational foundation dedicated to the principles of individual liberty, limited government, free markets, and peace. Cato scholars conduct independent research on a wide range of policy issues. To maintain its independence, the Cato Institute accepts no government funding. Cato receives approximately 80 percent of its funding through tax-deductible contributions from individuals. The remainder of its support comes from foundations, corporations, and the sale of books and other publications. The Cato Institute does not take positions on legislation.

I appreciate the opportunity to provide the Committee with my thoughts regarding H.4123, which would require Massachusetts prisons to provide naloxone kits to incarcerated individuals, along with proper training and education on how to use them, upon their release.

A large body of research shows a significantly higher recidivism and fatal overdose rate among incarcerated individuals after they leave prison.1 Because they had abstained from drug use while incarcerated, their tolerance level has dropped. Still, the underlying compulsive behavioral disorder fueling their tendency to use drugs remains unaddressed, and they are more prone to overdose when they resume taking their usual dose of the drug. Because of this, Massachusetts was one of the first states to offer inmates treatment for substance use disorder, including treatment using medications for opioid use disorder (MOUD), such as methadone or buprenorphine, which comparative effectiveness research shows to be the treatment approach associated with the lowest incidence of opioid-related morbidity.2

Sometimes the treatment is involuntary. Research shows that involuntary treatment usually doesn’t work.3 In fact, research suggests that coercing drug treatment might increase the risk of subsequent overdose.4 A 2016 systematic review of research on compulsory rehab found no evidence of improved outcomes, with some studies suggesting that compulsory rehab did more harm than good.5 A 2017 report by the Massachusetts Department of Public Health found that fatal overdoses were twice as high among people who were subjected to compulsory treatment compared to those who entered treatment voluntarily.6 This is because patients complete mandatory treatment but still retain their underlying compulsive disorder. After release from the treatment program, they have a high relapse rate.7

Non-compulsory rehab for incarcerated individuals is linked to lower recidivism and overdose rates, but it does not fully prevent overdose and recidivism.8

Therefore, as a matter of principle, if the state is going to incarcerate people who have a substance use disorder and, as a side effect of their incarceration, make them more likely to overdose after release, it is reasonable for the prison to provide them with naloxone kits and educate them on how to use them when they are released.

The Committee should remember that, although the Food and Drug Administration has reclassified naloxone nasal spray as over-the-counter and generic versions are now available, the FDA still requires a prescription for the injectable form of naloxone.9 The injectable form has been off-patent for several years and is significantly less expensive. For this reason, many harm reduction organizations, which operate on a tight budget that relies mainly on grants and individual donations, still prefer to procure the injectable form.

Most states, including the Commonwealth of Massachusetts, have found ways to bypass the prescription requirement for injectable naloxone. Usually, this involves allowing a licensed health care provider—typically a physician—to issue a standing order, instructing pharmacists to dispense naloxone to anyone at risk of overdose under that prescriber’s authority. In Arizona, the state where I am licensed to practice medicine, I often volunteer to issue standing orders to Sonoran Prevention Works, a large and well-established harm reduction organization, enabling them to distribute injectable naloxone to their clients.

The organization’s executive director told me that, although they can buy naloxone nasal spray over the counter, the injectable form is much cheaper and more cost-effective for them to get on their tight budget that relies solely on grants and individual donations.10

Injectable naloxone has a well-established safety record and is simple to use with minimal training, typically via a straightforward intramuscular injection. After over 50 years of experience with injectable naloxone, I believe it’s time for the FDA to make it available over the counter. This change would improve access to more affordable versions of the antidote.

However, until the FDA reclassifies injectable naloxone as over-the-counter, Massachusetts correctional facilities can use the standing order system to distribute injectable naloxone along with proper training on how to administer it to people being released from incarceration, serving as a cost-effective alternative to naloxone nasal spray.

In summary, I believe that H.4123 recognizes the higher risk of subsequent fatal overdoses in people with substance use disorder after release from incarceration, regardless of whether they received treatment during incarceration. I think it is reasonable and proper to provide individuals with naloxone upon release. I also believe correctional facilities should consider distributing injectable naloxone through the standing order system, when appropriate, to reduce costs to taxpayers.

Respectfully submitted,
Jeffrey A. Singer, MD, FACS
Senior Fellow
Cato Institute