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Distribution Models and Strategies to Consider to Expand Access to Naloxone

Improving access to naloxone, a medication that reverses opioid overdoses, is one of the core strategies from the National Settlement’s Exhibit E that states and communities can use to address the opioid epidemic. As highlighted in the Primer on Spending Funds from the Opioid Litigation: A Guide State and Local Decision-Makers, the settlements state that funds from the litigation should be used to increase the availability of naloxone—a medication approved by the FDA to reverse opioid overdoses—particularly among vulnerable groups who may be uninsured or underinsured.

Two recent studies highlight the different approaches that states and communities can take to expand access. As they decide how to spend money from the opioid litigation, jurisdictions should examine their laws and regulations around naloxone, and their method of distributing naloxone, to determine how best to improve access.

Four States and Four Distribution Plans 

Kentucky, Massachusetts, New York, and Ohio have partnered with the NIH in the HEALing Communities Study (HCS) to research and implement intervention strategies to address the effect of the opioid crisis on especially hard-hit communities.

Researchers examined each state’s naloxone distribution model and policies as of September 2022. The analysis included an examination of:

1) States’ naloxone access laws (NALs)

2) Medicaid coverage policies

3) Infrastructure to support overdose education and naloxone distribution programs.

Not surprisingly, the researchers found variations in these three domains across the four states. For example, Massachusetts has an educational requirement for pharmacists and requires that they maintain a sufficient stock of naloxone, while other states do not. Kentucky’s Medicaid program uses prior authorization and/or quantity limits for all forms of naloxone, while New York does not do that for any form of the medication.

The researchers then compared the dispensing rates of naloxone across the four states in 2019, looking both at naloxone dispensed from pharmacies and in the community. They found significant differences between states, with the rates in New York and Massachusetts roughly twice that of Ohio and Kentucky.

Prediction Model for Rhode Island Distribution

Researchers in Rhode Island modeled different approaches that the state could take in distributing additional naloxone kits. Their microsimulation model estimated the outcomes and costs generated by different distribution strategies over a three year period, taking into account demographics, geographic location, and drug use behavior patterns.

The researchers found that distributing naloxone kits geographically based on where people of the highest risk were found, rather than on the historical distribution of the medication, would result in higher numbers of overdoses prevented. They also found that focusing on people who inject drugs–rather than broader categories of people who use drugs or the community at large–resulted in the prevention of more overdoses.

Takeaways for States and Local Jurisdictions

States and local jurisdictions must grapple with challenging questions as they decide how to address the number of opioid overdose deaths. The studies discussed here demonstrate the importance of looking at a strategy such as improving naloxone access comprehensively.

The four states studied in the first paper show how state policies can dramatically affect the volume of naloxone circulating in the community. No one policy from Massachusetts or New York is responsible for the higher naloxone rates in those states; rather, a combination of multiple policy approaches and other factors are likely driving the increased naloxone distribution. In deciding what naloxone strategies to implement, states should examine which naloxone distribution policies could be adopted from Massachusetts and New York.

The Rhode Island study demonstrates the stark differences that can result from decisions around how best to distribute naloxone. States and local jurisdictions should use this modeling, other research, and conversations with community members to determine which plan is appropriate in their community.

Overall, taking a comprehensive approach to issues such as this will help jurisdictions ensure that the dollars from the opioid litigation is spent in the way to best reduce overdose deaths.