Amid the latest surge in opioid overdose deaths in Virginia, the state has begun rationing the number of naloxone kits that local health departments and civic organizations are eligible to receive and hand out in their localities.
The Virginia Department of Health – the agency that is responsible for distributing the medicine in the commonwealth along with the Department of Behavioral Health and Developmental Services – informed its community partners across the state of the cutbacks in an email on July 7, citing a funding shortage.
“As we anticipate increasing demand along with the current funding levels available, VDH has asked that orders be minimized to 1,000 kits per month, with no new sites being enrolled at this time,” Linda Scarborough, public information officer for the department’s Western Region office, confirmed in an email earlier this week.
The VDH’s move has caught off-guard many of the local departments and organizations that require significantly more doses, leaving them unprepared for a potential increase in deadly overdoses. “The drugs are getting stronger, and fentanyl is more and more out there, so these cutbacks are detrimental to folks that are using,” said Lisa Via, manager of the Council of Community Services Drop In Center North in Roanoke, which has been handing out between 1,200 and 1,300 kits in the valley every month.
Last year, 2,667 Virginians lost their lives in fatal drug overdoses, the deadliest year yet. Virginia is on pace to match that again this year, according to an estimate by the federal Drug Enforcement Agency.
Naloxone has been an important tool in the fight to prevent such deaths. It comes in two FDA-approved forms – injectable and as a prepackaged nasal spray, which is also known by the brand name Narcan. It is light to carry and anyone can use it without medical training or authorization.
If administered quickly, and sometimes repeatedly, it can revive someone who has overdosed. In recent years, health officials have been working to put more and more naloxone kits into the hands of people who use drugs or are around those who do so that they have the tool nearby. It is not known how many lives have been saved.
While the VDH has increased the number of naloxone kits dispersed by 52 percent to more than 55,000 in the last six months, an unexpected demand has forced them to cap the number of kits each of the authorized distribution sites may receive.
Via said that her team normally asks participants in their naloxone program how many kits they need, but because of the now limited supply they will have to start rationing to one or two boxes per person. “A lot of them take Narcan back to their friends they use with, so we’ll have to cut back there as well,” Via said.
And Danny Clawson, the executive director of the Virginia Harm Reduction Coalition in Roanoke, a nonprofit that hands out kits three times a week at various locations across the city, said that the VDH’s decision to ration will cost lives. “For your average organization, capping it at 1,000 kits may be reasonable. But we are distributing way more than other organizations,” Clawson said, adding that the supply the VHRC received before July was barely enough to meet the demand.
Clawson cited concern that the cutbacks by the state will stretch the limited supply even further. “Our goal is to get Narcan in every first aid kit, every car and every house, because you never know when you will come across somebody who is overdosing,” Clawson said. “It’s so prevalent, you just never know when anybody is going to come up on an overdose, which is why creating a ration mentality is very scary to me. If we can’t give out as many kits as our participants want, we will have overdoses. That is my nightmare scenario.”
The number of drug overdose deaths in Virginia continues to climb after the state declared a public health emergency in 2016. Three-quarters of the deaths now involve fentanyl, according to the latest VDH data. Like morphine, fentanyl – a prescription drug that is also manufactured illegally – is a medicine that is typically used to treat patients with severe pain, especially after surgery, but it is 50 to 100 times more potent. It is also sometimes used to treat patients with chronic pain who are physically tolerant to other opioids.
When prescribed by a doctor, fentanyl can be given as a shot, a patch that is put on a person’s skin, or as lozenges that are sucked like cough drops. The illegally used fentanyl most often associated with recent overdoses is made in labs. This synthetic fentanyl is sold as a powder, dropped onto blotter paper, put in eye droppers and nasal sprays, or made into pills that look like other prescription opioids.
For opioid-induced overdoses Narcan has been a game changer, said Charles Tarasidis, a clinical pharmacist at Carilion Clinic in Christiansburg. “When an opioid gets on a particular receptor in the brain, it can create respiratory depression, first slowing down the breathing until the breathing stops and death occurs,” Tarasidis said.
Narcan became widely known in 2016, when music icon Prince was resuscitated by EMS personnel treating him with the nasal spray after he overdosed on a private plane on the way back to his hometown Minneapolis following a concert in Atlanta. The incident happened just days before he died from another overdose caused by prescription painkillers that unbeknownst to him were laced with fentanyl.
Narcan quickly reverses an overdose by blocking the effects of opioids. It can restore normal breathing within two to three minutes in a person whose breath has slowed, or even stopped, as a result of an overdose.
“When injected in the nose very rapidly and firmly, it gets up in the high sinuses, where there are a lot of membranes, and it gets absorbed into the system,” Tarasidis said. “That Narcan is like a very potent magnet with a much higher attachment and attraction to the receptors than the opioid.”
But there’s a downside: Narcan has a very short halflife of between just 30 to 60 minutes. “If more help isn’t coming and there is still a tremendous amount of opioid in the patient’s system, the big bullet is gone and it will create respiratory depression again,” Tarasidis said. “You can overdose twice on the same amount of drugs. That’s why we always call for help and stay with the patient.”
And because of the high potency of fentanyl, the demand for Narcan has increased dramatically in recent years as overdosing patients often require a second dose to stabilize. “You used to be able to get by with one dose for a regular heroin overdose, but now you might need two. It’s mean stuff,” Tarasidis said of the fentanyl. “It’s giving us some serious challenges in the EMS world. Heroin takes acres of poppy to make, but you can make fentanyl in your basement.”
To counter fatal overdoses at the beginning of the most recent opioid epidemic, the VDH started distributing naloxone at no cost to various community partners, including Community Services Boards, law enforcement, fire departments, EMS, VDH local health districts, the Department of Corrections, the Department of General Services Division of Consolidated Lab Services, and public schools.
In 2019, the department launched the Comprehensive Harm Reduction Partner Program that also includes the distribution of sterile and disposal of used hypodermic needles and syringes, education, referral to drug treatment, testing, and an array of other health services. In order to join the program, organizations must undergo a vetting and approval process. The program is administered by the VDH’s Central Pharmacy and the Department of Behavioral Health and Developmental Services.
Of the six sites that are currently part of the program, half of them are located in Southwest Virginia: the Lenowisco Health District, the Mount Rogers Health District and Roanoke’s Council of Community Services. The remaining three are in Harrisonburg, Richmond and Northern Virginia. At least three more applications are currently under review, including that of the VHRC.
During fiscal year 2021-22, the VDH Division of Pharmacy Services (DPS) distributed or dispensed 87,590 naloxone kits to all its partners. The department has entered into a proprietary information agreement with the manufacturer – prohibiting the department to share or disclose the pricing. The regular market price is $75 at the public interest price for nonprofits for a two-pack of nasal Narcan, or about $30 for two doses of injectable naloxone, said Stephanie Wheawill, the VDH’s Division of Pharmacy Services Director in the Office of Epidemiology. “It is simply too high to match the need,” she said.
For the current fiscal year, the VDH has received $1.3 million in state general funds to stock up on naloxone. The department also anticipates about $3.2 million in additional federal funding during the current fiscal year, but this has not yet been fully realized. These funds would support the purchase of approximately 87,000 kits.
The VDH was forced to limit the distribution of kits due to increasing demand from its existing local and regional partners, Wheawill said. “We are working to solidify additional funding sources, and are optimistic that this will be a temporary measure to reduce distribution,” she said of the caps.
Del. Sam Rasoul, D-Roanoke, who during the last legislative period sponsored legislation directing the state to look into the feasibility of turning Catawba Hospital into a state-of-the-art campus offering substance abuse treatment, called the rationing of Virginia’s Narcan supply concerning.
“We hear from first responders of the critical need and growing use of Narcan, and it’s clear that lives are being saved. We should not be limiting but rather expanding the distribution of Narcan,” Rasoul said, adding that with the state’s budget surplus, Virginia has the resources “to be helping in these situations, and we should be putting more dollars toward substance abuse treatment and emergency care treatment.”
Macaulay Porter, a spokeswoman for Gov. Glenn Youngin, said in an email that many of the state’s response programs are funded through a combination of federal and state grants. “We are supportive of these programs and their ability to meet the needs of the community. Alongside his Secretary of Health and Human Resources and Secretary of Public Safety, the governor is continuing to look at solutions to combat this epidemic,” Porter said.
But for those working on the ground, a sufficient Narcan supply is a matter of life or death – especially in the midst of the current surge of fentanyl overdoses.
“Demand fluctuates depending on drug supply, and for our participants alone, each month we average around 700 kits for our syringe service participants. But that doesn’t include people who cannot make it to our meetings, because they live an hour or so away and they take 12 to 15 kits to bring back to their communities,” said Clawson, the VHRC’s executive director.
Government needs to do whatever it takes to provide an unlimited supply of Narcan, Clawson added. “So many lives can be saved, and we shouldn’t be giving Narcan only to people who use drugs themselves,” Clawson said. “Often it is another family member finding a loved one who overdosed, and if they had Narcan and knew how to use it, it would save their lives. We should be making massive campaigns to get it in every school, every office, and every household.”
Tarasidis, the clinical pharmacist at Carilion Clinic, is pushing to make Narcan kits easily available, including in vending machines. “I know there has been a lot that has gone out, and that’s great,” he said, “but in terms of harm reduction volunteers who work in the street to not have the Narcan with them when the overdose occurs in front of them, that’s gonna be tough. And I’m scared.”
Correction: An earlier version of this story stated that the Virginia Department of Health and the Virginia Department of Behavioral Health and Developmental Services informed their community partners via email of the Narcan cutbacks. But the latter agency did not send out the email, it was sent by the VDH’s Division of Disease Prevention at the Office of Epidemiology.