FDA Advisors Vote: Is Narcan the Answer to the Opioid Epidemic?

Nearly 200 people died a day from opioid overdose in 2021. Heartbreakingly, these tragedies are preventable. Not by stemming the tide of opioids coming over the border or getting every user into treatment – both goals worthy of pursuit – but also simply by using Narcan to stop an overdose before it kills.

FDA Advisors Recommend Narcan be Sold Over-the-Counter 

“’Over seven years of having marketed this product, we know that [it] is very easy to use. It is being used by a variety of community groups, including lay individuals. It is a single four milligram dose that is safe and effective.’”

– Manish Vyas of Emergent BioSolutions, maker of Narcan

In order to make a dent in opioid overdose deaths, Narcan must be widely available with as few barriers to obtaining it as possible.

On Wednesday, Food and Drug Administration advisors took an important first step toward making this happen. After a day of deliberations, two FDA advisory panels unanimously voted to recommend offering Narcan over the counter. A final decision by the FDA is expected by March 29.

Although Narcan is currently available behind-the-counter at pharmacies without a prescription, it must still be requested from pharmacy personnel. The stigma and fear attached to illicit opioid use could be stopping some from getting their hands on this lifesaving medication. Selling Narcan over-the-counter would also open distribution dramatically. It could be available everywhere from grocery stores to vending machines and be sold online as well.

What Does Narcan Do?

“’Millions saw me overdose after a photo taken of me by a police officer went viral,’ wrote Hurt above an image of her in her car juxtaposed with a new happy photo of her and Parker, now 3, holding signs that read, ‘Narcan saved my life,’ and ‘Now I get to have my mommy.'” 

-Erika Hurt, in an interview with the Washington Post  

Narcan is one of the brand names for naloxone hydrochloride, an FDA-approved medication that comes in the form of nasal sprays or injectables. As an opioid antagonist, naloxone quickly reverses opioid’s effects in the event of an overdose. Widely used by first responders and healthcare professionals, naloxone is safe and easy to administer.

In addition to Narcan nasal spray, a four-milligram nasal spray, sold two to a package, and Narcan injectable, naloxone is also sold other brand names, including:

• Evzio – an auto-injector available in 0.4 and 2 milligram prefilled syringes.
• ZIMHI – containing two prefilled, five-milligram syringes per pack
• Kloxxodo – an eight-milligram nasal spray approved by the FDA in April 2021 that comes two per package.

Harm Reduction: If You’re Going to Use, Have Narcan Nearby

“One doesn’t have to operate with great malice to do great harm. The absence of empathy and understanding are sufficient.”

–Charles M. Blow

Narcan is an important harm reduction strategy. While traditional addiction treatment is centered around stopping drug use, harm reduction strategies aim to prevent injury or death in those who use drugs.

Harm reduction saves lives. Case in point: According to one study, there is another person present in one in three overdose deaths. If that other person had Narcan and knew how to use it, tens of thousands of lives could be saved every year – approximately 60 of the nearly 200 a day who died from opioid overdose in 2021 alone. Evidence from the real world supports this. A national study revealed that the first states to enact  Narcan access laws achieved a 14 percent reduction in fatal opioid overdoses.

The CDC likens carrying Narcan to having epinephrine on hand for those with allergies. If you or someone you know uses drugs – any kind of street drug, as nearly every type could be laced with opioids – it’s a good idea to have Narcan with you.

How to Get Narcan

“Dan figures he has had nearly a dozen overdoses, ‘The first when I was 18 and the worst [was] at the end of 2014, when I ended up in the ICU. That time, Narcan saved my life.’ That close call, and seeing his own mother die of an overdose, is what he claims got him into recovery. ‘If that stuff (Narcan) wasn’t around, I wouldn’t be around to do the right thing.’

-Catholic Charities Maine

Again, as of this writing, you can get Narcan behind-the-counter at pharmacies across all 50 states, Washington, DC, as well as Puerto Rico. Although you will need to ask pharmacy counter personnel for it, you do not need a prescription.

What is the Cost of Narcan?

The cost of Narcan can vary considerably:

• GoodRx currently has a one-time coupon for $44.64 for two Narcan 4mg nasal sprays at Walgreens, which was the least expensive shown. It is $48.04 Publix, $61.78 at Winn-Dixie, $52.10 at Target, $52.10 at CVS, and $87.90 at Sam’s Club (their retail price), according to GoodRx.
• Drugs.com reports a price of $141.13 as of this writing.
• The injectable solution of Narcan is about $61 (10 milliliters), according to Drugs.com, if paid in cash.

How to Get Free Narcan

Because cost can be a barrier to obtaining Narcan, there are programs that do provide it for free. Here’s what you should do:

1. Check with your health insurance company to see if they cover it. Nearly all (98%) of Medicare plans cover it, as well as all state Medicaid programs.
2. Call your local health department. The Florida Department of Health, for example, announced plans to have all 67 local health departments carry free Narcan kits in September 2021. Search for your state and “department of health” to find your local contact information.
3. Request free Narcan by mail with NEXT Distro. NEXT Distro is an online harm reduction platform. You can request free Narcan by mail on their website by clicking here, selecting your state, and submitting the form electronically
4. Ask your local pharmacy if they provide free Narcan. Some participate in state programs that provide it.
5. Check with each naloxone manufacturer. Some pharmaceutical manufacturers will provide their medications for free or at a reduced cost to those who qualify. You can locate contact information online; simply google the name of the drug and “manufacturer” to find their website.

How to Administer Narcan

“Not even two weeks after meeting up with Utah Naloxone, I found my son unconscious on the couch. I was able to give him naloxone and get him breathing again. He said after waking up and seeing me crying with a room full of EMTs, paramedics, and police there, he was ready for help. He went to detox that day, then to rehab. He was finally ready for the fight for his life! He had a slip up after rehab and I was able to save him again, but after that, I finally had my son back.”

-Utah Naloxone

While Narcan works within two to three minutes to quickly reverse the effects of opioids, including fentanyl, it must be given within four to six minutes of an overdose.

Because of its small window of effectiveness, it is wise to become familiar with how to administer it before you need it. You should also learn how to spot the signs of opioid overdose in a friend or loved one.

Recognize the Signs of an Opioid Overdose

Please note: Before administering Narcan, check for the signs of an opioid overdose if you are not sure that is what is occurring. If there is another person with you, have them call for emergency medical help while you are checking for the signs and administering Narcan. 

• Shallow Breathing – Decreased Respiration
• Falling Asleep – Loss of Consciousness
• Limp Body 
• Choking – Gurgling Sounds
• Pale Skin – Blue or Cold Skin – Clammy Skin
• Discoloration of the Lips and Nails
• Constricted Pupils

How to Administer Narcan Nasal Spray

Note: Do not prime or test the spray before administering. If Narcan is frozen, it will not spray. If this happens, call emergency medical personnel immediately; do not wait for Narcan to thaw. Previously thawed Narcan, however, can be used if available.

• Step 1: Lay the person on their back.
• Step 2: Remove Narcan from the box. Peel back the circle-imprinted tab.
• Step 3: Put your thumb at the bottom of the red plunger. Your first finger should be on one side of the nozzle and your middle fingers on the other.
• Step 4: Tilt the head of the person receiving Narcan back. Support their neck with your hand. Insert the tip of the nozzle into one of the person’s nostrils until your fingers touch the bottom of the nose.
• Step 5: Press firmly on the red plunger to administer a Narcan dose.
• Step 6: Remove the nozzle from the nose.
• Step 7: Move the person on their side (the recovery position) after giving Narcan
• Step 8: Call for emergency medical help
• Step 9: If the person remains unresponsive, a new Narcan nasal spray can be given every two to three minutes, alternating nostrils with each dose, until they are responsive or medical help arrives. DO NOT REUSE A NARCAN NASAL SPRAY
• Step 10: Return the used Narcan to the box and dispose of it in a place where children cannot get to it.

After administering each dose, the recipient should be watched closely for responsiveness, including

• Responding to voice or touch
• Returning to normal breathing
• Waking up

How to Store Narcan Nasal Spray

Narcan is temperature sensitive. It should be stored below 77°F or 25°C. Excursions up to 104°F or 40°C are permitted. Narcan should not be frozen. Narcan freezes in temperatures below 5° Fahrenheit or -15° Celsius. Protect Narcan from the light and keep it in the box until you need to use it. Pay attention to the expiration date and replace expired Narcan.

How to Administer Injectable Narcan

Before an emergency happens, it is important to become familiar with the type of injectable you have. Narcan is sold as a generic and there are other brands as well that come in different forms. Depending on the type, you may need to fill the syringe before injecting or you may have pre-filled syringes. Evizo goes one step further in offering an autoinjector. Always read the package insert for the type of naloxone you have; below are general instructions for administering injectable naloxone.

Non-Prefilled Syringes

Please note: Many naloxone generics come with a syringe and a vial. However, if yours does not, obtain one from a pharmacy and keep it with the medication. It needs to be at least an inch long to penetrate muscle. The Harm Reduction Coalition recommends using 3 ml 25g 1″ syringes. Always follow the directions on the package. Below are general instructions.

• Step 1: Remove the orange top on the vial
• Step 2: Draw approximately 1cc from the vial
• Step 3: Attach needle to the syringe
• Step 4: Forcibly insert the needle into the thigh or shoulder muscle and administer the medication
• Step 5: Call emergency medical personnel.
• Step 6: Monitor the patient. If needed, additional injections can be given every two to four minutes, or until medical help arrives.

Pre-Filled Syringes

Please note: Pre-filled syringes can either be in auto-injector form (Evizo) or not, meaning that you will have to pierce the skin and then administer the medication. Always follow the directions on the package. Below are general instructions. Evizo packaging contains instructions that play through a speaker as well. If for some reason the speaker malfunctions or does not work, it does not mean the medication will not. 

• Step 1: Check to see if the medication is discolored, cloudy, or contains large particles. If so, do not use the syringe.
• Step 2: When ready to use, remove the safety guard
• Step 3: Inject the medicine through the clothing into the outer thigh (for infants, or children less than one year of age, pinch the thigh muscle while administering the medication).
• Step 4: Call for emergency medical help
• Step 5: Monitor the patient. If needed, a new injection can be administered every two to three minutes. Use a new syringe each time.

Narcan Side Effects & Opioid Withdrawal

It is rare to experience Naloxone side effects. Allergic reactions, also rare, can occur. Patients e that have received Naloxone should be monitored for at least two hours after receiving the drug, and any allergic reactions should be reported to and by medical personnel.

Naloxone Allergy Symptoms

Naloxone allergy symptoms include but are not limited to:

• Hives
• Difficulty Breathing
• Swelling of the Face, throat, lips, or tongue

Severe reactions to naloxone include low or high blood pressure, arrhythmias, pulmonary edemas, abnormal brain function, seizures, coma and even death.

Emergency medical help should be called as soon as Narcan or any form of naloxone is administered, whether patients have a reaction or not.

Opioid Withdrawal Symptoms

While allergic reactions and severe side effects are rare with naloxone, experiencing opioid withdrawal symptoms after naloxone is not. This occurs because Naloxone is an opioid antagonist.

Opioid Withdrawal Symptoms Include but are not limited to:

Again, always call 911 when an overdose is occurring. Medical personnel can aid in management of possible side effects as well as overdose and opioid withdrawal care.

Is Narcan the Answer to the Opioid Epidemic?

Drug abuse is a complex problem requiring a complex solution. However, the lifesaving capability of Narcan proves it is a vital weapon in battling the still-intensifying opioid epidemic plaguing the United States.

Narcan may not the only answer, but it is definitely an answer. If expanding access to it saves just one life in the coming year, it is well worth the effort.

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Narcan Prices, Coupons, Copay & Patient Assistance. (n.d.). Drugs.com. Retrieved February 17, 2023, from www.drugs.com

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