Naloxone can be used to reverse an opioid overdose in an emergency situation. It’s available over the counter at a pharmacy, but some advocates say that’s not enough to get it into the hands of people who need it most. Project Red offers overdose prevention supplies like naloxone to restaurants, bars and other establishments. The Naloxone Project is an organization with chapters in several states including Colorado and Washington. Its goal is to have hospitals distribute naloxone to at-risk patients.
The following transcript was created by a computer and edited by a volunteer:
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. Naloxone is a life saving medication that can reverse opioid overdoses. It’s available over the counter at pharmacies, but some advocates say more must be done so it’s on hand when it’s needed the most. We’re going to hear about two efforts in the Northwest right now to do that. The Portland-based Project Red offers overdose prevention supplies like naloxone to restaurants and bars and other establishments. The Naloxone Project focuses on getting hospitals to distribute the drug to at risk patients across the country. Ellen Wirshup is the program manager for Project Red. The Seattle ER doctor Stephen Anderson is the chair of the board for the Naloxone Project. They both join me now. It’s great to have you on the show.
Ellen Wirshup: Thank you so much.
Stephen Anderson: Thank you, it’s an honor to be here.
Miller: Stephen Anderson, first, can you give us a sense for the scale of the overdose crisis right now?
Anderson: Well, I can summarize it quickly by just saying it’s the number one cause of death in America between the ages of 18 and 58. That may shock some people. I think it opens up even more eyes to say that it’s the number one cause of death in pregnant expectant mothers. By the time this program is over, three more people will have died in the United States.
Miller: When you started by saying it’s the “number one cause of death for people at age 18 to-,” I guess I wasn’t sure what age you would end up at. But the fact that it goes all the way to 58 is a breathtaking number.
Anderson: It’s even scarier to know that the numbers on both ends of those are increasing at a rate that even exceeds that. At risk individuals that are Social Security, Medicare, is a really expanding area. And just as your previous program talked about problems with teenagers, it’s getting to [be] and larger and larger problem in that population as well.
Miller: Ellen Wirshup, what is Project Red?
Wirshup: It’s a harm reduction initiative through the Alano Club of Portland, aimed to provide mass accessibility of free Narcan or naloxone in [the] Portland metro area - Multnomah, Washington, Clackamas County - and all across the state of Oregon as well.
Miller: What does mass accessibility mean?
Wirshup: Basically, the way that people are accessing Narcan right now is through smaller mutual aid organizations if they have them in their cities, a pharmacy now, they’ve just made it over the counter. But most people who need access to Narcan don’t want to spend between $40-$70 for one single box. And so mass accessibility is, I want it to be on every street, in every bar, in every restaurant, in every coffee shop, in everybody’s household, in everybody’s glove compartment, just so we can prevent more needless deaths.
Miller: How did you get involved in this?
Wirshup: Well, I’ve been in recovery for almost three years of substance use disorder, specifically opiates. I lost a very close friend of mine a little over a year ago. She died of a fentanyl poisoning. That’s what we call it when someone takes a substance they don’t know is laced with a lethal amount of fentanyl. And she didn’t make it. And in all my grief and anger and fear, I just decided to grab a case of Narcan from the Alano Club, and walked to the bars in that neighborhood and asked them if they wanted to know how to use it. And it’s grown in tremendous ways that I couldn’t have imagined in just a year alone.
Miller: What kinds of responses do you get?
Wirshup: Mostly positive. Most people are really excited to participate. There’s no degrees of separation now between knowing and loving someone who is struggling with substance use disorder, who has lost their lives or has experienced overdose.
And then sometimes negative. There are many people who do not want it, do not want to talk about it, do not want their kids to have it, don’t want their kids to know what it is or how to use it. And as we work to break down stigma around people who use drugs, that is something we face a lot, the “enabling” of having Narcan, meaning someone is more likely to use drugs, which is not the case.
Miller: There’s a lot to dig into there. But I want to go back to Stephen Anderson. How do you describe the Naloxone Project?
Anderson: The Naloxone Project is right along the lines of what Ellen’s trying to do, which is to increase access of naloxone across the entire community. We’re tending to focus first, however, on hospitals as distribution sites. There’s a famous bank robber named Willie Sutton who said “why do you rob banks? That’s where the money is.” Where do you look for individuals who are at risk for overdose? Frequently you’re going to find them in the emergency departments or admitted to the hospitals or even on the obstetrics wards. And so we’re trying to focus on having hospitals, without stigma, create programs that will identify those individuals that are at risk, and at the time that they’re discharged from the hospital, they’re actually handed the drug. Prescriptions are only filled at about a 2% rate. So we want to actually hand the drug to individuals.
And finally, the other paradigm in this is that hospitals need to be reimbursed for doing this. Hospitals hate what are called unfunded mandates. So they need to have insurance providers [like] Medicare [and] Medicaid reimburse the hospitals for creating such a program and distributing the drug. That’s where we’re focused at the moment.
Miller: How would you describe the different approaches you’ve seen in different states so far?
Anderson: It’s very different to try and create this in Texas than it is in Oregon or Washington. Colorado is definitely the groundbreaking gold standard at the moment for what they’ve done. It normally takes a combination of passionate advocates that want to make this happen, along with some amount of legislative involvement to remove some of those barriers if you will, like pharmacy distribution rules and coding and billing around all this.
Every state has some of the same problems. Like Ellen alluded to, stigma is still the biggest problem of all everywhere. But they’re very unique in some states - Massachusetts, which simply distributes it already but is doing it over grants and grants run out so we need a sustainable system, and other programs like Washington State, which has already passed a law that says this should be done. But we need to get engagement by the advocates in every hospital and every emergency department.
Miller: How would you describe Oregon right now, in terms of access to naloxone and hospital participation in distribution at discharge?
Anderson: First, of all we’ve gotten away from what I call thinning the herd, which is “I don’t want you here. Get out of my emergency department.” We’re really changing the whole paradigm in emergency medicine from trying to be, instead of an adversary, to try to be an advocate. And I would say that Oregon is outstanding as far as that goes.
But Oregon is clearly working on the grant programs to sustain these at the moment. And around the country, there was a large amount of money distributed in the opiate settlements. That’s going to run out in a couple of years, and then distribution of naloxone by handing it to all individuals won’t continue after that unless we find a sustainable system. There are definitely, I will call them apostles, in Oregon that want to see this happen. But we need legislative changes in Oregon to make it sustainable.
Miller: So you talked, Ellen, about a couple of different things. First, just going to, say, bars or restaurants. But talking to young people and going to places where young people spend a lot of time at, say, schools, seems really different. What kinds of conversations do you have at the school level? Or the district level?
Wirshup: I think that, parent versus child, the fear is very different. When you’re facing substance use, when you’re facing potential overdose, I think kids, students are more afraid for their peers, they want to help, and parents are afraid for their child. The work that I’ve done so far with Portland Public School systems has been smaller. It’s more educating parents, having those conversations, talking about stigma, how do we talk to our teens, how do we talk to students at the school level.
I’ve also done trainings: how to administer Narcan, how to spot the signs of an overdose, what we say when we call the paramedics, with students, with administrators. I would love to expand that more in 2024. I know that they have just finished striking and so we’ll probably reintroduce programs like that soon.
Miller: When you said that one of the negative comments you get is some people say “I don’t want there to be Narcan or naloxone,” is the thinking among some people that if you make naloxone available, you are making the use of opiates more likely? Is that what people tell you?
Wirshup: Oftentimes, that’s what people think, or they think that because they have Narcan or someone has Narcan, they feel safer consuming a substance. Which isn’t actually true. We’re just going to reverse the overdose, if it happens. But I definitely think that when we look at someone who’s dealing with substance use, giving them Narcan, it’s harm reduction. Harm reduction is band aids. It’s condoms. It’s a bicycle helmet. People are still going to engage in substance use. We just want to make sure they are as safe and cared for as possible. And I think people don’t really understand that, especially if they haven’t themselves dealt with substance use in their own life.
Miller: Stephen Anderson, naloxone seems like it’s only going to help somebody who has overdosed if there is someone else around to administer it. That’s the idea of groups like Never Use Alone. I’m curious what messaging is a part or should be a part of the distribution of this overdose reversing drug at a hospital discharge? What should people say when they give the drug out?
Anderson: There is a mandatory educational process that goes along with the handing it, it’s not just “here you go.” It is exactly like you say, harm reduction elements: you shouldn’t use alone. When it’s time for you to seek recovery that you want to get involved with, we want you to come back to the emergency department if that’s the only place you have to turn. But in the meantime, we wanna make sure that this drug is in your circle, that you know it exists, and that the other people that are around you know where it is and how to administer it. It’s as simple as spraying a nasal spray up your nose, so the training on how to administer it is not significantly difficult.
And then the other thing that we need to tell people is that you can’t do any harm with this drug. If you were to spray it in my nose right now, nothing would happen. It’ll only reverse an overdose. It may put someone into a very short bit, we’re talking 30 minutes, of withdrawal. Which is uncomfortable, and we can help with that. But withdrawal for 30 minutes is a whole lot better option than stopping breathing, and that inevitable consequence.
Miller: Ellen you talked about at the beginning the price if people go and get this over the counter just at a pharmacy. Do you see other barriers for individuals who want to access naloxone?
Wirshup: Oh, absolutely. Absolutely. Besides just the price and the cost, if you don’t have health insurance, if you don’t regularly see a doctor, you’re not going to walk into a pharmacy and ask them for Narcan. You might even be paying more than the $40-$60 price tag. I also think that, there’s a lot of places, like the Alano Club is an incredible space, but it’s also a recovery space. And not everyone who isn’t seeking recovery wants to walk up to the front desk of a recovery space and ask for Narcan.
I think there’s also a lot of barriers for people who don’t have access to transit. If you live up on 158th and Division, you’re not going to be taking a bus or a MAX all the way across town to go and access free Narcan from somewhere like the Alano Club or Outside In, for example. I do mail Narcan through NEXT Distro, which is an incredible organization across the United States. But still if you don’t have a mailing address, if you don’t have a PO Box, how are you going to access this medication for free?
Miller: Governor Kotek signed House Bill 2395 into law just a couple of months ago, this past August. What did that do?
Wirshup: The main thing that it did and one of the most incredible things was that it decriminalized testing strips. And what that meant is that an organization like mine can now go out and give those to people and individuals who need them for free.
Miller: To find out if the drug that they have somehow acquired has fentanyl.
Wirshup: Yeah. And for the most part, people are consuming fentanyl knowing that that’s what they’re taking. But there are a lot of people who aren’t, or who are consuming another substance - cocaine, methamphetamine, ecstasy, and things like that - who want to know if it has trace amounts of fentanyl in it. And when I was younger and using substances, we didn’t test our drugs. They also weren’t very likely to kill us if we took something not knowing what it was laced with.
Miller: Stephen Anderson, we were talking earlier about the state by state approach that you’ve been taking. Does it have to be state by state? I mean, what could happen at the federal level?
Anderson: There is a bill right now in front of the federal [legislature]. HR 5506, which would mandate this on a federal level. That would cover those with Medicare, VA patients, Tricare. But Medicaid is our high risk population. If we can get it passed federally, then every hospital has to institute the program. It makes it easier then to go state by state and create a program that will cover Medicaid patients and those with no insurance.
Miller: Stephen Anderson and Ellen Wirshup, thanks very much.
Anderson: Thank you very much, Dave.
Wirshup: Thank you.
Miller: Stephen Anderson is the chair of The Naloxone Project. He is an emergency department doctor in Seattle. He is the past chair of the American College of Emergency Physicians. Ellen Wirshup is the program manager for Project Red. They joined us to talk about their efforts to expand access to the overdosing reversing drug naloxone.
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