Introduction

Ohio´s new Naloxone policy, allowing pharmacists to distribute Narcan with no prescription, focuses on the public health issue of substance use, specifically opioid addiction, but also inherently addresses violence. Substance use disorder is defined as a “chronic relapsing disease”, and impacts the entire population in every location it spreads in, plaguing not only those who use the substances but also those who live in the community around them through increased criminal acts, health care needs, and an upsurge in health and economic costs (Lo et al., 2020). Substance disorder is a dense disease, introducing dealers and gang wars in the communities it infects. Substance use disorder drives people beyond their right mind, causing intoxicated driving and outbursts, domestic violence, and gun violence.

Naloxone reverses the overdose caused by opioid drugs, the most brutal outcome of substance use (Ohio Department of Health, n.d.). With increased access to naloxone and no prescription needed, users nearing overdose or who have overdosed will be given a second and possibly life-changing chance to consider rehabilitation. The issue of violence surrounding substance use will ultimately lessen. Narcan makes room for new possibilities and less trafficking of these opioids, switching the nature of violence to one of healing and peace.

Through the Lens of Public Health

Population health is defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig & Stoddart, 2003). The policy of increased access to naloxone was created as an approach to solve a public health issue while increasing population health. The opioid epidemic affects communities, cities, and regions at large. Death rates from opioid overdose rates have increased for all age groups in the United States from 1999–2016, but were highest for those aged 25–34, 35–44, and 45–54 (Collins et al., 2020). Opioid use spans all ages and even races, as it never relates directly to one person. To be put simply, many people are involved in the crisis, and the increased availability of Narcan will affect all those involved. Also, those who use opioids, supply opioids, help people with opioid addiction, and care for their well-being are all affected by this policy. Like a domino effect, those already dealing with the epidemic, that population of people are now provided with a tool that has the potential to stabilize the growing spread.

Widespread Availability

Narcan will transform the way we treat the opioid epidemic and shift the stereotypes surrounding addiction and overdose. Used to reverse opioid overdoses, Narcan is now available over the counter, prescription-free. Although a bright idea on the surface, those who see the realities of the epidemic reveal contrasting points of view. Free clinics and harm reduction groups for those dependent on opioids admit fears of the price and stigma surrounding the medication (Lo et al., 2020). A two-dose pack of Narcan is free to those with Medicaid or private insurance (Hoffman, 2023). Outside of Medicaid, many insurance companies do not cover over-the-counter medicines, and individuals must pay out-of-pocket for Narcan, a cost of approximately ten dollars (Hoffman, 2023). Thus, many individuals who truly need Narcan will not be able to afford it. Free clinics and harm reduction groups observe real people with a real disease daily and can see that the additional fee of Narcan will drive them away from it. Although a policy is aimed toward the people they work with and patients they see, the concealed factors make it so the targets of the policy do not reap its true benefits.

The Origins and Consequences of Fear

A main perspective on this policy is that of the pharmacists who are now allowed to distribute Narcan with no prescription. Initially, in light of the new policy came a sense of doubt and fear of societal judgment. A common barrier to naloxone is independent pharmacists and their refusal to stock nasal sprays and in turn, sell Narcan. On the basis of not wanting to engage with people who use drugs, independent pharmacists in rural and impoverished areas lack a sense of urgency to proactively combat this epidemic (Hoffman, 2023). The pharmacists have a lack of understanding of the policy and the price of the medicine. Educating pharmacists on the policy in detail and staging interventions would be the key to changing the stigma, and this key stakeholder perspective.

A Shift in Ohio

Ohio, the epicenter of the nation’s opioid epidemic, has made a conscious effort to ensure their pharmacists are well-informed which contrasts with the stigma the nation’s general pharmacists population seems to share (Thompson et al., 2018). In a survey conducted by the Journal of Pharmacy Practice in 2018, Ohio pharmacists were surveyed regarding their knowledge, barriers, perception, and comfort surrounding the new policy (Thompson et al., 2018). The results of the study showed that Ohio pharmacists have the proper education and training to identify individuals at risk for overdose, but have a lack of knowledge on the protocol, who they could dispense naloxone to, and who could provide patient education (Thompson et al., 2018). At first, this aligns with the previous perspective, but after this study, a requirement has been put into place that addresses opioid use and proper dispensing of naloxone. Conclusions from this study state that overall, “Ohio pharmacists were open to dispensing naloxone per physician protocol … and knowledgeable about the medication and confident in their ability” (Thompson et al., 2018). The implementation of this study deconstructed the education barrier and turned the perspective of pharmacists around where it matters most. Pharmacists are now more inclined to work with customers and dispense naloxone with the proper information and training as opposed to having little to no knowledge about it at all (Thompson et al., 2018).

Both clinical and harm reduction groups and distributing pharmacists agree on the policy’s attempt to address the opioid crisis (Thompson et al., 2018). Both perspectives focus on the essential users of Narcan, those more inclined to overdose. In the case of the pharmacists’ stakeholder point of view, there is a solution: education. Pharmacists against the policy are still scared and in a way ignorant (Thompson et al., 2018). Ohio has made changes from this point of view, and with new fixes along the way every day, the price and education barriers will be erased or addressed, and these stakeholders could find a way to unite on the terms of the policy, keeping those in need at the core.

The Legality of Narcan

The state of Ohio government states in section 3715.502 of the Ohio Revised Code as well as rules 4729:1–3 - 04 and 4729:2–3 - 04 of the Ohio Administrative Code the terms of this policy. The legislation comes from House Bill 558 at the 134th General Assembly of the Ohio Legislature passed in 2023 (Ohio, 2023). The first non-prescription naloxone, or Narcan, was approved by the U.S. Food and Drug Administration (Substance Abuse and Mental Health Services Administration [SAMHSA] n.d.). This issue is regulated at the state level as the Ohio government, not the federal government, has written the law.

In the US Constitution, the 10th Amendment states, “Powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people” (U.S. Const. amend. X). As per this amendment, since it does not specifically state the federal responsibility to regulate access to naloxone, the responsibility is handed off to each state to create its legislation concerning the medicine. The Ohio State Government or the Ohio Legislature, because of the 10th amendment, has the authority to regulate increased access to Narcan, the prescription requirement, and the safety of the pharmacists that dispense it. House Bill 588 was introduced in the House and Senate of the government of Ohio, reported by their committees, and passed by the two houses of Ohio Senate and House in 2023. The bill was eventually signed by the governor, passing the law again with the authority granted by the 10th Amendment.

Similarities Across the Country

South of Ohio, the state of Texas has a Naloxone Standing Order Request. This standing order gives any pharmacy in Texas the ability to request, and distribute naloxone, allowing the pharmacist to dispense it under the authority of the delegating physician in Texas (Texas Targeted Opioid Response, n.d.-b). Similar to Project DAWN, this standing order comes from the Texas Opioid Training Initiative which offers education to health professionals on preventing overdose and distributing naloxone (Texas Targeted Opioid Response, n.d.). Almost identical to Ohio’s new policy and actions, this Texas initiative takes charge of the growing opioid epidemic, informing and creating increased access to Narcan. This program has distributed over 300,000 doses of naloxone, saving thousands of lives and increasing the health of the population, dose by dose (Texas Targeted Opioid Response, n.d.).

Uncertainty and Concerns

Although this policy is rooted in legitimacy and honesty, increased access to Narcan comes with increased consequences, such as the lack of education in pharmacists, which is detrimental to those who need naloxone. A further concern also involves education for those who administer Narcan. How to recognize an overdose or to be self-aware of one incoming is a strong worry of researchers and physicians. Obviously, with increased access comes increased demand, and demand in rural areas (Collins et al., 2020). The stigma surrounding opioids and overdose is already great, and access to Narcan in rural or even suburban communities might be low if there is a reputation around the medication. All somewhat social consequences, the policy is inherently excellent, having small obstacles on its way to completeness.

Conclusion

The State of Ohio’s increased access to Naloxone is a policy made to aid in the public health issue of opioid overdose. Many stakeholders take a position either for or against the policy. The education of pharmacists is a leading barrier to the fulfillment of the policy to its best. Certain laws were made to increase the effectiveness of the policy, and regions outside of Ohio have begun implementing similar policies. A laser-focused program keen on the active education of healthcare professionals across the nation is crucial to the success of accessible naloxone. With education comes information and the ability to use an informed voice beyond initial horizons. Implementing this, as well as Narcan utilization and “how-to” programs are essential to ensuring the general population is knowledgeable too. A seemingly minuscule take, educating the source leads to stronger, more engaged populations. A population health issue at its core, the policy will naturally protect more people from opioid overdoses, acting as a proactive policy fighting a cruel epidemic.