The pricing and availability of drugs — legal and illegal — illuminate how markets chase profits and reward innovation. A comparison of heroin (and other illicit opioids) with naloxone, the lifesaving antidote for opioid overdoses, offers a devastating peek into the overdose epidemic that is ravaging the United States.

Let’s start with the price of heroin. In the early 1980s, a gram of pure heroin cost about $2,200. Today that same amount costs less than $500, nearly an 80 percent decrease. A bag of heroin today will set you back about $5, the cost of a pumpkin spice latte. And prices continue to fall with the introduction of new and more powerful synthetic opioids, such as fentanyl.

Compared to heroin, which requires lengthy cultivation of poppy plants and cumbersome processing, fentanyl and its ilk are relatively cheap to make. Humans have been growing poppies and harvesting opium for at least 6,000 years; manufacturing has historically been constrained by the 120-day growth cycle of the opium poppy plant and the distant geography in which it grows.

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Today, fentanyl and other illicit opioids are being rapidly mass produced. Much of the supply is coming from China, though Mexico and small U.S.-based labs are also creating these products. Innovation in the retail manufacturing and distribution of heroin and fentanyl is now as redundant and robust as the supply chain bringing coffee beans to your neighborhood cafe, though with far more “retail outlets.”

It’s a different story for naloxone, a drug patented in 1961. Naloxone is near miraculous in its ability to reverse an opioid overdose within minutes. Prompt access to it could prevent some or all of the 115 opioid overdose deaths that occur in the United States every day. Naloxone is cheap to make, and has been off patent since 1985.

Given the ongoing devastation of the opioid crisis, you might expect that naloxone would be widely available at a low price. Not so. A decade ago, a lifesaving dose of naloxone cost $1. Today, that same dose costs $150 for the nasal spray, a 150-fold increase. A naloxone auto-injector, approved in 2016, costs $4,500.

Pharmaceutical innovation hasn’t driven up these prices. Opportunity has.

Market forces are working from opposite directions to boost the death count from opioids. In the midst of this crisis, lethally potent street drugs are increasingly affordable and available, while their lifesaving antidote, naloxone, is increasingly expensive and difficult to obtain.

The aggressive marketing and sales of highly potent prescription opioids, combined with price-lowering innovations in the production and distribution of heroin, illicit opioids, and fentanyl, have not been matched by innovations in the legal market for naloxone. Its high price and restricted availability — despite its low production costs and excellent safety and effectiveness records — betray our collective ambivalence about the millions of Americans with opioid use disorder.

An approach taken by many states has been for a high-ranking state health official to issue a “standing order” for naloxone. This is essentially a prescription for everyone that makes it possible to obtain naloxone from a pharmacist without first having to visit your own doctor and get a prescription. While appealing in concept, this approach hasn’t worked for three reasons: most citizens are unaware of these programs, insurance companies rarely provide coverage for naloxone, and the price remains prohibitive.

We offer a different solution: Make naloxone available over the counter, in much greater quantities and at lower prices.

The FDA approved naloxone for use by prescription in 1971, and could easily transition the drug from prescription to over-the-counter status. If for-profit pharmaceutical companies are unable to see past their bottom lines to make naloxone available over the counter and at a low cost, then a nonprofit should step in and do just that, eliminating the exorbitant markups. This is what Civica, a nonprofit generic drug company launched by several hospital systems, aims to do to fight rising drug costs and chronic shortages.

FDA Commissioner Scott Gottlieb recently announced plans for a December meeting to discuss how to improve the availability of naloxone products. With a concerted national effort, this can be a solvable problem.

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The opioid epidemic is a tragic consequence of multiple forces — the aggressive marketing of potent prescription opioids, increased availability and decreased costs of illicit opioids, and insufficient access to medications that can quickly reverse overdoses as well as those that can treat opioid dependence. Increased access to inexpensive naloxone alone will not solve the opioid crisis. But individuals dependent on opioids must be kept alive if they are ever to have the opportunity to recover.

The pharmacoeconomics of the opioid epidemic are not on our side. But let us hope that common sense is. In a sane world, naloxone should be at least as available and affordable as heroin.

Michael Hufford, Ph.D., is co-founder and CEO of Harm Reduction Therapeutics, a Pittsburgh-based nonprofit focused on making naloxone more available. Donald S. Burke, M.D., is dean of the Graduate School of Public Health at the University of Pittsburgh.

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  • The story picture ain’t the point.

    Theaw anti-racism diatribes are junking up the discussion. They might have used a picture of my late white granny with a tab in her fingers – that is surely realistic – NOT. It would have been better to not use a photo at all, but that is water over the damn. Live and learn.

    • Mr Hilton,
      They should have used a more appropriate picture of a pharma CEO, swimming in cash, while on his Yacht. Using a picture of dead people, or a Graph of Suicides, among chronic pain patients would have been more appropriate. Maybe a Graph of who is cashing in on this so called epidemic, and how many people have died died to marketing and misinformation.

  • Ms Trust,

    Acupuncture does not work. They used to claim it worked through Chi, which is unrelated to the Limbic System. There is not documented evidence anywhere that Acupuncture cures either addiction or pain. Some billionaires provided millions in funds to several universities to try to prove it, and years later, nothing. Sure, they hyped a few misleading studies to give the science ignorant the idea that it worked, but it was all hooey.
    I bet that you believe in Battlefield Acupuncture too. I live in an area where there is an Acupuncturist on every corner, and we have the worst health outcomes in America,, high rates of suicide and drug addiction too. One would think that if acupuncture actually worked, we would not have these problems.
    I have seen how they operate, and it is really disgusting. They use the Hawthorne Effect to take advantage of sick and desperate people. No one tracks how many people have been harmed. The ones who allowed an Acupuncturist to treat them for a serious condition and ended up even worse off. That kind of research would be bad for business. Plenty of things work on our limbic system, it does not mean they cure anything.

    • Mr. Johnson,
      You seem very intelligent. Base on evidence, what pharmaceutical drug is better. If there were any, we, as a nation will not be in this epidemic crisis. Let’s find the truth, not base on biases.

  • Acupuncture can prevent psychological and emotional stress. It facilitates a feeling of well-being. See an Acupuncturist or Acupuncture physician near you.

    • Acupuncture is a fraud. it is nothing more than an amplification of the Hawthorne Effect, basically they are nice to their subjects. Acupuncture does not cure anything nor should it be marketed as if it does. They really need to track the number of adverse events due to postponing actual necessary medical care. North Korea has some of the highest death rates in the world, and not much healthcare. People regularly die from cancer and curable illnesses. The regime there promotes Acupuncture too, because they don’t have anything else, not because it works.

      https://sciencebasedmedicine.org/acupuncture-doesnt-work/

  • There was not much outrage when Sackler, from the same family that not only marketed Oxycontin as non addictive, they got around the laws and bribed our politicians. He took tax payer funded research too, which the media failed to explain. Not many of the concerned people, spoke up years ago, when this so called epidemic began. The biggest factor was the ignorance and the rush to cash in. Back in 2012, the financial pages were hyping the treatment industry as a good investment, right along with Pharma. The FDA is still fact resistant, and incapable of doing a fact based, scientific response to this.
    The writer failed to mention how the Medical Industry chose to prescribe opiates rather than treat people with certain conditions, it was cheaper. Now that prescription drugs are no longer a factor, they are making suicide or the pursuit of illegal drugs the only options for people with Intractable Chronic Pain. Of course these deaths were not counted.

    Once again all of the facts are inconvenient. There was no action when these reversal drugs, or even insulin prices were raised exponentially. The current Administration has proven they will not fix this problem, to much input from the profiteers!

    This research was paid for by the Tax Payers, yet a Billionaire is allowed to cash in! The Opiate Epidemic has been really profitable for some.
    http://nymag.com/intelligencer/2018/09/richard-sackler-oxycontin-billionaire-patent-opioid-addiction-treatment-buprenorphine.html?gtm=top&gtm=bottom

  • With more and more chronic pain patients being abruptly taken off opioid pain meds with no viable alternative being offered the use of illegal drugs like this will continue to rise. Some of these od’s are pain patients desperate for relief, some are intentional od’s seeking to permanently end their pain. I am speaking from the experience of someone with chronic severe pain. I was lucky enough to learn about kratom and cbd oil which helps control (not relieve) my pain when I was taken off of pain meds. Others in the support groups I have attended over the years have turned to illegal drugs to combat pain. Others couldn’t face life with uncontrollable pain and opted for suicide. My aunt was one of those. Until people stop looking through a tunnel and giving knee-jerk responses to a crisis and view the entirety of the issue with all its many facets no true resolution can happen.

    • I join Mark in objecting to this use of a stereotypical image. STAT is supposed to be a sophisticated aggregator of important medical news. I’m sorry to say that this makes STAT look ignorant.

      And Urs, are you really that clueless?

    • The use of an African American for the picture, drives readership, and appeals to Racism, and Denial. They don’t do this sort of thing lightly. They went through thousands of pictures and chose that one for “Impact.” There is still a serious disconnect between reality, and facts, and whatever drives advertising sales. There is still denial over the many Americans dying from addiction, lack of treatment, and mistreatment. The only reason this topic has even been covered is because most of the victims are white.

      Sites like this one failed to keep the public informed, back at the beginning of this scourge. They have been demonizing the addicted, while misleading the public on the facts about people with chronic pain. Racism is very well documented in the medical community, and clearly whoever chose this picture associated people of color with drug addiction. Perpetuation of this willful ignorance, discrimination, and fact free view, is killing Americans.

      People should be asking why we are allowing these profiteers to continue to control the governments response. Since the begging, the facts have not been fully gathered or disseminated by our media. Instead of protecting American lives, our government joined pharma and other industries to turn this scourge into a marketing opportunity. Even as the deaths rose, not one agency demanded an objective look at why.

      The rising death rates, increasing suicides, and overdose deaths might indicate a problem, yet there has not been any objective research, meaningful discussion or even fact based news coverage. Clearly dragging this out, while stigmatizing certain groups , and misleading the public, has been profitable. Peddling ignorance and racism has proven deadly, but that does not appear to put the brakes on this kind of behavior.
      One of the reasons so many people are dying, is that these news peddlers portray it as “those people.” The Pharma Execs that lied in their marketing materials to improve market share, along with the medical, treatment industry, and insurers, are still misleading the public. They used this scourge to enrich themselves while interfering with the collection of fact based data.

  • Beware of unintended consequences.

    Will noloxone save lives? Surely, but for how long? First, easy access at CVS may lull addicts into complacency. It might merely enable continued drug abuse with minimum fear of overdose.

    Second, not to be too morbid on the subject, but as Case and Deaton have asserted, many ODs are not accidental but suicides of despair. Everyone knows that sooner or later heroin users will get dosed with fentanyl, so heroin abuse is like painless Russian roulette. Thus, naloxone might increase the number of OD recoveries, but not necessarily the number of deaths.

    Finally, easy naloxone might discourage entering into treatment.

    • This doesnt make sense. Is there any data to back this up? I question if this is written by someone who is influenced financially or otherwise by the pharmaceutical or treatment industries.

    • Connie, I am a retired Nat’l Inst on Drug Abuse official who directed several national research programs in addiction. I have never had any financial interests in any pharma company or healthcare provider organization.

      If you want to learn more, read ethnographic studies like those of the Late Mike Agar on street addicts. Those reports show that opioid addicts know what they consume and from whom they get it. As for suicides, you likely can access several reports by Googling Anne Case and Angus Deaton at Brookings Inst. There was also an interesting report this year by Woolf & Aron in the British Medical Journal. Back in 2015 Thor Norström, Hans Grönqvist had a similar finding from an international perspective also in BMJ.

    • As someone who has buried a son and watched friends lose children ..at least in my experience and as an health care executive I don’t see suicide as the driver in many of these cases.
      I see so many lives lost that if an intervention had been made for many there was a chance to move past their addiction and have a future.

    • Thank You Mr. Hilton,
      There have been lots of unintended consequences, and you make valid points. the number of suicides among people with chronic pain have been downplayed of not outright removed from the conversation. There was not thought given to any of these adverse effects of the response which was ill advized and unscientific.

      The over-hyping of Naloxone, could very possibly be contributing to the rates of addiction, or drug abuse. People believe it is cure, while it only reverses overdoses. It might make people more likely to engage in risky behavior. Not much research has been done on that, by design. In my state I suspect the reason we don’t have more overdose deaths, is due to the availability of cheap Mexican Heroin. Instead of acknowledging that fact, our state officials, and policy makers, claim our state is at the forefront. Our addicted here are long term heroin addicts, it is generational. Out local politicians put a positive spin on is all, making it appear they did something that stemmed the number of deaths. Our local news journalists are still stigmatizing “Addicted Infants” in spite of guidance that suggests that could lead to pregnant women avoiding treatment.

      There is still no action or outage on the number of industries that have been cashing in on this scourge. I blame Neo Liberalism, and Market Based Healthcare. If there were not so many people trying to make a fast buck we would have seen this coming and mounted a sensible defense.

  • OTC naloxone maybe a good idea. How did OTC needle/syringe availability impact the AIDS crisis? More discussion is needed

  • My thoughts exactly Naloxone should definitely be ready available over the counter as should Suboxone just make it all ready available and Government controled

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