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.

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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  • Dr. Hilton,
    I am a research chemist is pharma. There is a simple test for clandestine and analogues of fentanyl in heroin. It is available in a simple flex-able vial similar to field tests for cocaine and methamphetamine. The chemicals that cause the color reaction are in the vial. Simple add a small amount of heroin and crush. The bright color develops immediately. The cost is about 15 to 20 dollars depending on quantity purchased. Unfortunately they are only available to forensic chemists with DEA clearance and law enforcement.
    So if someone is going to use heroin, tainting can be verified before use.
    These should also be made available not only to users but to those severe chronic pain patients that have lost their medications due to scared physicians.

    • Right, because addicts want to make sure the don’t get too high. Come on, folks! No heroin addict is sitting around with vials double checking purity and making sure their ‘kits’ are sanitized…

  • Suggesting Narcan as a viable solution to opioid addiction is ludicrous. Yes, it does save lives when the stars are aligned and those over-dosing are near by someone who has this stuff, but, really, that’s a theoretical premise that real life almost always foils. This notion that ‘grandma just took too many pills, Mom, grab the Narcan’ or that drug addicts are in living situations that provide “drug overdose chaperone’s” is just plain dumb. Might as well require everyone become a 12-stepper too. Maybe we should solve drive by shootings and gun deaths by requiring everyone to wear a bullet-proof vest?

    • I agree. We act like there is a cure for addiction despite evidence of a genetic predisposition in a tiny sliver of the gene pool, and despite multi-morbidity (especially psychiatric) being the norm, and despite relapse being the norm.

      All that FDA and the SG are doing is trying to shift the supplier of illicit addictive drugs to a licit supplier Big Pharma. I have seen anecdotal reports from EMTs that they Nalaxone the same people repeatedly until one day they arrive too late. Case & Deaton at Brookings call that suicide of despair.

      I keep saying that a genetic modification is the likely hope for a cure. Alas, we still do not know enough to prevent or blunt opioid highs without disrupting the dopamine and related systems. I think George Koob’s model makes it clear that for addicts they need more than to re-set their homeostatic set-point; they need to move it to where it should have been all along.

    • Narcan was another highly successful marketing campaign by pharma. They did Pr releases that touted how they “donated” their product to overworked financially strapped police departments, paramedics and emergency rooms. They created brand recognition, and increased sales of their expensive product. At the same time the availability of this product, made it appear that they were doing something.
      The opioid reversal products do help in limited circumstances, but that was all that they did. This problem goes back to 1996, if you believe the current false narrative. In that time they have done little or nothing, but market expensive programs, for the well insured. They even had reality shows, that marketed “treatment” at expensive beach-side resorts style programs. The fact that the reality stars were dying, after discharge from these expensive programs, did not matter. People like Dr Kieth Ablow, made a lot of money, and spread a lot of lies.

      This serious social problem, is nothing more than a genocidal marketing campaign. Even communities that had problems prior to Perdues deceptive marketing campaign, have still not tackled the problem.

    • I know many integrative Doctors here in Nevada. Each of them is required to also be certified and licensed as medical practitioners. This notion that they or their services are fraudulent shows what a complete lack of knowledge and utter biases you have toward these practices (that have been successfully used a hell of a lot longer than ‘Western Medicine’.

    • Dear M. Johnson,
      I’ve used acupuncture to almost completely stop allergy reactions (for up to 8 months after 7 visits) that were causing headaches so severe I couldn’t work. My MD ENT’s recommendation was to take ephedrine medication that spiked my blood pressure so high that I’m now on medication for elevated blood pressure, by the way, acupuncture did not relieve the blood pressure issue, I tried it. At least try to pretend you have an objective mind.

  • Agreed. Acupuncture has an extraordinary number of studies now demonstrating its efficacy for pain relief. Here’s a systematic review of nonpharmacological treatment for chronic pain. For people like Mavis Johnson below, who may not be at all familiar with research, a review study provides a much higher level of evidence than a single study. This review explores acupuncture AND other forms of pain management that do not involve pharmaceutical drugs: https://www.ncbi.nlm.nih.gov/pubmed/30179389

    • Ms Boice,

      When the NIH allowed the Acupuncture and Quacks industries to use their site for marketing purposes, they lost a lot of crediblity. These acupuncture studies are deceptive, unscintific, and biased. They actually prove that accupuncture does not work. Read up on how Scince works adn then look at that junk “research.” People are really gullible!

  • This is really simple: 1. The opioid crisis touted is the news is actually a Heroin/Clandestine Fentanyl crisis.
    2. The opioid crisis should really be defined as the forced taper of life saving medications of Chronic Pain Patients .

    • How creepy! A marketer calling themselves “Trust.” Acupuncture is Fraud, plain and simple. There is still no evidence it does anything. Universities were given millions to “study” acupuncture, yet no evidence of any benefit. it should be criminal to peddle this garbage and lies. No one counts the deaths and adverse events associated with acupuncture or other quackery.
      Norht Korea forces their people to rely on acupuncture, they have nothing else. They have the worst healthcare outcomes in the world.

    • Unless there is a better treatment, acupuncture will prevail as always.

      Acupuncture is the best treatment available thus far.

    • I have gotten to see how acupuncturists operate on a very close level. There also seems to be a correlation between the number of acupuncturists in an area, and the number of heroin addicts. There is an acupuncture school, where I live and the highest rates of addiction, suicide and heroin addiction. Coincidence I think not. Not one of the people afflicted with addiction or the other issues acupuncturists pretend to treat have ever been helped. I do not know one person, and i know many that was ever helped in the least by an acupuncturist. Most of them become acupuncturists, because it is an easy way to get credibility, and rip people off. They prey on vulnerable people with all kinds of health problems, including addiction, only because there is money to be made.

      It is really easy to see there is no beneficial effect to acupuncturists, in fact they are dangerous. This new age hooey has led to even more deaths due to addiction.

    • Johnson,
      Mention a better pain treatment than acupuncture. There’s no need to debate, unless you can provide a better treatment, until then acupuncture, acupuncture medicine all the way.

    • Just about any other treatment is better than acupuncture. One country where they really like acupuncture, in N Korea. A country with the worst healthcare outcomes in the world. They don’t have much healthcare, and people regularly die from malnutrition, curable cancers, TB, and routine easily treatable infections.

      “Battlefield Acupuncture” went over like e lead balloon, because it is useless. Leeches are more effective than acupuncture, or maybe a hot cup of tea.

      https://sciencebasedmedicine.org/improperly-performed-acupuncture-linked-to-spontaneous-human-combustion/

    • Johnson,

      Here you go again mentioning N. Korea. Sanitation decreases the prevalence of diseases especially bacterial diseases as occur in NY in the 20th century. Furthermore any society with lack of critical care medicine will have a high mortality rate. And last acupuncture is an adjunct medicine as any other medicine. It has it place. It’s not for everything, like any drug or treatment.

    • Agreed. Acupuncture has an extraordinary number of studies now demonstrating its efficacy for pain relief. Here’s a systematic review of nonpharmacological treatment for chronic pain. For people like Mavis Johnson below, who may not be at all familiar with research, a review study provides a much higher level of evidence than a single study. This review explores acupuncture AND other forms of pain management that do not involve pharmaceutical drugs: https://www.ncbi.nlm.nih.gov/pubmed/30179389

  • If we are to consider OUD a disease we must hold unscrupulous or wreckless prescribers criminally responsible. As clinicians we must offer and promote safe alternatives to our clients. However, just as smokers continue to smoke and diabetics continue to be non-compliant we must accept that some and possibly many who choose to abuse drugs of all kinds will meet an early demise. I have worked both sides of the opioid epidemic (as a responsible provider opioid prescriber and one that worked for a detox facility). Abuse is a human problem wether it be food, sex, deviate behavior or opioid abuse. I have seen many legal and legitimate opioid users of all ages continue to lead productive lives. Many work full time jobs to provide for themselves and their families. I believe they suffer but play by the rules even with the added financial and time burdens. I agree Naloxone should be cheap and should be over the counter. But Don’t punish the people that suffer more and continue to play by the rules. Where are the studies comparing the total number of people taking opioids legitimately to those who abuse them? I would bet the majority is legal by far. Spend our tax dollars somewhere else.

  • Unfortunately making naloxone over the counter and available everywhere has done nothing to help the opioid epidemic and has only worsened it. Addicts are now using more fentanyl and laced heroin because the fear of dying is gone. Enabling addicts does nothing to help the addiction. We also have heroin safe houses in our state which allow addicts to shoot up with clean needles provided by the state in a facility manned by medical staff to allow quick narcan if they overdose. And the war on drugs continues and my state is about to legalize marijuana for recreational purposes!

  • This article is problematic on a couple of levels:

    1. Naloxone does nothing for the addictive process. What it does is bring a person who has overdosed back from death. That’s a big deal, but it should not be confused with treatment for the Opioid Use Disorder.

    2. With the spread of naloxone, even though limited, we are seeing an increasing number of deliberate overdoses. In other words, some individuals are using sufficient quantities of opiates to induce overdose so that they can “die” and then be revived. I haven’t seen any attention paid to this phenomenon, but selling naloxone over the counter may well have the unintended consequence of increasing this behavior.

    3. One of the greatest deterrents to Opiate misuse has been the fear of dying from OD. I wonder what happens when we finally remove all potential negative consequences to addictive behavior?

    • The so called Opiate Epidemic has been a cash cow for pharma, and the medical and Insurance industries. They are not going to start relaying facts, as long as there is a buck to be made. Plenty of states stocked these drugs in order to appear to be doing something, while benefiting their friends in pharma. They provided the expensive drugs instead of evidence based treatment. It made good public relations pieces in local papers and enriched pharma. They have been deceiving the public on the nature of this problem, since many overdoses involve multiple drugs and alcohol. This is a market based solution to a market created problem. The writer here is very likely funded by the pharma industry, these publications don’t appear to make a distinction between advertising and fact based information.

      There is no evidence there are deliberate overdoses. There is a lot of evidence that a good portion of the deaths attributed to opiates are suicides. They have been keeping the number of chronic pain patients, and sick people denied healthcare out of the announced numbers. They also deliberately conflated pain patients, with legitimate medical needs, with heroin addicts. The profiteers saw an opportunity there.