Pharmacists have been called on to make naloxone widely available. But do they know how to use it?

ALEXANDRIA, Va. — Sixty pharmacists began a recent Friday here in the company of a limbless dummy, watching an animation of a bird named Kiwi develop an addiction to golden nuggets.

It was a pointed, if simplistic, way to explain the opioid crisis, and why first responders and even non-health professionals are often called upon to administer naloxone, the overdose-reversal drug. So at a conference just outside Washington, the dozens of pharmacists spent an hour of their free time learning to assemble nasal naloxone kits, squirt a milliliter of the drug into each nostril of someone experiencing an overdose — or use an autoinjector to stab them in the thigh and hold it there until a robotic voice finished counting to five.

It was all part of an effort to bridge a basic gap in the national response to the opioid crisis: That while public health figures have called for naloxone to be made universally available, pharmacy customers seeking the medication will need to be trained to use it, and pharmacists will be the ones to train them.

“We all have fire extinguishers,” said Sarah Melton, the lead trainer and a professor of pharmacy practice at East Tennessee State University, calling naloxone a similarly logical precaution and urging the audience to help their customers become “lay rescuers.”

Major health figures, including Surgeon General Jerome Adams, have joined that call, asking local governments and health providers to make naloxone available to all hoping to carry it. While most health professionals increasingly see themselves as vital in lessening the country’s 72,000 annual drug overdose deaths, the degree to which pharmacies have listened varies dramatically.

Pharmacists have been called on in a variety of ways to address the opioid crisis, including counseling patients who’ve been prescribed high-dose opioids, participating in drug-monitoring programs, and more carefully vetting patients being prescribed risky combinations of anti-anxiety medications and the powerful pain drugs.

“It’s easy to use, it’s lifesaving, and it’s available throughout the country fairly easily,” Adams said in April, when he issued a rare public health advisory calling on friends and family of those at risk for overdose to stock the drug. Doing so, however, isn’t quite so simple.

In California, according to a recent study published in the Journal of the American Medical Association, fewer than 25 percent of pharmacies expressed willingness to provide the drug without a prescription, despite a 2016 law allowing them to do so.

Yet in Texas, according to a separate JAMA research letter, 84 percent of pharmacists surveyed said they would dispense naloxone without a prescription. (The drug is not a controlled substance and has no effect other than to reverse an opioid overdose.)

Pharmacy Quality Alliance’s training attempted to address head-on the many reasons not all practitioners and first responders have warmed to the cause. Among the potential roadblocks: a simple but multistep assembly process for nasal naloxone kits and the potential for individuals that have been revived to re-enter an overdose state once the naloxone wears off.

One question from an attendee even addressed rare instances of people revived by naloxone treatment exhibiting aggressive behavior, not because naloxone makes them aggressive but because reversing an overdose sends people into a state of withdrawal that can carry with it excruciating physical symptoms.

Then there is the issue of cost.

While increasing naloxone accessibility is a priority, the financial aspect has sometimes proven an obstacle, even as manufacturers donate thousands of doses to schools and nonprofits willing to stock and distribute it.

Adapt Pharma, the manufacturer of the common, nasally administered naloxone version known as Narcan, retails a two-pack of the drug at $75, but has donated tens of thousands of naloxone kits in recent years to schools and first responders.

Kaleo, the drug company that manufacturers another version of naloxone — an auto-injector that requires no assembly and no training to administer — has itself donated a quarter-million Evzio devices. But the company has taken heat for hiking Evzio’s price from $575 to $4,100 in a four-year span, which a Senate report released Sunday said has cost U.S. taxpayers $142 million.

“The fact that one company dramatically raised the price of its naloxone drug and cost taxpayers tens of millions of dollars in increased drug costs, all during a national opioid crisis no less, is simply outrageous,” Sen. Rob Portman (R-Ohio), said in a statement.

As long as Narcan remains the affordable option, however, much of the training for non-health professionals hoping to stock naloxone is likely to fall on pharmacists.

“Pharmacists are going to help with monitoring for risk, educating patients, and storage and disposal (of unused opioids),” said Anne Burns, the vice president for professional affairs at the American Pharmacists Association. “These core, foundational aspects are where pharmacists are getting involved.”

The profession, accordingly, is also becoming more cognizant of its role in the crisis from several vantage points, beginning with the fact that medical professionals have long overprescribed opioids. In many cases, the powerful pain drugs have been prescribed alongside benzodiazepines, which are often prescribed as anxiety medications and are increasingly recognized as posing an overdose risk when combined with opioids.

Another growing fear, acknowledged formally last week by the American Medical Association: That in some practitioners’ haste to reduce prescription levels and conform to recent Centers for Disease Control and Prevention prescribing guidelines, some patients have been undertreated and driven to use illicit opioids, including heroin.

While the conversations about preventive steps have become common, the move toward hands-on overdose reversal — whether for pharmacists themselves or customers seeking naloxone — is new territory for many in the profession.

“Ten or 15 years ago, it was only emerging that pharmacists could provide vaccinations,” Burns said, adding that the profession is moving in the right direction on naloxone access. “It is improving markedly, but there’s work to do.”

After Friday, at least, she and Melton are 54 pharmacists closer to their goal.