Will 2015 Be the Year of Harm Reduction?

The past couple of years have been game-changers for harm reduction. The movement to reclaim the health and dignity of people who use drugs has celebrated the rapid passage of overdose prevention and syringe decriminalization laws, expanded access to the life-saving overdose reversal drug naloxone, and welcomed endorsements from such prominent, previously skeptical agencies as the Office of National Drug Control Policy, the American Medical Association and the Centers for Disease Control.

But all that is just a warm-up for what’s coming in 2015. Keep an eye out for big changes as the pharmaceutical industry elbows its way into overdose prevention, a bold new flavor rises from the South, harm reductionists revolutionize how naloxone is distributed and much more.

Big money behind naloxone?

Big Pharma’s new interest in naloxone is a key development to watch this year. When naloxone first debuted on the market in 1961, emergency departments and ambulances scrambled to stock the miracle drug and pharmaceutical companies rushed to make it. But once this very specific demand was met, the drug was no longer considered profitable and interest in manufacturing petered out. By 2008, one company, Hospira, held a monopoly on injectable naloxone, while another, IMS/Amphastar, sold the only form of naloxone that could be adapted for intranasal use.

But over the past of couple years things have changed, thanks to community-based harm reduction programs that distribute naloxone to people at risk for opioid overdose. Harm reductionists have offered naloxone to lay people since 1996, but demand has skyrocketed over the past three years due to the rash of opioid-related deaths and greater public awareness of naloxone. No longer a drug only for emergency rooms and ambulances, naloxone is now considered something that every person who takes opioids should have in their home—and Americans take home over 200 million prescriptions for opioids every year. So Big Pharma is now interested. Very interested.

Last year the FDA fast-tracked approval for a new auto-injectable naloxone device. In 2015 and beyond, expect to see the market flooded with user-friendly naloxone gadgets from a variety of new pharmaceutical companies.

“We entered a deal with [a pharmaceutical company] because we can’t afford naloxone otherwise, but we’re afraid they will pull out and our program will collapse. At the end of the day, we are in this to save lives, but they are in this for the money.”

This could be mixed news for harm reductionists. On the one hand, pharmaceutical companies can use their considerable influence in the media and the medical community to market their products, which will save us many resources that were previously spent on raising awareness. Pharma companies also help reduce stigma against naloxone by marketing it as an emergency medication that should be kept at home by anyone who takes painkillers—thereby distancing it from being associated only with illegal drugs. The more people who know about naloxone, the more it is available and the less it is stigmatized, the more lives it will save.

On the other hand, pharmaceutical companies’ involvement in overdose prevention comes at a high price, literally. As interest in naloxone has increased, so has its cost. Last year the price of newfangled gadgets such as the talking auto-injector hit hundreds of dollars per unit. To counter the sticker shock, some pharma companies have offered a limited supply of naloxone to a small number of harm reduction agencies at reduced price or as donations. But with donations comes dependency, leaving many programs vulnerable to the fickle generosity of Big Pharma.

“We entered a deal with [a pharmaceutical company] because we can’t afford naloxone otherwise, but we’re afraid they will pull out and our program will collapse,” says one anonymous source who works at a naloxone distribution site. “At the end of the day, we are in this to save lives, but they are in this for the money.”

Naloxone pricing won’t be the only area in which 2015 will likely be a defining year in the relationship between harm reduction and the pharmaceutical industry. A similar dance is happening over the price of a new hepatitis C treatment. Last year Gilead Sciences introduced a medication with up to a 90% effectiveness rate. The cure for hepatitis C could finally be within reach. Unfortunately, the new medications run at $1,000 per pill, taken daily for 12-24 weeks. Harm reductionists are lobbying for donations, but even if they succeed, relying on gifts once again leaves them with a risky dependency on the whims of the pharmaceutical industry.

Gatherings for change

While the battle around prices for life-saving medication continues, 2015 also promises change from an unlikely place: the South. For too long, harm reduction has been dismissed as hopeless under the Mason-Dixon line. Southern states are years, even decades behind their northern counterparts in terms of legal syringe exchange, naloxone access, and disease prevention. Instead of opening discussions on the merits of safe injection sites, they are working to deflect allegations that HIV is God’s punishment for sin.

“We deal with more stigma, more obstacles to syringe access and treatment for hepatitis C and HIV, and fewer resources than any other part of the country. Despite that, Southern states have accomplished a lot.”

But this year, the Red Zone has something to brag about. Seven Southeastern states (North Carolina, Virginia, Kentucky, Tennessee, Georgia, Florida and Louisiana) recently passed 911 Good Samaritan and/or naloxone access laws, and two (NC and GA) have launched statewide overdose prevention programs. Even more impressively, five plucky states (NC, KY, TN, FL and Texas) plan to introduce syringe legislation in 2015—a bold step in a region where syringe exchange is currently illegal. To discuss these plans and strategize, advocates will gather this June for the 2015 Southern Harm Reduction and Drug Policy Conference in Asheville, North Carolina.

“The Southern Harm Reduction and Drug Policy Conference is a chance to talk about the unique challenges facing red states,” says my colleague Robert Childs, executive director of the North Carolina Harm Reduction Coalition, which will host the conference. “We deal with more stigma against people using drugs, more obstacles to syringe access and treatment for hepatitis C and HIV, and fewer resources than any other part of the country. Despite that, Southern states have accomplished a lot in the past few years, in part due to alliances and relationships built at conferences like these.”

Another hugely important event will take place this November, when the Drug Policy Alliance hosts its biennial international drug policy reform conference in Washington, DC with over one thousand delegates from around the world. As always, this will be a major opportunity to learn, network and strategize about harm reduction and ending the war on drugs, and it should build further on the success of the Harm Reduction Coalition‘s conference in Baltimore last October.

Over-the-counter naloxone

In 2015 you can also expect to see naloxone available in a place so obvious you’ll wonder why it wasn’t there all along—pharmacies. While some states will continue to push for laws that allow health departments and community-based organizations to distribute naloxone without a doctor present, others are moving on to the next challenge: making naloxone available over-the-counter.

“Ultimately the goal [of the harm reduction community] is to make naloxone affordable and accessible over-the-counter,” says Dan Bigg, director of the Chicago Recovery Alliance. “The message [of 2015] is that people should be empowered to save lives and pure antidotes like naloxone should be available to them.”

Technically, naloxone cannot be considered an over-the-counter drug until the FDA approves it as such. That means years of red tape and costly research trials that no one is anxious to pay for. So harm reductionists are going about it another way by introducing state laws that give pharmacists the ability to dispense naloxone upon request. New Mexico, Washington, New York, Rhode Island, Vermont and California have so far passed such laws, which effectively make naloxone available over-the-counter. The laws are supported by the National Association of Boards of Pharmacy (NABP), which issued a statement last October stating that it “resolves to address the drug overdose epidemic crippling our nation by engaging with state and federal officials and representatives from national associations to support programs that involve an active role for pharmacists in expanding access to the opioid overdose reversal drug.”

As the states with pharmacy access laws start to implement them and other states follow suit, obtaining naloxone could become as easy as walking into a local pharmacy and asking for it. The community-based programs that currently distribute naloxone should continue to provide it free to people who can’t afford the counter price, but the addition of an over-the-counter option means an exponential increase in access.

Fighting for better times ahead

Competition in the pharmaceutical industry, new Southern initiatives and over-the-counter naloxone are not the only changes to expect in 2015. Other exciting prospects include a push to lift the federal ban on funding for syringe exchange programs, efforts to increase access to medication-assisted treatment (methadone and Suboxone) for people with opioid addiction—plus calls for supervised injection sites, safe syringe disposal and dedicated federal funding for overdose prevention programs.

Ultimately, the harm reduction community hopes to turn the conversation on drug use away from criminality and towards the promotion of health and human dignity. That includes taking the resources now dedicated to locking nonviolent people in cages and funneling them into initiatives that promote safety, community and human life.

That is the real fight behind all the others. 2015 will be a pivotal year. Let’s make sure it turns in the right direction.


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