Statewide Free Naloxone

Research SummaryPublished Dec 19, 2023

Allows any resident to visit any pharmacy across the state and anonymously obtain naloxone at no cost without an individual prescription or appointment.

A panel of experts rated how they expect this type of policy to affect four outcomes: naloxone distribution through pharmacies, opioid use disorder (OUD) prevalence, rates of nonfatal opioid overdose, and opioid overdose mortality. Another panel of experts rated the policy on four implementation criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
No
Yes

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
Naloxone Pharmacy Distribution
No
No
Yes
OUD Prevalence
No
Yes
No
Nonfatal Opioid Overdose
No
Yes
No
Opioid Overdose Mortality
No
No
Yes
Criteria Implementation Rating
Low Moderate High
Acceptability
No
Yes
No
Feasibility
No
Yes
No
Affordability
No
Yes
No
Equitability
No
No
Yes

Summary of Expert Comments

  • Experts expect this policy to substantially increase naloxone pharmacy distribution because it would eliminate out-of-pocket costs to individuals, which could decrease fatal overdoses.
  • Experts view the policy as only moderately acceptable due to potential pushback against using public funds to provide naloxone given the stigma around naloxone and moral hazard concerns.
  • Experts believe the policy is only moderately feasible due to concerns about naloxone costs and the logistics of implementing this policy.
  • Experts rated the policy as only moderately affordable: It depends on the cost of naloxone, the number of people who participate, and existing infrastructure to monitor its implementation.
  • Experts believe the policy to be equitable because it would eliminate out-of-pocket costs and has high potential for destigmatizing naloxone.

Outcome Summaries

Naloxone Pharmacy Distribution

Amount of naloxone dispensed through retail pharmacies (e.g., chain pharmacy stores, independent community pharmacies).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
 Removes the financial threshold to obtain naloxone, thereby increasing distribution. "Cost and access are 2 big barriers to patients and caregivers getting naloxone, and this would probably be the best-case scenario to make sure it is widely available (especially the anonymity component)"
Little-to-no Depends on whether the policy also has a positive impact on pharmacist attitudes toward and public awareness of the free availability of naloxone. "It's unknown if temporary, free, anonymous, and confidential naloxone distribution from pharmacies affects pharmacist stigma, recommendations, etc. However, perhaps it's a stimulus to the normalization of naloxone"
Harmful N/A N/A

Opioid Use Disorder Prevalence

Percentage of the general population with a pattern of opioid use leading to clinically and functionally significant impairment, health problems, or failure to meet major responsibilities.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial N/A N/A
Little-to-no
(selected)
 No credible mechanism linking policy with OUD prevalence. "Not related to OUD prevalence"
Harmful Potential for revival from overdose could (1) have a small, indirect, and mechanistic impact on OUD prevalence due to increased survivorship and (2) lead to continued opioid misuse. "I don't think we currently have the data necessary to evaluate how increasing the naloxone supply so dramatically will affect risky behaviors. I don't expect the moral hazard effects to be large . . . but I don't think we can rule them out entirely at this point"

Nonfatal Opioid Overdose

Per capita rates of nonfatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial N/A N/A
Little-to-no
(selected)
 No credible mechanism linking policy with nonfatal overdoses. "I do not think this has an effect on the instances of overdoses"
Harmful Potential for revival from overdose could (1) have a small, indirect, and mechanistic impact on OUD prevalence due to increased survivorship and (2) lead to continued opioid misuse. "Would definitely expect some fatal OD [overdose] events to become nonfatal overdose events, likely raising this number even if total OD comes down"

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
 Increase in naloxone pharmacy distribution will yield meaningful decreases in fatal overdoses. "I expect this policy to lead [to] the largest increase in naloxone provision and in turn the largest reduction in fatal opioid overdoses"
Little-to-no Depends on the number of overdoses that are witnessed by bystanders with naloxone. "Fatal overdoses are generally when patient is alone with lack of bystanders and/or timely interventions prior to cardiac arrest"
Harmful N/A N/A

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Public supports a low-barrier method to improve naloxone access and thereby address the overdose epidemic. "I think this would be very popular and an excellent way to ensure that naloxone is made widely available. Stigma regarding naloxone and using public dollars to fund distribution would lead to some opposition. The ongoing escalation in overdose deaths would likely drive support overall"
Moderate
(selected)
 Concerns about potential for pushback against using public funds to provide free naloxone, given stigma around naloxone and moral hazard concerns. "While I think this is a great idea, I'm not sure how the general public would feel about this especially if the 'free naloxone' was somehow being paid for through state taxes, etc."
Low Significant pushback given stigma around naloxone and moral hazard concerns. "Concerns about cost and providing a 'free' good; concerns about encouraging opioid use"

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Reduces administrative burden for pharmacies of working with insurance companies on naloxone coverage. "Aside from setting up billing to the state, I would expect this would reduce administrative burdens at pharmacies (not having to deal with insurers), increasing the feasibility of naloxone distribution"
Moderate
(selected)
 Concerns about naloxone costs and the logistics of implementing the policy. "Some operational complexities (how do pharmacies get paid/stocked, how do they ensure that people are getting an appropriate amount for personal use and not resale/distribution, etc.) but overall feasible to have pharmacies as a point of distribution of free naloxone"
Low Concerns about naloxone costs, who is paying for it, and receptivity of pharmacies to implement the policy. "Not clear how it would be paid for, and how receptive pharmacies would be to take this on, especially without payment for providing the service"

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Reduces administrative costs and is cost-effective. "This could both reduce societal costs by reducing fatal overdose, as well as reducing costs associated with seeking naloxone among patients because it would both not require an office visit with a provider and not require money or insurance. There would be lesser administrative costs for pharmacies compared to the other payment models that involve insurers"
Moderate
(selected)
 Depends on the cost of naloxone, the number of people who participate, and existing infrastructure to monitor implementation. "It all depends on which formulation and the contract the State has with the pharmaceutical co."
Low Purchasing naloxone wholesale would incur substantial costs to the state. "This could incur substantial costs for the state or community. Might work better if this was reserved for those without insurance coverage or means"

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
 Eliminates out-of-pocket costs for everyone (including uninsured) and has high potential for destigmatizing naloxone. "I think this seems about the most equitable policy options presented so far. It would mean a person could go into every pharmacy in their state, as many times as they wanted and get naloxone"
Moderate Eliminates out-of-pocket costs for everyone (including uninsured) and has high potential for destigmatizing naloxone — but it still would require pharmacy access. "Would still require travel to a pharmacy. Pharmacies should not be the be all end all location for obtaining naloxone"
Low N/A N/A
Cover: Statewide Free Naloxone

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Statewide Free Naloxone, RAND Corporation, RB-A3054-15, 2023. As of September 8, 2024: https://www.rand.org/pubs/research_briefs/RBA3054-15.html
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Statewide Free Naloxone. Santa Monica, CA: RAND Corporation, 2023. https://www.rand.org/pubs/research_briefs/RBA3054-15.html.
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