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Reply to Letter to the Editor Regarding Article: “Considering the Potential Benefits of Over-The-Counter Naloxone” [Response To Letter]

Authors Evou KE , Hill LG , Davis CS

Received 1 July 2021

Accepted for publication 1 July 2021

Published 9 July 2021 Volume 2021:10 Pages 77—78


Kirk E Evoy,1,2 Lucas G Hill,3 Corey S Davis4

1Division of Pharmacotherapy, The University of Texas at Austin College of Pharmacy, San Antonio, TX, USA; 2Department of Pharmacy, University Health, San Antonio, TX, USA; 3Division of Pharmacy Practice, The University of Texas at Austin College of Pharmacy, Austin, TX, USA; 4Harm Reduction Legal Project, Los Angeles, CA, USA

Correspondence: Kirk E Evoy Email [email protected]

View the original paper by Dr Evoy and colleagues

This is in response to the Letter to the Editor

Dear editor

We concur with Dr. Fuehrlein that increasing naloxone access is only one component of a comprehensive strategy to reduce opioid-related overdose (ORO) mortality. We believe efforts to increase access to medications for opioid use disorder (MOUD), including permitting healthcare professionals such as pharmacists and paramedics to facilitate initial and ongoing MOUD treatment,1–3 are crucial.

However, we strongly disagree that efforts to remove barriers to this lifesaving medication are incompatible with connecting people with opioid use disorder (OUD) to MOUD. To our knowledge, there is no evidence that requiring a patient to interact with a healthcare professional before obtaining naloxone increases the likelihood that the patient will receive MOUD. Unfortunately, prescribers do not routinely discuss OUD risks or co-prescribe naloxone when prescribing opioids, and even patients who experience an ORO often do not begin treatment with MOUD.4–6 Furthermore, pharmacists rarely assess the need for, or counsel on the benefits of, OUD treatment when dispensing naloxone, and often report feeling unprepared to do so.7,8

Despite continuing legal and regulatory barriers associated with naloxone’s status as a prescription-only medication, many people currently obtain naloxone without ever meeting a medical provider. In fact, harm reduction organizations were for many years the dominant source of take-home naloxone. In 2018, a limited subset of syringe services programs distributed over 700,000 naloxone doses, compared to approximately 550,000 naloxone prescriptions dispensed from retail pharmacies.9,10 In 2019, a single harm reduction initiative distributed over one million doses of naloxone across the United States.11 These and similar low-barrier sources of naloxone are critical for reaching the many people who use drugs who avoid traditional healthcare settings due to past negative, stigmatizing experiences with healthcare professionals, as well as those without the financial means to access traditional care.12 Low-barrier harm reduction programs are also extremely effective at connecting people to evidence-based treatment.13

We further note that not all illegal drug use is disordered use, and even occasional use of illegal or illegally-obtained drugs can lead to a potentially fatal ORO. Thus, many people who are at risk for ORO do not have an indication for MOUD. The need to facilitate naloxone access for people who are at risk of overdose but do not have OUD is increasingly urgent due to the increase of potent synthetic opioid adulterants in both non-opioid drugs and counterfeit opioid tablets.

Ensuring widespread access to naloxone is not sufficient to ensure that people with OUD engage with treatment, but in many cases it is necessary. People with OUD will not commit to treatment until they are personally ready. Imposing unnecessary naloxone access barriers may tragically reduce the likelihood they survive to that point. We therefore support the removal of barriers – stigma, legal, financial, and otherwise – that keep people from accessing both naloxone and MOUD, including moving at least one naloxone product OTC.


No funding was obtained to develop this communication.


Dr. Hill served on a community advisory board for Hikma Specialty USA Inc. in 2020. The authors of this communication have no other conflicts of interest to disclose.


1. Davis CS, Samuels EA. Opioid policy changes during the COVID-19 pandemic – and beyond. J Addict Med. 2020;14(4):e4–e5. doi:10.1097/ADM.0000000000000679

2. Peterkin A, Davis CS, Weinstein Z. Permanent methadone treatment reform needed to combat the opioid crisis and structural racism. J Addict Med. 2021. doi:10.1097/ADM.0000000000000841

3. Davis CS, Carr DH, Glenn MJ, Samuels EA. Legal authority for emergency medical services to increase access to buprenorphine treatment for opioid use disorder. Ann Emerg Med. 2021;78(1):102–108. doi:10.1016/j.annemergmed.2021.01.017

4. Jones CM, Compton W, Vythilingam M. Naloxone co-prescribing to patients receiving prescription opioids in the medicare part D program, United States, 2016–2017. JAMA. 2019;322(5):462–464. doi:10.1001/jama.2019.7988

5. Evoy KE, Leonard CE, Covvey JR, et al. Receipt of substance use counseling among ambulatory patients prescribed opioids in the United States. Subst Abuse. 2020;14:1–4.

6. Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a Cohort Study. Ann Intern Med. 2018;169(3):137–145. doi:10.7326/M17-3107

7. Contreras J, Baus C, Brandt C, et al. Pharmacist counseling when dispensing naloxone by standing order: a secret shopper study of 4 chain pharmacies. J Am Pharm Assoc. 2021;61(2):e94–e99. doi:10.1016/j.japh.2020.10.010

8. Thompson EL, Rao PSS, Hayes C, Purtill C. Dispensing naloxone without a prescription: survey evaluation of ohio pharmacists. J Pharm Pract. 2018;32(4):412–421. doi:10.1177/0897190018759225

9. Lambdin BH, Bluthenthal RN, Wenger LD, et al. Overdose education and naloxone distribution within syringe service programs — United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(33):1117–1121. doi:10.15585/mmwr.mm6933a2

10. Guy GP Jr, Haegerich TM, Evans ME, Losby JL, Young R, Jones CM. Vital signs: pharmacy-based naloxone dispensing - United States, 2012–2018. MMWR Morb Mortal Wkly Rep. 2019;68(31):679–686. doi:10.15585/mmwr.mm6831e1

11. Wheeler E, Doe-Simkins M. Harm reduction programs distribute one million doses of naloxone in 2019. Available from: Accessed June 28, 2021.

12. Donovan E, Case P, Bratberg JP, et al. Beliefs associated with pharmacy-based naloxone: a qualitative study of pharmacy-based naloxone purchasers and people at risk for opioid overdose. J Urban Health. 2019;96(3):367–378. doi:10.1007/s11524-019-00349-1

13. Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000;19(3):247–252. doi:10.1016/S0740-5472(00)00104-5

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