A drug used to reverse opioid overdoses has been hailed for saving thousands of lives nationwide, but some municipalities are having trouble accessing it.
There has been a widespread push to distribute the drug, naloxone, to first responders and civilians in places that have been affected by the opioid crisis. It is now available over the counter at all Walgreen's pharmacies.
But in some places, the strain on municipal budgets and a need for an increasing amount of naloxone has made it difficult to keep enough in stock.
In Baltimore, public health officials have fewer than 10,000 doses available for use between now and July 2018 because they do not have the money to purchase more. One dose costs between $70 and $90 for the type of the drug the city purchases, which is administered as a nasal spray.
"Every day I have to make decisions about who has access to this medication and who does not," said Leana Wen, the Baltimore city health commissioner, who has made it a priority to provide universal access to the drug.
The nation, she said, is in the middle of a public health emergency because of opioid abuse. If it were for any other reason, she said, an inadequate supply of medication would be unacceptable.
"We are rationing our very limited supply of naloxone at a time when people are dying every day," Wen said.
Part of the issue, public health officials said, is the price of the drug. Two doses of an injectable form of naloxone, Evzio, cost $4,500, up from $690 in 2014. The price of other forms of the drug, including the nasally administered Narcan, typically range from $70 to $150 per dose. The drug also comes in a syringe that allows the drug to be injected intravenously.
The rise of fentanyl, a powerful synthetic opioid that is now driving overdose deaths, has made it necessary for first responders and others to have more naloxone on hand. The drug is so powerful that it can take multiple doses of naloxone to reverse an overdose.
"With fentanyl you need more doses," said Tom Miller, the West Virginia director of the National Volunteer Fire Council. Miller said many in the state have "trouble getting it and getting it replaced."
In Washington, North Carolina, Doug Bissette, battalion chief of the city's fire and EMS services, said there has been concern that the city - about 100 miles east of Raleigh - might run out of naloxone because of the high demand for the drug in the area.
"We want to make sure we don't run out on our trucks, and while there's enough to keep on the trucks, we have to keep enough in our supply closet," he said. "We have not run out of any, but we have come close."
Bissette said he has just one dose in his storage room, but the department's trucks are fully stocked - and he is expecting five more doses this week.
In a statement, Kaleo, which manufactures the auto-injector naloxone known as Evzio, said it has donated more than 280,000 naloxone auto-injectors to public health departments, first responders and nonprofit organizations.
Thom Duddy, director of communications for Adapt Pharma, which makes naloxone in nasal spray form, said there have been no shortages of their form of the drug. He said the drug has 94 percent insurance coverage, including with Medicare and Medicaid, and about 75 percent of patients pay a $10 co-pay, or less, for it. The company also has brokered direct purchasing deals with a number of municipalities. A box of the drug, which contains two doses, costs $75.
Duddy said grant money and federal funding is available to municipalities purchase the drug. The company donated 30,000 doses of naloxone to Hamilton County, Ohio, earlier this year, and researchers plan to study how availability of the drug affects the overdose rate there.
"We need to help educate these folks on where the money's at and where there's available funding," he said.
But Robin Pollini, an associate professor at the West Virginia University School of Medicine, said the funding system can be burdensome. She said West Virginia received $1 million to distribute 8,250 naloxone kits earlier this year; they were all gone in four months.
"We give them out, and then we wait for the next funding opportunity," she said.
She said the state is dependent on the federal government putting out requests for grant proposals, which are cumbersome and take time. The national request model doesn't take into account local need: Some places might need to equip their police with naloxone, while other places might want it to give to the friends and family members of known drug users.
Places like West Virginia, she said, need to face the reality that the opioid crisis is getting worse with the introduction of fentanyl and will require long-term investment.
"We don't have a long-term established distribution and funding plan for this drug for the state," she said.
Clif Johnson, director of clinical compliance and physician services at Southeast Missouri Behavioral Health, said his center has expanded thanks to a two-year federal grant given to the state. But three months later, the center has nearly reached its patient limit and Johnson can't find money to help local law enforcement get the opioid antidote.
"There still is not funding to help cover those costs," Johnson said. "The firefighters and the police have to foot their own bill for Narcan."