AUGUSTA — In New Hampshire, an online map locates scores of pharmacies where anyone can buy an over-the-counter dose of naloxone, a medication that saves lives by reversing the effects of an opioid overdose.

In Utah, the state health director issued a standing order authorizing any pharmacist to dispense naloxone.

In North Carolina, the Republican governor signed a 2016 law that made naloxone widely available at pharmacies under a standing order issued by the state health director.

But in Maine – where an average of one person a day dies of an overdose – Gov. Paul LePage and his administration have stifled efforts to expand access to the life-saving drug.

Rules that would allow Maine pharmacists to dispense naloxone over the counter have sat on LePage’s desk for five months. Other rules that would allow overdose prevention groups and needle exchanges to distribute naloxone to clients haven’t even been drafted by the Department of Health and Human Services – two years after the Legislature passed the law.

Gov. LePage: Narcan ‘does not truly save lives.’

The administration’s inaction comes even as conservative Republicans nationally – including President Trump and former New Jersey Gov. Chris Christie – have called for increased and widespread access to the overdose antidote.

Although it’s unknown how many deaths may have been prevented had LePage moved more quickly, what is clear is that Maine is falling behind most other states – including many headed by Republican governors or controlled by Republican legislatures – that have made naloxone available to save lives.

Rep. Karen Vachon, R-Scarborough, who sponsored the legislation to make naloxone widely available, said some have still failed to recognize that substance use disorder is an illness that should be treated. Too many people, she said, blame the individual trapped in addiction, which often starts with the use of opioid painkillers prescribed by a doctor.

“I just don’t know how they consider themselves pro-life,” said Vachon, who describes herself as a devout Catholic. The stories of those who recover from addiction are stories of redemption that show the value of human life, she said.

CRIPPLING LAWMAKERS’ EFFORTS

The state’s failure to publish rules for dispensing naloxone has left pharmacists without official guidance. As a result, some of Maine’s largest pharmacy chains, including Hannaford and CVS, say they will not dispense the medication over the counter until the rules are put in place. Maine’s attorney general, Janet Mills, contends that the pharmacy board could publish the rules but the board’s president, Joe Bruno, has said the board is following protocol in awaiting LePage’s approval.

LePage said “I don’t know a thing about it,” when asked about the naloxone rules on Jan. 19. His press secretary has said only the rules are “pending” in the governor’s office.

“Naloxone does not truly save lives; it merely extends them until the next overdose,” LePage wrote when he vetoed a naloxone bill in 2016. “Creating a situation where an addict has a heroin needle in one hand and a shot of naloxone in the other produces a sense of normalcy and security around heroin use that serves only to perpetuate the cycle of addiction.”

Bruno, a pharmacist who owns Community Pharmacies, a chain of nine pharmacies across the state, has refused multiple requests for comment from the Maine Sunday Telegram and Portland Press Herald. Anne Head, LePage’s commissioner for the Department of Financial and Professional Regulation, the state agency that oversees the pharmacy board, also has not responded to multiple requests for comment.

Some lawmakers, including legislative leaders, said they’ve been blamed for not doing enough to address Maine’s opioid crisis, but the reality is that the LePage administration is crippling lawmakers’ efforts.

“It is just clear that the Legislature has intended for years now to make sure that we are doing everything we can to save people’s lives, I believe in the hopes that we can get them into treatment and then get people back on their feet,” said House Speaker Sara Gideon. “And this doesn’t help; we are losing people every day and every single life is worth saving every time.”

Gideon, D-Freeport, and Senate Minority Leader Troy Jackson, D-Allagash, sent a letter Friday to LePage and Bruno urging them to release the rules. Neither man responded.

Maine reported 376 drug overdose deaths in 2016, more than double the number just three years earlier. The Attorney General’s Office has not finalized the numbers for 2017 yet, but Maine was still averaging more than one overdose death a day for the first six months of last year. For the past several years, the vast majority of deaths were caused by heroin, the powerful synthetic opioid fentanyl, or a mix of opioids.

‘A VITAL MED THAT NEEDS TO BE EVERYWHERE’

Maine law allows a medical doctor to issue a standing order to a pharmacy to allow the distribution of naloxone without a prescription, but there is no readily available list of those pharmacies. Staff photo by Joe Phelan

While Maine has failed to act, other states – including Texas, Georgia, Kentucky and West Virginia – have moved to expand access to naloxone, building an increasing body of evidence of how the drug can save lives.

In North Carolina, for example, a state harm reduction coalition, under a statewide standing order, distributed 15,870 naloxone doses in 2015 and recorded that 1,547 of those were used to reverse an overdose. In the year before the law was changed, only 201 naloxone doses were dispensed by outreach workers, who recorded 30 overdoses reversed.

Robert Childs, executive director of the North Carolina Harm Reduction Coalition, said the growing presence of fentanyl – an opioid that is 50 times as potent as heroin – in the black market drug supply makes widespread access to naloxone even more pressing.

“It is a vital med that needs to be everywhere in America and especially around people that use drugs or have a history of drug use at that level,” Childs said, adding that naloxone availability is even more important in rural states like his and Maine, where response and transport times for emergency medical services can be delayed.

Beyond what Childs considers the human rights issue of saving a person’s life are the financial costs of overdose treatment.

In North Carolina, Childs said the average cost of an overdose response that involves an ambulance service and a hospital emergency room intervention is $17,000. He said the costs of treating a patient who has not entered respiratory distress because of a naloxone dose is far less.

“It’s not just a human rights issue, we are talking about costs,” Childs said. “If we as a society are paying more and more costs for overdose-related issues and drug dependency, it is foolish to treat those in an emergency room setting.”

Maine paramedics and EMTs regularly use naloxone to save lives. In 2017 emergency medical personnel gave naloxone 1,534 times, down from 2,380 doses in 2016 and comparable to the 1,585 doses given in 2015. About 70 police departments in Maine are also now administering naloxone, with funding for the drug being provided by the Office of the Attorney General. The program, which started in 2016, has documented 350 overdose reversals.

Portland Police Chief Michael Sauschuck also told the Legislature’s Health and Human Services Committee this month that officers in his department had used naloxone on overdose victims 95 times over the last 15 months.

ACCESS MIXED AT MAINE PHARMACIES

Maine law allows a medical doctor to issue a standing order to a pharmacy to allow the distribution of naloxone without a prescription. Walgreen’s has obtained a standing order and sells naloxone at its Maine stores.

But many pharmacies have no standing orders, and others have flatly said they will not distribute the drug without the rules from the Maine Board of Pharmacy.

Bruno, the pharmacist and board chairman, has said that “most” pharmacies in Maine could provide the drug without a prescription, using a standing order. However, the pharmacy board does not identify where those pharmacies are located, nor does there appear to be any readily obtainable listing elsewhere.

At least one of Bruno’s pharmacies, Community Pharmacy in Randolph, has a standing order to provide naloxone without a prescription to a friend or family member of a person at risk of an overdose, according to a pharmacist who answered a reporter’s phone call last week. The pharmacist said the antidote was stocked in a nasal version and that while most insurance policies cover at least a portion of the drug’s cost, the cash price for a two-dose rescue kit was $170.

An employee at another of Bruno’s pharmacies, located in Saco, said that store could not dispense the drug without a prescription from a doctor.

Other states are broadly promoting access to naloxone, with some states like Kentucky even creating online registries and locator maps showing pharmacies where over-the-counter naloxone is available. Many state websites supplement naloxone directories with links to other resources related to addiction recovery.

In New Hampshire, the state’s Department of Health and Human Services has created an awareness campaign, as well, featuring an online map detailing pharmacies with standing orders to dispense naloxone over the counter. The site also spells out New Hampshire’s law on obtaining a prescription for naloxone and provides links to additional resources, including where free naloxone rescue kits can be found. Vermont and Massachusetts also have similar campaigns and programs.

In Maine, Dr. Christopher Pezzullo, the state’s chief health officer, has not issued a standing order for naloxone, as his counterparts in other states have done. In a report he issued in 2016 on the state’s response to the opioid crisis, Pezzullo makes no mention of expanding access to the antidote.

Pezzullo did not respond to a request for comment and apparently forwarded the Sunday Telegram’s request for an interview to Emily Spencer, spokeswoman for the Maine Department of Health and Human Services. Spencer sent an email to the Telegram saying it should direct questions about naloxone to the pharmacy board.

HARM REDUCTION PROGRAMS IN MAINE

One place where Mainers can get naloxone is at Portland’s India Street Free Clinic needle exchange program, which offers naloxone rescue kits under the standing order of the clinic’s medical director, a physician. Zoe Odlin-Platz, a community health promotion specialist with the clinic, said the program distributed 2,791 doses of naloxone in 2017, and those doses were used to reverse 291 overdoses. The program has been in place since 2015 and has distributed more than 5,000 doses of naloxone.

Those who request a naloxone kit not only receive training on how to use it but also information on what causes overdoses and current information about the potency of drugs circulating in the city at that time.

“The presence of fentanyl on the streets of Portland has certainly had a major impact on the rates of overdose that we are hearing,” Odlin-Platz said.

Other harm reduction programs in Maine, like those run by the Health Equity Alliance, have also been distributing naloxone rescue kits to clients who may be at risk or to those who have a loved one at risk of a drug overdose.

Kenny Miller, the alliance’s executive director, said his organization distributed 252 kits in 2016, of which 60 kits were reportedly used to reverse an overdose, and in 2017 the organization distributed 190 kits and recorded between 95 and 100 overdose reversals. The alliance distributes the kits from its Bangor and Ellsworth offices at no cost. Miller says they do so under the standing order of a doctor, but without the pharmacy rules approved they are operating in a “gray area.”

“But we cobbled together our own program because we could not in good conscience sit back and watch people die,” Miller said.

 

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