By Robb Layne
San Francisco Chronicle
In the face of California’s escalating overdose crisis, Gov. Gavin Newsom and the state Department of Public Health recently took necessary action by introducing a statewide standing order to streamline the distribution and administration of the opioid reversal medication naloxone across the state.
However, this move, while laudable, does not fully address the complexities of the crisis, especially with the rise of synthetic opioids like fentanyl. This inadequacy becomes all too apparent when considering the tragic and heartbreaking incident of a 2-year-old in Sacramento who, despite receiving two doses of naloxone, still died from an accidental — and preventable — overdose.
California’s opioid response dashboard shows that 87% of deaths from opioid overdoses involved fentanyl in 2022. The urgency of the situation demands a more comprehensive and collaborative response, one that acknowledges the evolving challenges posed by the “fourth wave” of the epidemic.
This fourth wave is being driven by the lethal combination of fentanyl and other recreational drugs like methamphetamine, cocaine and marijuana, as well as counterfeit prescription opioids, which places a larger population unknowingly at risk of an overdose. A study from UCLA and Harvard researchers found that roughly 22 teens aged 14 to 18 died from overdoses each week in 2022 in the country, predominantly influenced by the rising prevalence of fentanyl-laced, counterfeit prescription pills.
Naloxone, while a crucial tool, often proves insufficient in fentanyl-related overdoses, necessitating multiple doses that still might be ineffective.
In community settings where there is no oxygen available, the window in which the medication can successfully reverse an overdose is limited, according to a study funded by the Food Drug Administration published in January. Current recommendations for naloxone dosing are inadequate in the era of illicit fentanyl unless oxygen is available — and it typically isn’t. Staff members from the publication Alcoholism & Drug Abuse Weekly recently saw this firsthand in San Francisco, witnessing an overdose where four doses of naloxone were not adequate.
Because of naloxone’s limitations, last year the FDA approved nalmefene, a longer-lasting opioid reversal nasal spray that is well-suited for counteracting potent opioids like fentanyl as well as mixtures of synthetic opioids and other illicit drugs.
Following the FDA’s approval, a county in Michigan launched a pilot program so their frontline responders could start using the new rescue agent.
“We’ve successfully reversed more than 40 overdoses with just one dose — the recovery has been nothing short of miraculous. We are saving lives and have not seen any negative outcomes thus far,” Steve Norris, harm reduction and recovery support director for the Alliance of Coalitions for Healthy Communities, told me.
In addition to the pilot program in Michigan, New Hampshire’s Department of Health and Human Services recently expanded its standing order to include nalmefene. And a county in Florida is doing the same.
Although Michigan’s pilot program and New Hampshire’s expanded standing order are new, and naysayers may say that there isn’t enough data to prove cost-effectiveness, I echo New Hampshire Gov. Chris Sununu in saying that we must increase “access to every resource possible in our continued work to combat substance use disorder and save lives.”
If the FDA approves a medication as safe and effective, then states should assume the same.
Cancer treatments, new gene therapy infusions for sickle cell disease and hemophilia, and other innovative therapies are hailed as beacons of hope when approved by the FDA — yet we have a new rescue agent in our arsenal and critics are more focused on perpetuating stigma-based concerns instead of realizing the potential we have in front of us. A product that can reverse an overdose with one dose, is inherently going to be more cost-effective than a product that necessitates multiple doses to be successful. It’s also imperative we don’t lose sight of the big picture: saving more lives from preventable overdoses.
When California first implemented its standing order, naloxone was the only reversal medication approved by the FDA. Now that other products are available and proven safe and effective, we should remove barriers and streamline the ability for our communities to access these lifesaving rescue agents.
Statewide policymakers had an opportunity to do so last year through our co-sponsored bill, SB641 by state Sen. Richard Roth, D-Riverside, which would have provided those on the front lines with “every tool in the toolbox” to effectively combat the diverse challenges presented by the opioid crisis. The bill passed the Legislature unanimously but was surprisingly vetoed by Gov. Newsom.
It is time for California to take a proactive stance, acknowledge the gravity of the situation and demonstrate a commitment to saving more lives. The expansion of the state’s standing order is not merely a bureaucratic procedure, but a lifeline for all Californians, particularly those on the frontlines, working tirelessly to prevent and reverse overdoses.
California can — and should — do more to save lives, and we will continue to fight to ensure our policymakers seize this opportunity. It is not a question of luxury, but a necessity to have access to a range of medications that cater to the specific nuances of opioid overdoses.
Robb Layne is executive director of the California Association of Alcohol and Drug Program Executives.