Idaho lawmakers placed limits on OD reversal drug. Result could be ‘fewer lives saved’

As Idaho combats a surge in opioid deaths, a recent bill limiting who may receive free overdose reversal kits from the state could lead to more fatalities, according to state health officials and the governor.

Last month, legislation pushed through by Republican lawmakers restricted eligible recipients of federal grant funds for naloxone — commonly distributed under the brand name Narcan — a drug that reverses the fatal effects of an opioid overdose. Starting in July, only first responders will be able to receive free naloxone kits from the Idaho Department of Health and Welfare, which oversees the grant program.

Records obtained by the Idaho Statesman show that state health officials said the move would “dismantle” Idaho’s existing distribution system, potentially leading to more overdose deaths and increasing administration costs. Had the limits been in place last year, the state’s overdose death rate could have been four times higher, Department of Health and Welfare officials wrote in an analysis of the legislation, House Bill 350.

Groups representing first responders urged Idaho Gov. Brad Little to veto the bill. In a letter to the Republican governor, Jeff Lavey, executive director of the Idaho Sheriffs Association, said that local law enforcement offices are “overworked and understaffed” and have limited time to distribute naloxone kits.

“These live-saving devices need to be distributed to our important members of our communities such as teachers, nurses, restaurants, etc.,” Lavey wrote.

Rep. Josh Tanner, R-Eagle, proposed the grant limits, and most Republicans in the House and Senate supported the bill. Tanner, a freshman lawmaker, sits on the Legislature’s budget committee and is a commissioner for the Eagle Fire Protection District, an elected board that oversees portions of Ada, Gem and Boise counties.

Tanner told the Statesman that the naloxone distribution limits will ensure that people administering the drug are trained by first responders, and he said he doesn’t believe accessibility will be hindered.

“I just wanted to make sure that it’s actually going out to the right people, people that we can actually educate and give training,” Tanner said by phone. “The more we can educate the public, the better off we are.”

Most naloxone administrators aren’t first responders

Little, who made combating illicit opioid sales a primary goal of his first term, criticized the new “red tape” imposed by the naloxone restrictions, but he signed the legislation anyway.

House Bill 350 is an annual appropriation bill for the Division of Mental Health Services, Psychiatric Hospitalization, and Substance Abuse Treatment and Prevention. The division’s $149.5 million budget was tied to the legislation.

“We know that most naloxone administrations in Idaho are by people other than first responders and thus distribution to community partners is critical,” the governor wrote in a letter to lawmakers. “This significant policy change may result in fewer naloxone doses available to administer in Idaho and, tragically, fewer lives saved.”

Between 2011 and 2021, the Idaho drug overdose death rate increased from 12.9 per 100,000 people to 19 per 100,000, according to the Kaiser Family Foundation. In 2021, 241 of the 353 known deaths related to drug overdoses involved opioids, according to the latest available data from the Idaho Department of Health and Welfare.

Naloxone, which can be injected through a needle or administered via a nasal spray, rapidly reverses an overdose by attaching to opioid receptors in the body and blocking the effects of the drugs, according to the National Institute on Drug Abuse. Making the drug widely available has been a common policy at federal and state levels to combat rising opioid-related deaths.

Idaho lawmakers in 2019 passed a law guaranteeing legal protection to anyone who administers naloxone to someone experiencing an overdose. Previously, obtaining the drug required a prescription or health care coverage, but federal drug regulators last month approved naloxone for over-the-counter retail sales.

Last year, a citizens advisory group convened by Little to collect input on curbing illicit drug use recommended adequate supplies of naloxone for law enforcement, public health officials and social services as “a minimum requirement.”

Since 2017, the Department of Health and Welfare has provided no-cost naloxone kits directly to first responders, but also to substance abuse treatment programs, shelters, and other groups and individuals that associate with opioid users.

Since 2021, the state has distributed the kits through a contractor, the Idaho Harm Reduction Project, a nonprofit that assists drug users through programs like HIV testing and needle exchanges.

During the 2022 federal fiscal year, which ran from Oct. 1, 2021, to Sept. 30, 2022, the nonprofit distributed 25,467 kits and storage cases, according to data from the Department of Health and Welfare. Four in five kits went to the general public, and 94% of overdose reversals were carried out by people other than first responders.

First responders told the governor that they often “unfortunately” can’t reach someone experiencing an overdose in time to effectively administer naloxone, particularly in rural areas.

“These important devices need to be placed on the ground level as there is limited time to treat those effected by the overdosing of opioids/fentanyl,” Lavey said.

Restrictions will lead to higher costs, health department said

The limits on naloxone recipients will “dismantle” Idaho’s current centralized distribution system, Department of Health and Welfare officials wrote in an analysis of HB 350.

The department works with a single contractor at a cost of $24,108 to pay program administrators. That cost will be “significantly higher” as a result of the new law, the analysis said.

“This action will force the department to subcontract with at least one first responder entity within each of Idaho’s 44 counties, unnecessarily increasing the administrative costs to distribute naloxone to organizations throughout Idaho,” according to the analysis.

Sen. Julie VanOrden, R-Pingree, a budget committee member who sponsored HB 350 in the Senate, pushed back on claims that the grant restrictions would limit naloxone availability.

“They would just take that extra step,” she told the Statesman by phone. “Instead of going straight to Health and Welfare to get it, they would go through their first responders, their police, their sheriffs or firefighters, whoever is closest to them or that they’re comfortable going to.”

Making first responders the only provider of naloxone might be achievable for some firefighting and emergency medical services (EMS) agencies, Lewiston Fire Chief Travis Myklebust told the governor in a letter. Myklebust is president of the Idaho Fire Chiefs Association.

But rural agencies rely on partnerships with health clinics and other providers that wouldn’t be eligible to distribute the medication, Myklebust said.

The Idaho Office of Performance of Evaluations in 2021 found that only 18% of rural EMS agencies — which rely on volunteers — are able to maintain sufficient staff, and most are experiencing delayed response times as a result.

“These first responder agencies simply do not have the personnel or logistical support to add this program into their operations as a sole provider,” Mykleburst said. “The proper distribution of this program must involve everyone within the health care community, including Fire/EMS responders, to ultimately be effective.”

Is training for naloxone necessary?

In a legal analysis, Idaho Attorney General Raúl Labrador wrote that HB 350 blocks the state from giving naloxone directly to non-first responders, but law enforcement officers, firefighters and emergency service providers can give the medication to others.

“This adds increased accountability on product use and increases the likelihood that information and training will accompany its distribution,” Labrador wrote in an April 4 opinion, which he gave to co-chairs of the budget committee.

Officials with the Food and Drug Administration said naloxone can be safely administered by untrained people. The FDA in March approved the over-the-counter sales, which required that Narcan manufacturer Emergent BioSolutions demonstrate that the drug is safe to use as directed on the label, an FDA news release said.

“The manufacturer also showed that consumers can understand how to use the drug safely and effectively without the supervision of a health care professional,” according to the release.

Administering naloxone for someone experiencing an overdose — after first calling 911 — requires inserting a device into their nostril and pushing a plunger, according to a 4-minute training video shared by the Idaho Harm Reduction Project.

People with an opioid dependence may have withdrawal symptoms, such as headaches, blood pressure changes and a rapid heart rate, after they’re given naloxone, according to the National Institute on Drug Abuse. But the drug has no effect on someone who doesn’t have opioids in their system.

The restrictions on naloxone recipients in Idaho take effect July 1.