Retail pharmacies in some smaller, more affluent communities in New Jersey can be nearly three times more likely to stock life-saving overdose-reversal medicines, compared with drug stores in poorer cities — where residents are at greater risk to die from opioid use.
Those findings, published last week by a group of Rutgers University researchers, followed a national report that showed OD deaths related to fentanyl — a powerful synthetic opioid used as a mixing agent or replacement for heroin — spiked significantly in recent years, particularly among African-Americans. Other research suggests the mortality rate is now rising faster in East Cost cities with large numbers of black residents.
The team from Rutgers New Jersey Medical School discovered that at least six in 10 pharmacies in wealthier municipalities like Hunterdon County’s Flemington and Readington, and Little Silver in Monmouth County, had forms of naloxone available for customers. But just over 21 percent of retailers in Newark carried the medicine; less than 17 percent in Atlantic City; and just over 15 percent in Cumberland County’s Vineland City.
“These cities with limited naloxone access also have the most severe opioid-related public health concerns,” said lead author and NJMS student Kevin Lozo. The study, which consulted more than 90 stores in 10 municipalities during the first half of 2017, was published in the April issue of the Journal of Medical Toxicology. “This shows that New Jersey has naloxone ‘deserts’ where the medication is needed most,” he said.
Naloxone, sold primarily as the brand Narcan, comes in spray forms or preloaded auto-injectors and syringes (similar to epi-pens) that deliver the drug to an arm or leg muscle. The drug, which blocks the brain’s opioid receptors, has been a hospital staple since the 1960s and is now a common tool for first responders; in 2015 drugstores in New Jersey started to make it available to the public, without a prescription.
“Naloxone can be a life-saving drug in the hands of bystanders,” said Dr. Lewis Nelson, a study author and chair of emergency medicine at NJMS. “Although retail pharmacies in New Jersey are permitted to dispense naloxone without a prescription, not all do.”
The researchers suggested that the disparities might reflect demand, a factor that could be influenced by the price and the lack of insurance coverage in some communities; they found the medication costs between $70 and $4,500 for a two-pack auto-injector. (The drug is now covered by Medicaid.) They also found that some retailers, like CVS/Walgreens stock the drug in three out of four stores, but these chains are less common in some urban communities.
“This study demonstrates that there is much more to be done to get naloxone into the hands of people who most need it,” said author Diane Calello, director of New Jersey Poison Control, which is part of NJMS.
First responders and OD reversals
The New Jersey Attorney General’s Office tracks naloxone use among emergency medical responders and police officials, who are responsible for most of the state’s overdose reversals; the office also has a rebate program designed to help public agencies pay for participation. Records show it was deployed more than 30,000 times between 2015 and 2017 and another 16,000 doses were administered in 2018 — two-thirds by EMTs. More than 3,000 of those applications were in Camden County, nearly twice the number conducted in Essex County, and three times the rate in Middlesex County.
While it once took only one application, first responders have said fentanyl — which can be 100 times stronger than heroin — sometimes requires multiple naloxone shots to override. Last year, the state approved a law permitting EMTs and police to administer multiple doses, if needed.
Fentanyl’s strength is also driving up the death rate, experts said. Legal opiate prescriptions declined significantly nationwide and in New Jersey and options for treatment have expanded, but the opioid-related mortality rate continues to climb.
In 2013, more than 1,300 Garden State residents died of drug overdoses; by 2017 it exceeded 2,700 and in 2018 it topped 3,100, state figures show.
Data published in late March by the federal Centers for Disease Control and Prevention illustrates how fentanyl is responsible for rising death rates in communities of color. While fentanyl kills more white people than those from other communities, its mortality rate has risen faster for African-Americans — an annual increase of 141 percent between 2012 and 2016, versus 118 percent for Hispanics, and 108 percent annually for whites.
Former prisoners particularly vulnerable
Some, including former Gov. Jim McGreevey, who heads the New Jersey Reentry Corp., suggest this dynamic also reflects the racial disparities of incarceration. Since black and brown residents are jailed at far higher rates, and many inmates struggle with addiction but get little treatment behind bars, these individuals are particularly vulnerable to relapse on release. In addition, they are likely to have a new level of low tolerance, which makes them highly susceptible to overdose.
“When (an inmate) is released from state prison on a Thursday or Friday, he may come back to his home county without any medicine, without a Medicaid card, and no physician appointments, no clinical referral,” McGreevey explained. “The overwhelming probability is that he will use heroin/fentanyl before the weekend is over, and the strong possibility is that he will be one of the overdose deaths,” he added.
McGreevey would like to see more pharmacies provide naloxone. But he is also working with state officials and healthcare leaders to try and create an integrated system — with drugstores playing a key role — to better support people leaving prison and help them address mental health, addiction, and physical needs.
The Rutgers study, which also involved input from research associate Christine Ramdin, focused on pharmacies in 10 towns that were chosen based on income level, population, and the number of opioid-related hospital visits. Their research also revealed the percentage of pharmacies that stocked naloxone in the following communities: 29 percent in Millville, Cumberland County; 29 percent in Old Bridge, Middlesex County; and 50 percent in Wildwood, Cape May County.