In my first class at Temple University’s Master of Public Health program, we discussed Philadelphia’s raging opioid epidemic and efforts to curb its overdose rates. One of my classmates, a harm reductionist and outreach worker in the city, mentioned she’d recently been denied life insurance because an item on her prescription list suggested she was at risk of overdose: Narcan. Our professor said she’d been denied for the same reason.
I Googled more after class. NPR covered the issue last year when a nurse at an addiction treatment center in Boston was denied coverage because Narcan was among her prescription medications.1 She applied to a second insurer, who said if the doctor who signed off on the prescription wrote a letter explaining the need for it, it would consider her case. That physician, Dr. Alex Walley, works in addiction medicine and had already written these letters on behalf of another half-dozen healthcare providers. The nurse, meanwhile, stopped carrying Narcan.
Insurance companies deeming Narcan carriers liabilities has far-reaching ramifications. It deters people who want to help—EMS providers, Good Samaritans, loved ones of people who use substances—from purchasing the antidote, limiting the numbers who might be revived following overdoses. The Boston nurse and her colleagues were discouraged enough to drop the drug from their personal tool kits. Sacrificing the potential to save a life to insure one’s own defeats the purpose of statewide standing orders for OTC Narcan.
“I’m looking for a porch to crawl under.”
This is the sentiment a dear friend shared with me earlier this year before succumbing to his heroin addiction. This sentence has stuck with me every day since. He had Narcan but was using alone. Narcan is a wonderful tool that has saved many lives, but it’s just a Band-Aid on an issue that requires extreme measures of social, political, and legislative intervention.
In 2017 drug overdoses—the vast majority opioids—took the lives of 1,217 Philadelphians. In 2016 and 2017, the city saw by far the highest overdose death rate among the 10 largest U.S. cities.2 In Kensington, the north Philly neighborhood most affected by the crisis, people in the throes of addiction wander the streets like zombies or sit slumped over under the elevated train tracks. I would like to believe those working and residing here would especially comprehend the necessity of publicly accessible Narcan, but not so. Public health initiatives and campaigns have helped destigmatize the disease to an extent, but the stigma still stands among some.
When I lived in Northeast Philadelphia, I called a pharmacy from the list of state Narcan distribution centers to confirm they carried the drug. The pharmacist said it was in stock, but his cagey tone told me all I needed to know. When I arrived at the pharmacy, I was met with leery employees exchanging uncomfortable glances. I was confused and disappointed—I was dressed professionally, having just come from work, but felt treated like a drug-seeker off the streets. And had I not looked presentable, wouldn’t that have indicated an even greater need for the antidote? Shouldn’t educated health professionals understand the urgency of providing whatever preventative measures exist for those at risk?
With even the U.S. Surgeon General advocating for the public’s access to Narcan, how can insurers justify impeding it? Who are the stakeholders arguing for Narcan possession as barrier to life insurance? Clearly, even healthcare professionals don’t have a strong enough voice with the insurance companies. Politicians may have polarized opinions on the epidemic as a whole, but their influence could perhaps enact change in this sphere if the right ones advocate enough.
I don’t know all the answers to this problem, but education is a good starting point. Across the board, EMS providers’ views on substance use disorder remain mixed. Some are desensitized after years of overdose calls, while others recognize a manageable disease that requires ongoing support and care. We should aim to correct the mind-set that addiction is a moral failing or calculated choice, but rather a disease to which some are genetically predisposed, especially in the presence of comorbidities like mental illness, low socioeconomic status, and environmental factors like trauma and chronic stress.
People don’t think poorly of individuals with substance use disorder (SUD) because they understand it, but because they don’t understand it. Integrating content on social determinants and the neurobiology of addiction into EMT and paramedic schools may change the mentality of incoming providers. If we train younger medics now to understand addiction for what it truly is, then we may be setting the foundation for a larger body of people with a louder voice to advocate for the destigmatization of SUD.
1. Bebinger M. Nurse Denied Life Insurance Because She Carries Naloxone. NPR, www.npr.org/sections/health-shots/2018/12/13/674586548/nurse-denied-life-insurance-because-she-carries-naloxone.
2. Data: Department of Behavioral Health and Intellectual disAbility Services. City of Philadelphia, www.phila.gov/programs/combating-the-opioid-epidemic/reports-and-data/.
Valerie Amato, NREMT, is assistant editor at EMS World.