The Naloxbox at IUPUI, containing opioid rescue kits (Narcan).
An odd looking box has shown up at the Campus Centerat Indiana University – Purdue University, Indianapolis (IUPUI) on the first floor in the Vermont Street parking garage. It’s a 24/7 “Opioid Rescue Kit” filled with naloxone nasal spray, and seeing it should make us all ecstatic. There’s also a vending machine filled with free naloxone nasal spray bottles at the Eskenazi West 38th St. clinic, repurposed from selling snacks, to giving away these free devices. These boxes and machines known as NaloxBoxes will save lives, help address an enormous public health problem, and could improve understanding and rational responses to drug addiction. While bioethics often focuses on debates and dilemmas, this is a case of clearly ethical action. Some people have concerns about NaloxBoxes and the attitude they reflect, which I will describe and try to address here, but let me explain why we should all embrace this approach..
In 2021 and 2022, there were more than 2,000 deaths each year from drug overdose in Indiana alone, a majority being in Marion County. This number would have been higher without naloxone, a medicine that blocks the effects of opioids and is effective in treating overdoses. Naloxone, commonly known by the brand name Narcan, is an FDA-approved medication that binds to opioid receptors to block the effects of opioids; such as heroin, morphine, or oxycodone. Naloxone can be administered through intranasal spray or injected into a muscle, vein, or under the skin. The benefit of naloxone is that it is safe to administer to a person even if they are not overdosing. However, one drawback is that it wears off 30 to 90 minutes after administration, so the life-threatening effects of an overdose can return after this time. Treating an overdose sometimes requires multiple doses of naloxone, which is why it is crucial to seek medical help immediately after administering it.
Naloxone is available through emergency medical services and in some areas through pharmacies (prescription requirements vary), local health departments, or community-based distribution programs. The cost varies depending on where, how, and which form is administered. Indiana is one of many states that have since acted in fighting the epidemic using naloxone. In 2021, Governor Eric Holcomb approved $1.3 million in funding, making it the state’s third investment in naloxone distribution since May 2020. In March 2023, the FDA approved Narcan’s nasal spray for over-the-counter use, thus no longer requiring a prescription, and capped the price at less than $50 for two doses.
These are great steps for getting naloxone out there to save lives, but access remains an immense challenge. The price is an issue: $50 seems a small amount to pay to save a life, but many individuals, including those with opioid addiction, cannot or will not put out that money. Another barrier is that this is not widely accessible; it requires going to the pharmacy to get the medicine and asking a pharmacist for it.
In May 2023 Indiana Health Centers, Inc. (IHC) made the decision to install NaloxBoxes at all their health centers and WIC locations across the state. Other organizations across Indiana are following in these footsteps. Marion County now has NaloxBox installations at Salvation Army, Indianapolis Fire Department stations, various churches, and Eskenazi Health Centers among several other locations, providing the public 24/7 access to free Narcan nasal spray. Vending machines dispensing the nasal spray in larger quantities can be found in locations such as Marion County Jail and the Eskenazi Health Center on 38th St.
These boxes and vending machines are a great step: People who use drugs or know people who do might notice a machine and pick up naloxone just in case they were to encounter an overdose. Any of us can find ourselves in a situation where we see someone having an overdose, and if we have naloxone, it can save a life. This is a case where there is innovation in getting medicine to victims that can save lives. It’s the essence of an ethical step.
Could there be any reason to resist this step? Some believe that naloxone holds the potential to encourage drug abuse in that it minimizes the consequences and risks of opioid abuse, in that when the risk of death is decreased, then risk-taking behaviors increases, such as the use of higher or more frequent doses, and/or the use of more potent drugs such as Fentanyl. Some worry about the costs of naloxone distribution, with the concern that it consumes too much of the public’s funding and attention.
Studies indicate that naloxone is cost-effective through various means of distribution, specifically intranasal naloxone -- “one-time distribution of naloxone prevented 14 additional overdose deaths per 100,000 persons, with an incremental cost-effectiveness ratio of $56,699 per quality-adjusted life year”. Despite this high return on investment, opponents of naloxone argue that the cost may still be too high. Those who still oppose the distribution of naloxone despite the cost-effectiveness suggest that “if drug users just got out of the way by dying of an overdose, we’d have less of a problem.”
Researchers and physicians that favor greater naloxone access say that these normative challenges additionally have no effect on the ethical issue at stake; “The moral component here is that a lot of people think drug use is ‘bad’ […] but we don’t deny people health care because they make bad decisions.” Many who favor naloxone distribution, including addiction specialists, claim that the opposing argument stems from an incomplete understanding of addiction.
Most importantly, they emphasize that addiction is a chronic disease, not a choice, as some might think -- and whether it’s a disease or a choice, empathy with the person who’s made the poor choice, and/or suffers from the disease, is the essence of bioethical action. If we can save lives by making naloxone widely available, and it is affordable by at least some reasonable measures, then we should do it and do it as much as possible. The distribution of NaloxBoxes is an inspiration in continuing the fight for more affordable and accessible healthcare.
The views expressed in this content represent the perspective and opinions of the author and may or may not represent the position of Indiana University School of Medicine.
Morgan Rich is a current MA student at the IU School of Liberal Arts, studying philosophy with a concentration in bioethics, and is a Graduate Assistant at the IU Center for Bioethics.