Texas revamps Narcan distribution following delays, unpredictable supply

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After years of struggling to consistently provide the overdose-reversing medication naloxone to organizations that rely on a free supply of the medication, the state government is revamping its centerpiece distribution program.

That program, until recently called More Narcan Please, has been run by the University of Texas Health Science Center at San Antonio. In February, however, following years of supply and distribution struggles, UT Health San Antonio shuttered the More Narcan Please website and shifted distribution to Be Well Texas, a separate initiative within the center that addresses substance use. It’s now branded as Naloxone Texas.

Experts say that offering consistent and reliable care and services is important to building trust with people who use drugs, particularly people who are unhoused, but the state’s inconsistent supply of free naloxone has made that difficult. Officials at UT Health San Antonio say they have improved distribution and communication in recent months.

Delays and unpredictable supply

After the Texas Health and Human Services Commission launched the Texas Targeted Opioid Response in 2017, the state began offering free naloxone to individuals and organizations, including law enforcement agencies, recovery centers and community-based groups working with people who use drugs. The effort is funded by federal grants that have so far sent a total of $45.47 million to Texas. In 2019, HHSC began contracting with UT Health San Antonio to use those funds to purchase and distribute naloxone and conduct training about how to administer the medication.

In its early days, More Narcan Please was able to quickly ship large amounts of naloxone, delivering pallets of medication to harm reduction organizations at the forefront of combating opioid overdoses. Harm reduction is a strategy for providing services to people who use drugs without attaching stigma or strict parameters and involving people who use drugs in planning and implementing that strategy.

But as demand grew, the program struggled. In 2022, it ran out of money; HHSC said that was due to a shortage of the much cheaper injectable version of naloxone. In the fiscal year ending last August, the agency renewed funding to UT Health San Antonio, but More Narcan Please limited organizations to 48 doses and asked them to request more only after those had been distributed.

Distribution has also been unpredictable. At the end of last year, after experiencing long delays for small deliveries of naloxone, harm reduction organizations suddenly received large deliveries courtesy of More Narcan Please, leaving many wondering why shipments had not come sooner. In January, More Narcan Please said it would take between 14 and 45 days to process requests for naloxone. Some harm reduction organizations said they ran out of the state-provided naloxone while waiting for more doses.

UT Health San Antonio said that it made changes earlier this year that addressed those delays, and naloxone is now shipping much more quickly.

Groups handing out the naloxone say the lack of clear communication about when the drug was available made it hard to plan their own distribution strategy.

“A lot of the time when we'd put an order in it would take weeks,” said Bret Flores, executive director of the DFW Harm Reduction Access Movement, a grassroots organization that provides education and resources to people who use drugs. When his organization did receive shipments, “it was just very small quantities,” Flores said.

Naloxone, known under the brand name Narcan, is available as a nasal mist over the counter for about $40. One box contains two doses. But experts say the cost and stigma associated with drug use means many people who use opioids are unlikely to walk into a pharmacy and purchase it. The first person to respond to an overdose is most likely someone who uses drugs or their family member, and free distribution to those populations is considered one of the best ways to reduce opioid overdoses.

The Texas Harm Reduction Alliance, which provides resources and services to people who use drugs, offers naloxone at its drop-in center in Austin, where it also provides education, counseling, wound care and necessities like personal hygiene products and clothes. Last year, the group distributed nearly 13,000 doses of naloxone. After delays from More Narcan Please, the alliance began receiving naloxone from the city of Austin and Travis County.

Mike Prado, the Abilene-based director of West Texas Harm Reduction, distributes naloxone across a swath of the state that stretches about 200 miles. He used to rely heavily on More Narcan Please. In an interview last year, Prado said he was getting about 90 percent of his naloxone from other organizations that donated expired doses, which remain viable long after the expiration date.

“We used to get a nice chunk of naloxone from More Narcan Please,” Prado said. “Then I don’t know what happened.”

Revamping Narcan distribution

Since Be Well Texas took over naloxone distribution in February, shipping to organizations requesting bulk orders is now happening within about five days, said Jennifer Sharpe Potter, UT Health San Antonio’s vice president for research and Be Well Texas’s executive director. Individuals can still request two-dose boxes by filling out a form on the Be Well Texas website.

“I am aware that individuals have expressed concern about the rapidity with which they receive naloxone,” Potter told Texas Community Health News. “This is life-saving work, and we want to make sure that people get naloxone as quickly as possible.”

UT Health San Antonio’s contract with HHSC requires it to distribute at least 120,000 doses a year. with a focus on “individuals that are most likely to experience or respond to an opioid overdose, as well as organizations that directly serve individuals who are most likely to experience or respond to an opioid overdose.”

The contract also directs UT Health San Antonio to implement a “county-level saturation approach,” which HHSC defines as ensuring that every county has 20 times as many doses of naloxone as it does recorded overdoses.

UT Health San Antonio’s contract expires in August and the state is expected to announce who will continue administering naloxone distribution in September.

When More Narcan Please initially launched, about 40 percent of the naloxone it distributed went to law enforcement. Last year, Texas Community Health News found that some recipients of state-funded naloxone were destroying expired doses, although More Narcan Please was encouraging them to donate it to other groups that would use it.

In recent years, UT Health San Antonio began asking recipients not to give away naloxone at conferences and stopped distributing to pharmacies. In its request for the new contract, HHSC instructed applicants to outline a plan for redistributing older doses before they expire, sidestepping any restrictions on handling expired doses.

Flores, with the DFW harm reduction group, said he’s seen an improvement this year, not just in how quickly naloxone is delivered but also in communication. When Naloxone Texas warns him it will be shipping a smaller amount of naloxone, he can make sure he has another source lined up.

“At least now they're letting us know ahead of time we’re not going to get the full order,” Flores said.

Last year, the state expanded its naloxone access programs. The Texas Division of Emergency Management began distributing $75 million in naloxone, provided by a pharmaceutical company as part of a legal settlement with the state government, to county sheriffs.

While the state government has said naloxone access is a key component of its response to opioid overdoses, it has been slow to use state funds to buy the medication. This year marks the first time Texas will be using state funds for the distribution of naloxone after years of relying on federal grants. The Texas Comptroller’s Office, which oversees a $1.6 billion opioid abatement fund generated by legal settlements with pharmaceutical companies. The comptroller’s office is currently accepting proposals for a program that would distribute $18.75 million in naloxone statewide and another $3.13 million for naloxone distribution in counties of less than 100,000.

And last year the Legislature directed an additional $18 million for UT Health San Antonio to purchase naloxone in 2024 and 2025. Those funds have fewer parameters, and Potter said that gives her program flexibility to meet demand, because she can direct applicants who aren’t a priority for one program to the other.

“We have greatly increased the output of naloxone being distributed and been able to fulfill the requests that have come through our door,” she said.

Jason Buch is an Austin-based freelance journalist who works with Texas Community Health News, a collaboration between the Texas State University School of Journalism and Mass Communication and the university’s Translational Health Research Center.

Disclosure: University of Texas Health Science Center at San Antonio has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

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