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Maryland House Bill 1268, Senate Bill 497, and Naloxone Accessibility

Write-up by IRIS team members: Victoria Barreira & Yali Deng
 To check the status of these and other bills, please visit: https://mgaleg.maryland.gov/mgawebsite/search/legislation

House Bill 1268

Increasing availability and access to naloxone in schools could potentially decrease opioid related overdose deaths for Maryland youth. Montgomery County Maryland now allows students to carry personally obtained naloxone on campus (Office of the School System Medical Officer, 2023) as one response to a 78% increase in youth overdoses from 2021-2022 (Montgomery County Public Schools, n.d.). A statewide policy that expands access to naloxone in schools is now being considered through House Bill 1268 (HB 1268), which expands school personnel who may administer naloxone, as well as naloxone and opioid education in public schools.  
 

HB 1268 was first read to the house committee on February 8, 2024, with the next hearing on March 6, 2024. The draft bill focuses on in-school naloxone and other opioid overdose reversal drug policies, education, and administration. HB 1268 requires public schools to allow any lawfully present individual acting in good faith to administer naloxone or other opioid overdose-reversing medications to a student or other person on the premises that is reasonably believed to be experiencing an opioid overdose. The bill further stipulates that such persons would be void of liability in taking such actions. This bill amends current Maryland law that states a designated person, either teacher, nurse, or other school staff will be allowed to administer the medication. HB 1268 also includes several other training, education, and reporting requirements for schools throughout the State of Maryland, which can be found here. By expanding persons who can administer opioid overdose-reversal medications in schools, this bill increases accessibility and thus may save more lives. 

Senate Bill 497

One way to achieve greater naloxone access is to lower the financial cost for this lifesaving medication. Higher out-of-pocket costs for naloxone can limit such access, especially for socioeconomically disadvantaged residents (Peet et al. 2022 & Project RAND 2022). SB 497 would cap insurance copayments and potentially expand access to naloxone. 

This bill was first read to the senate on January 24, 2024, subsequent hearing on February 15, 2024, and withdrawn by sponsors on February 26, 2024. The draft bill proposed that Maryland Medical Assistance Program, specific insurers, nonprofit health service plans, and other health maintenance organizations to cover naloxone hydrochloride and other Federal Food and Drug Administration (FDA) approved opioid reversal products, making sure not to impose an insurance copayment that exceeds ten dollars per item. A copayment ceiling could limit help to not only maintain coverage for but also create a barrier to insurance companies' charging more for naloxone or opioid overdose reversal products. 

Additional Research on Benefits of Naloxone Accessibility 

Article: Opioid Overdose Rates and Implementation of Overdose Education and Nasal Naloxone Distribution in Massachusetts: Interrupted Time Series Analysis

This article evaluated the impact of a community-based naloxone distribution program on opioid overdose death (OOD) rates in North Carolina (NC) and estimated this program’s cost-benefit. The naloxone distribution program (including distribution of kits and related training) was implemented in August 2013 in NC. This study obtained two administrative data sources including annual counts of naloxone kits distributed by county from 2013 to 2016 and the mortality data in NC from 2000-2016. The cost of this program was quantified by the sum of the unit price of the naloxone kit and distribution cost, including staff time and training. Benefits were quantified by avoided death (not including avoided medical costs, or losses of productivity, and quality of life).  
 

Results from the Generalized Estimating Equation showed that controlling for secular trends (e.g., change in policies during the study period), the rate of OODs in counties with a cumulative distribution of 1-100 naloxone kits (and > 100 cumulative kits) per 100,000 population was lower than counties that had not received kits. This study estimated that the naloxone distribution program prevented approximately 352 deaths in NC. On average, for every dollar invested in the program, an estimated $2,742 was saved due to the OOD avoided. Potential confounders such as county demographic distributions and urbanicity were examined and resulted in negligible change in estimates. Although this study cannot draw a causal effect of naloxone distribution on OODs due to limitations on research design, the findings contribute to the evidence base on the public health and societal benefits of naloxone distribution.  

Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., Ruiz, S., & Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ, 346(jan30 5), f174–f174. https://doi.org/10.1136/bmj.f174

Article: Impact of a Community-Based Naloxone Distribution Program on Opioid Overdose Death Rates

This summary introduced a study that evaluates a state-supported overdose education and nasal naloxone distribution (OEND) program in Massachusetts (MA). Between 2006 to 2009, MA implemented an OEND program which provides naloxone rescue kits and training on how to prevent, identify, and respond to overdose for people who use opioids, families, friends, and social service agency staff. This study used interrupted time series analysis to examine the rates of opioid-related overdose death and acute care utilization from 2002 to 2009 in 19 MA communities.  
 

Results showed that compared with communities with no OEND implementation, the communities with greater OEND enrollment rates (1-100 enrollments and >100 enrollments per 100 000 population) have significantly reduced adjusted rates ratios for annual opioid-related overdose death. There is no significant difference between rates of acute care hospital utilization. This study also analyzed data that was collected at enrollment and whenever the enrollee requested a naloxone refill. Results indicate that among 2,912 program enrollees/trainees, most of them (74%) reported a history of witnessing an overdose at enrollment. Enrollees reported a total of 327 overdose rescue attempts from 2006-2009. About 70% of the rescue was conducted for a friend. Naloxone was reported to be successful (defined as the person’s unresponsiveness and respiratory depression improved) in 98% of rescue attempts (150/153, denominator less than total rescues due to missing information). It is worth noting that this study cannot infer that the OEND caused the decrease in opioid-related overdose death rates due to limitations such as restriction on available data and potential misclassification of overdose death. Despite this, this study provides observational evidence on the benefits of implementing and expanding overdose education and naloxone distribution programs. Offering rescue kits to potential bystanders (including laypersons) is essential considering there is a high rate of witnessing overdose. 

Naumann, R. B., Durrance, C. P., Ranapurwala, S. I., Austin, A. E., Proescholdbell, S., Childs, R., Marshall, S., Kansagra, S., & Shanahan, M. E. (2019). Impact of a community-based naloxone distribution program on opioid overdose death rates. Drug and alcohol dependence, 204, 107536. https://doi.org/10.1016/j.drugalcdep.2019.06.038

If you would like to learn more or engage in policy advocacy, please see below for useful resources and organizations: 

References

Center for Disease Control and Prevention. (2023, April 21). Lifesaving naloxone. National Center for Injury Prevention and Control, Division of Drug Overdose Prevention, https://www.cdc.gov/stopoverdose/naloxone/index.html. 

Maryland Department of Health. (November, 2023). Unintentional Drug- and Alcohol-Related Intoxication Deaths in Maryland, 2022. https://health.maryland.gov/vsa/Documents/Overdose/Preliminarys/2022_PrelimIntoxReport_20231027.pdf 

Montgomery County Public Schools. (n.d.). Preventing substance use and opioid overdoses in youth—Montgomery County public schools. Montgomery County Public Schools, Rockville, M.D Retrieved February 26, 2024, from https://www.montgomeryschoolsmd.org/info/fentanyl/ 

Office of the School System Medical Officer. (May 1, 2023). Emergency Care for Individuals Experiencing Symptoms of Opioid Overdose. Montgomery County Public Schools. https://ww2.montgomeryschoolsmd.org/departments/policy/pdf/jpd-rc.pdf 

Peet, E. D., Powell, D., & Pacula, R. L. (2022). Trends in out-of-pocket costs for naloxone by drug brand and payer in the us, 2010-2018. JAMA Health Forum, 3(8), e222663. https://doi.org/10.1001/jamahealthforum.2022.2663 

Project RAND. (August 19, 2022). Out-of-pocket cost of naloxone may keep many uninsured from using lifesaving treatment. Retrieved February 26, 2024, from https://www.rand.org/news/press/2022/08/19.html 

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