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In January 2020, a 17-year-old young man died of an opioid overdose in Johnson, a rural community in northern Vermont.
Such a tragedy naturally reverberates in a town of barely more than a thousand people. “The whole community felt it,” said Caroline Butler, a nurse practitioner and cofounder of the Johnson Health Center.
The Johnson Health Center is a nonprofit healthcare provider offering primary care and treatment for addiction, including medication for opioid use disorder. In the aftermath of this death, the center redoubled its efforts to prevent such tragedies by expanding the availability of naloxone, a medication that can quickly reverse the effects of an opioid overdose and restore the person’s breathing.
“We did a big push,” within the health center and throughout the community, Butler said, to make naloxone abundantly accessible.
In the course of this effort, Butler made an illuminating observation: Of the naloxone they made available within their own building, the supply provided in the bathroom was being depleted the fastest – presumably “because people could just slip it into a bag,” unobserved.
This got Butler thinking about the allure of anonymity, and about offering a similar option on a larger scale.
The University of Vermont’s Center on Rural Addiction (CORA), based in Burlington, 45 miles to the southwest of Johnson, has become a trusted partner to health providers throughout the state.
“We do technical assistance calls every week with providers,” Kelly Peck, CORA’s director of clinical operations, said. “‘What do you need? We’ll get it out to you.” Placing naloxone into the hands most likely to use it has always been a priority.
Peck and his colleagues were familiar with naloxone vending machines in urban settings. “We thought, ‘Why can’t we? Why can’t we do that in a rural community? Nobody’s really tried that before.’”
Butler was thinking likewise. CORA offered a grant, and the Johnson Health Center now has a vending machine that dispenses free boxes of nasal-spray naloxone – also known by its brand name, Narcan – the first of its kind in the state.
Communities Are Responding
Misconceptions of what naloxone is and does persist, said Gail Rose, an assistant professor of psychiatry and a member of the CORA team.
“It’s a lifesaving medication,” she said. “It’s not something that will get you high. In fact, it’s quite the opposite.” It competes for the same receptors in your brain and prevents the opioids from bonding. And it does no harm if administered to someone who isn’t overdosing on an opioid.
A 2018 national study found that opioid overdose deaths decreased by 14% in states that had enacted naloxone access laws. But while naloxone is now available over the counter in every state, it’s not more accessible to everyone: The retail price is commonly in the $50 range for a box of two doses.
Rose noted that given the increased strength of the drug supply today, two doses or more are frequently required for one reversal.
Throughout rural America, communities are rallying to get this lifesaver where it’s most urgently needed. In 2020, Charleston, West Virginia-based SOAR WV launched “Save a Life Day” in two counties. Things took off from there. This September, the first-ever “Appalachian Save a Life Day” was held across all 13 Appalachian states, with some 30,000 free doses of naloxone distributed at more than 300 sites, including county health departments, fire stations, churches, fast-food restaurants, and Walmarts.
Similar grassroots efforts to make naloxone more widely available are gaining momentum in rural communities across the country.
Easy to Use, No Limit
The Johnson Health Center is teaming with Jenna’s Promise to provide this service. Jenna’s Promise is a recovery community founded by the family of Jenna Tatro after they lost her in 2019, at age 26, to substance use disorder.
The health center, Rose said, was a great fit for a naloxone vending machine. It’s on the primary road through town, Lower Main Street, and is within easy walking distance for most in-town residents.
You simply enter a code, which is posted on the machine. The boxes include information on where to seek treatment for opioid use disorder.
In the first month, 107 boxes were distributed, and the machine was accessed all but three days, with the average person taking a couple of boxes per visit, though there’s no limit.
“We did have an incident where somebody took 20 doses,” Butler said, “and we were, like, ‘Oh, god; that’s a lot.’ And then we found out it was actually somebody from the school … which made it feel really good.”
The machine is manufactured by Iowa-based Intelligent Dispensing Solutions, which provides a variety of vending options to clients that include emergency medical services, universities, corporate firms, and the leisure and hospitality industry.
IDS’s John Van Horn said the cost of their naloxone machines runs between roughly $8,000 and $12,000. At last count, he said, they had some 80 to 90 deployed.
Van Horn said the company is now interested in offering naloxone machines for workplaces.
Butler believes most people in Johnson are aware of the depth of the overdose crisis. “This community has been pretty hard hit,” she said. “And the naloxone machine actually has been a really good place for conversations to start.”
Johnson resident Dave Joseph agrees. The drug crisis is “a part of the social fabric now,” he said.
On the evening after the naloxone machine was unveiled, Joseph was driving past Johnson Laundromat and saw a man slumped over out front. Surmising, correctly, the man was experiencing an overdose, he called 911, drove the quarter mile to the health center, and retrieved a box of naloxone.
The man regained consciousness and, fortunately, the naloxone wasn’t needed. But, Joseph said, “it just made sense to me at that time to get it and be prepared.” He believes most of his neighbors are aware the vending machine is there, and that most appreciate that it is.
CORA has since extended grant opportunities for five more machines in rural communities throughout the region.
Rose points out that CORA’s team members are researchers and are obviously interested in at some point evaluating the impact of this effort. Previous research has indicated that naloxone vending machines do save lives.
The Centers for Disease Control and Prevention reported that more than 111,000 people died from a drug overdose in the U.S. in the 12-month period ending in April. Rose acknowledges there’s plenty of cause for despair. However, she said, “People are learning more about naloxone and the value of harm reduction,” which often opens the door to treatment options.
She’s encouraged by a heightened awareness of the multiple paths through recovery.