It’s not very often that members of the public have a chance to chat with a pharmaceutical executive. But for the next two days, David Renwick, general manager of Adapt Pharma Canada, will be hanging out at Metro Vancouver transit stations and has invited anyone interested in the country’s overdose epidemic to stop by and say hello.
Of course, there’s a product that Renwick is pitching. His company is the Canadian distributor of Narcan Nasal Spray (better known in Canada by its generic name, naloxone), the so-called overdose antidote that’s used to save lives by blocking the effects of opioids.
“We’re trying to create some noise at a grassroots level,” Renwick said in a telephone interview ahead of his trip to Vancouver. “It’s already available in Ontario without a prescription and completely free of charge to anyone. In Quebec, it’s also available to anyone over the age of 14, completely free….But there is no political will right now in British Columbia.”
The primary difference between Adapt Pharma’s Narcan Nasal Spray and the generic naloxone that’s already widely available for free in B.C. is the two products’ delivery systems.
Generic naloxone is a liquid that comes in a vial. To use it, the individual responding to an overdose must snap off the top of a glass vial, load up an accompanying syringe, and then perform an intramuscular injection, usually in the thigh, buttocks, or upper arm. Nasal Narcan Spray comes ready to use and, like its name suggests, is administered via the nose. One simply inserts the delivery device into an overdose victim’s nostril and gives a push on the other end.
Tomorrow (January 15), Renwick and an accompanying group of UBC pharmacists and students will be giving out free Narcan Nasal Spray and will be available to answer questions at SkyTrain’s Stadium-Chinatown Station in Vancouver (590 Beatty Street). The following day, people can find the group at the Surrey Central SkyTrain station (10277 City Parkway). Both days, they’re scheduled to remain on-site from 7 a.m. to 7 p.m.
In addition to utilizing a simpler administration system, Renwick noted that nasal Narcan is also of a higher concentration than a single dose of intramuscular naloxone. While one vial of generic naloxone consists of 0.4 milligrams of the drug, one of Adapt Pharma’s nasal devices carries four milligrams of Narcan (with the body actually absorbing about two milligrams of the drug per administration).
“Eighty percent of [overdose] deaths reported in British Columbia are due to fentanyl,” Renwick noted. (In 2018, the percentage of illicit-drug overdose deaths in B.C. associated with the synthetic opioid fentanyl was actually 85 percent, up from 82 percent in 2017, according to the B.C. Coroners Service). “These are incredibly toxic drugs and you need a more concentrated naloxone to combat them.
“That was the reason why the other provinces in the country said, ‘Okay, we need to make this available,” Renwick added. “’We need a more concentrated, more powerful naloxone in order to combat what is on the street today.’”
Naloxone was once only available in Canada with a prescription but the federal government dropped that requirement in March 2016. Today, the generic intramuscular form of the drug is available in pharmacies throughout B.C., free of charge. There’s also a 30-minute course available online that teaches how to administer the drug as part of a complete response to an opioid overdose.
Meanwhile, Narcan Nasal Spray is theoretically available in B.C. but much harder to find. The Straight contacted half a dozen pharmacies—a mix of London Drugs, Rexall, and Pharmasave locations—and found that none of them had nasal Narcan in stock. (London Drugs and Pharmasave staff did, however, offer to order the drug and said they could have it in their stores for pickup within a day or two.)
Another tool in the toolbox
An easier delivery system and higher concentration of a life-saving medication are obvious points of superiority. But a number of Vancouver’s nonprofit-housing providers told the Straight they’re not especially eager to see their stocks of intramuscular naloxone replaced with Nasal Narcan.
For this article, the Straight conducted quick interviews with representatives for a number of those organizations, including RainCity Housing, Lookout Housing and Health Society, PHS Community Services Society (the Portland Hotel Society), and Atira Women’s Resource Society. All four provide services to drug-using populations and receive large amounts of naloxone from the provincial government via the B.C. Centre for Disease Control’s Toward the Heart program. Everyone expressed a similar sentiment: Narcan Nasal Spray is nice to have as an alternative option, and they’ve paid out of pocket to have limited supplies at certain locations. But, in general, nonprofit-housing staff are accustomed to intramuscular naloxone and find it’s working well.
Catharine Hume, co-executive director of RainCity Housing, told the Straight it’s a matter of having access to as many tools as possible.
“Any additional evidence-informed option that supports our staff in responding to overdose is deeply welcomed,” she said.
In a separate telephone interview, Coco Culbertson, PHS senior manager of programs, similarly said her organization is happy with the intramuscular formation but would appreciate nasal Narcan more widely available as an alternative. “Especially for folks who are not working directly in overdose prevention,” she added.
“For folks working in social enterprise, it might reduce trauma for our staff if they didn’t have to inject,” Culbertson explained. “It would allow us to get more people into those roles [of overdose response] if they didn’t have to use such a clinical intervention when someone is overdosing.”
A projected 1,500 people in B.C. died after taking drugs last year, based on data covering the first 11 months of 2018. That compares to 1,486 overdose deaths in 2017 and an average of 204 deaths each year from 2001 to 2011.
Cost is always a factor
Dr. Jane Buxton is the B.C. Centre for Disease Control’s medical lead for harm reduction and a professor and practicum director with the UBC school of population and public health. She told the Straight that there are benefits to intramuscular naloxone and the smaller doses with which it’s distributed that might not occur to members of the public.
For example, she said, naloxone works by blocking the brain’s opioid receptors. That reverses an overdose, but, in larger amounts, it can also push a person addicted to heroin or fentanyl into instant withdrawal. A smaller dose of naloxone can reverse an overdose without bringing on the intense craving for opioids that an addicted person can feel after they’re administered nasal Narcan’s larger dose of medicine.
“The last thing we want is for someone to feel so sick that they go and seek other substances and inject again when the naloxone has worn off,” Buxton said.
In addition, she noted that in B.C., fentanyl is showing up alongside cocaine, and if someone has used large amounts of cocaine over an extended period of time, they may suffer from vasoconstriction (a construction of blood vessels in the nose). That can make nasal Narcan less effective, Buxton warned.
Then of course there are considerations for cost, Buxton added.
The B.C. Centre for Disease Control’s free naloxone kits cost the provincial government roughly $20 for an overdose-response package that contains three doses of 0.4-millgrams of naloxone. Meanwhile, Adapt Pharma said it can supply its Nasal Narcan Spray devices for $46 for one dose of four milligrams of the drug.
Buxton said the difference is partly because the formulation of naloxone adopted by B.C. is generic, whereas Adapt Pharma's remains proprietary.
Renwick maintained the cost differential is primary the result of different amounts of the drug used in different formulations, and not as great as it sounds. That’s because B.C.’s fentanyl overdoses often require several 0.4-millgram doses of naloxone to reverse, whereas his company’s four-milligram doses usually work with just one administration. “You cannot equate one injectable vial to one nasal spray,” Renwick emphasized. “They are not equal.”
A potential backlash from the public
Amy Vilis, director of health services for Lookout Housing and Health Society, said that although she keeps a dose of nasal Narcan in her car, she wouldn’t want to see B.C. entirely switching from intramuscular naloxone to Nasal Narcan.
“If we’re looking at implementing a change across the board with basic, boots-on-the-ground service providers, confusion would be a concern,” Vilis said.
She also noted there has been some negative feedback from the public regarding the B.C. government’s decision to provide intramuscular naloxone for free. This group argues that if the province is going to make naloxone free for drug users, it should also make EpiPens available for free to people allergic to bees, for example. Vilis said she worries that if the B.C. Centre for Disease Control’s free-naloxone program were extended to include the more-expensive nasal Narcan, that backlash could grow.
“I think people would like it [nasal Narcan] because I think it is easier [to administer],” Vilis said. “But I don’t think they’ve thought through all these other pieces.”
Preparing for his visit to Vancouver, Renwick said that at the very least, he would like to see nasal Narcan stocked in more B.C. pharmacies.
“At a grassroots level, people have to say, ‘I want this in my home, I want this in my first-aid kit, I want it at my workplace, I want it in my car, so that I can intervene in a life-and-death situation and make a difference’,” he said.