By Jason Buch/Texas Community Health News

In 2019, the state of Texas gave out more than 230,000 doses of naloxone, a life saving medicine that can reverse opioid overdoses, through its More Narcan Please program. More than three years later, that medication, in the form of a nasal spray known as Narcan, is past the expiration date printed on its label.

For some organizations, that expired Narcan is gold. Experts say it remains effective for years after its expiration date. So while some recipients through More Narcan Please, particularly government agencies, may have policies preventing them from administering expired doses, grassroots organizations are clamoring for them. But some of the recipients from the state program are destroying Narcan as it expires.

“I always recommend groups with expiring doses that don’t feel comfortable continuing to distribute then redistribute to community harm reduction” organizations, said Lucas Hill, the director of the Pharmacy Addictions Research and Medicine Program at the University of Texas College of Pharmacy.

In Texas, there’s no centralized system for collecting and redistributing expired naloxone. That’s because state law limits who can collect and store expired medication – pharmacies are expressly forbidden from doing so – and federal regulators discourage using expired doses.

Medications are tightly regulated in the U.S., and for good reason, said Joy Alonzo, a clinical associate professor in the Department of Pharmacy Practice at the Texas A&M Irma Lerma Rangel School of Pharmacy and co-chair of the Texas A&M University School of Public Health’s opioid task force. It’s difficult for the government to get involved in a program that would encourage people to collect and distribute medication that regulators say is expired.

“It would take some kind of COVID-type response where (regulators say), ‘OK these rules are waived for this circumstance,’” like when the shelf life of vaccines was extended in 2021 and 2022, Alonzo said.

In the meantime, unofficial exchanges of expired naloxone are popping up. Aside from strict rules for pharmacists, donating expired Narcan likely doesn’t run afoul of Texas law, said Amy Lieberman, a senior attorney at the Network for Public Health Law. And while the U.S. Food and Drug Administration prohibits distributing expired medication, “it doesn’t seem to be in line with the federal government’s harm reduction goals to come after people using naloxone,” Lieberman said.

“It’s sort of a gray area, but we feel that the argument is that aside from the professions that specifically say you can’t distribute expired drugs, other people are protected from civil or criminal charges if they distribute or use (expired) naloxone,” she said.

In 2019, as part of a response to increasing reported opioid overdoses in Texas, the state launched More Narcan Please, using federal grant money to purchase the lifesaving drug then distributing it free of cost. The University of Texas Health Science Center at San Antonio was chosen to administer the distribution. Individuals can request a box containing two doses. Organizations that distribute naloxone can make bulk orders. In its first year, More Narcan Please was delivering large shipments, sometimes thousands of doses at a time, according to data provided by the Texas Health and Human Services Commission.

As demand has grown, More Narcan Please has had to scale back how much it distributes to individual organizations. This year, the program is limiting orders to 24 units, or 48 doses, and asks organizations to give out all those doses before requesting more. The now publicly available data can help journalists around the state report on the opioid epidemic. It also provides insight into which organizations received naloxone from the More Narcan Please program.

Distributing life saving medication is also a facet of harm reduction, a broadly defined 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. Harm reduction organizations are among those most likely to use expired naloxone.

The data provided by HHSC does not show which organizations have expired doses, and it’s not clear how many recipients track the use of naloxone.

“At this time, the More Narcan Please program does not participate in organized re-distribution of expired naloxone,” said Lisa Cleveland, a professor of nursing at UT Health San Antonio who oversees the state’s overdose prevention education program as well as the More Narcan Please program. “On occasion, and in cases of dire need, our program has facilitated communications between community partners wishing to redistribute expired, yet still usable naloxone, to other organizations in need.”

More than 40% of the doses given out by More Narcan Please in 2019 went to institutions within the criminal justice system, including police departments, according to the data obtained by Texas Community Health News. Local governments made up more than 5% of the recipients that year. The share that went to government agencies fell in the following years, but a new statewide program has almost exclusively sent naloxone to law enforcement agencies.

Government officials who spoke with Texas Community Health News said they generally do not use expired doses. Melissa Lucio, the substance use disorder program coordinator at the Bexar County Department of Behavioral Health, said there’s no official policy against using expired doses but added that county agencies didn’t want to use expired doses “to avoid any liability concerns.”

And anecdotal evidence shows law enforcement agencies rarely use doses before they expire. For example, between Jan. 1, 2019, and Aug. 15, 2023, the Fort Worth Police Department obtained 760 doses of naloxone through a different program and administered 14, or 1.8% of the total doses. The Houston Police Department has received 22,000 doses through More Narcan Please. Since 2017, its officers have administered Narcan, sometimes multiple doses, in 278 suspected overdose incidents, according to information the department provided in response to a records request.

“What I assume through previous observations, when a law enforcement agency requests naloxone, it’s going to give one to every officer, one to every patrol car, along those lines,” Hill said. “If they happen to encounter an overdose, they use it. If not, it expires. At that point it can be contributed to a harm reduction agency.”

But the top law enforcement recipients of doses from More Narcan Please have inconsistent policies about what to do with expired Narcan. The Webb County Sheriff’s Office, which received 4,300 doses in 2019, destroys expired naloxone, according to records provided in response to a public information request. In response to questions and records requests, the sheriffs offices for Denton and Harris counties indicated they donate expired doses.

According to the Houston Police Department: “Doses which are beyond their expiration date are currently stored in secure department storage until authorized for disposal. These doses will not be reissued or redistributed within HPD or to other organizations.”

 The Texas Department of Public Safety, which received more than 8,000 doses in 2019, did not respond to Texas Community Health News’ inquiries. The Austin Police Department, which received 3,800 doses from More Narcan Please, said in a statement that it “does not presently store expired doses.”

“Currently, we are not re-distributing Narcan to any other organization,” the department said.

Narcan became available over the counter in September, driving its price down to about $45 in the pharmacies that have it — pharmacists can also provide it without a physician’s prescription, but that version costs more. Despite its availability, providing the medication free of cost is expected to remain an important part of statewide and local strategies to reduce overdose deaths. And as long as federal and state spending on free doses doesn’t meet demand, expired doses will continue to be a sought-after resource.

In 2020, the FDA extended Narcan’s shelf life, changing the expiration date on the label from two years after manufacturing to three years. Between 2020 and 2022, More Narcan Please distributed more than 300,000 additional doses, according to the data obtained by Texas Community Health News. The program had $5.59 million in fiscal year 2023, enough to purchase more than 175,000 doses, according to the Health and Human Services Commission. The Texas Division of Emergency Management will distribute another $75 million worth of naloxone to first responders and hospitals over 10 years, according to records provided in response to a public information request. So far, those doses have largely gone to county sheriffs.

The lack of coordinated redistribution of expired doses is frustrating for people like Em Gray, who runs Austin’s N.I.C.E. Project, a harm reduction organization that stocks vending machines with free naloxone. Gray said she gives out about 7,500 doses a year, mostly to people who use drugs, but she says demand exceeds the amount she’s able to supply. She and other experts say that’s important, because the person most likely to first respond to an overdose is another person who uses drugs or their loved ones.

“It’s kind of a special treat if I get something from More Narcan Please,” Gray said. “So I’m really having to diversify and rely on interorganizational support.”

Sometimes that means using expired naloxone donated from organizations that can’t or won’t use it.

“Naloxone has been proven to be a very stable molecule that can withstand both high and low temperatures,” Gray said. ”So I will take it in whatever form anyone’s got. I’ve made that known in the community and folks give it to me when they have it.”

Because there’s no formal sharing program, government agencies and grassroots organizations are working out ad-hoc arrangements to redistribute expired naloxone. In 2019, Bexar County’s emergency operations center received 6,000 doses from the state program, which it distributed to various agencies, including the sheriff’s office.

By last year, hundreds of those unused doses were expiring, said Lucio, the county’s substance use disorder program coordinator. Lucio sits on the board of several organizations dedicated to combating the opioid crisis, and has gotten to know people working at nonprofits that provide services to people who use drugs. It was clear they needed more doses, and she had a way of providing them.

“These are the folks that receive Narcan … through the More Narcan Please,” Lucio said. “Once those funds depleted early, in January 2022, they were desperate for more units.”

So Lucio put out a call to county departments: Drop off your expired Narcan at the county jail. She was able to provide 500 doses to the nonprofit Corazón Ministries.

People who end up with expired doses don’t always know they can be used. A number of the organizations that received doses from More Narcan Please said they give training sessions when they distribute the medication. Some officials, like Texas A&M Public Health’s Alonzo, said they make a point of explaining that it’s usable after the expiration date.

But not all. The Texas Municipal Police Association received 4,800 doses between 2019 and 2022 that it distributed to law enforcement officers who attended trainings about the opioid crisis. Tyler Owen, the organization’s social media and communication manager, said he’s not aware of any efforts to get those departments to donate expired doses.

“I don’t think there’s any recommendation that we provide any agency,” Owen said. “I will say that anything is better than nothing.”

The University of North Texas Health Science Center at Fort Worth received 9,000 doses in 2019 that were distributed during training sessions around the region, including at churches, schools and businesses, said Teresa Wagner, the interim director of SaferCare Texas, the school’s community education program. Wagner said her organization instructs recipients to take expired doses to a drug takeback program, which generally destroy the medication they receive.

“If they have a closet full of naloxone, expired, unexpired, however it comes, and my friends are out there dying in the street, that’s more than frustrating, that’s repugnant” said Gray, the Austin harm reduction worker.

The Colorado Consortium for Prescription Drug Abuse Prevention, the coordinating body for that state’s response to the opioid crisis housed at the University of Colorado Anschutz Medical Campus, operates an expired naloxone donation program. The consortium doesn’t have funding to store and distribute the expired medication, said Director José Esquibel. Instead, it publicizes the value of expired naloxone and coordinates donations to organizations that will use it, Esquibel said. Colorado’s access to naloxone law explicitly states it’s legal to possess and administer expired doses.

“It was essential,” Esquibel said of the legislation. “We wouldn’t be promoting (donating expired doses) if we didn’t have that.”

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