The Connecticut General Assembly this year approved the use of vending machines by approved practitioners and organizations to distribute Narcan nasal spray for free to help combat opioid drug overdoses, but activists and nonprofit organizations worry that restrictions placed on those vending machines may decrease easy access to the life-saving drug.

The primary concern is a requirement that Narcan, which is recommended to be stored at room temperature, according to the manufacturer, be stored in a temperature-controlled environment, meaning vending machines placed in outdoor locations would have to be temperature controlled, greatly increasing the price of the machines.

According to the Illinois Supply Company, a non-temperature-controlled vending machine for Naloxone runs between $300 and $400. However, the temperature-controlled units are sold for $4,500 per unit, with other companies selling them for between $5,000 and $7,000. 

According to the company’s website, “Our research tells us that governments do not want to spend $3000 on a cabinet with air conditioning and heat to protect an $80 medication.” Although the company sells temperature-controlled units, they go on to say that the Naloxone could be stored in their cheaper vending boxes and just thrown away and replaced following periods of extreme temperature.

While non-temperature-controlled units could be placed indoors by approved organizations and practitioners, outdoor boxes provide more accessibility for those who need it, and the price point for temperature-controlled outdoor machines would limit nonprofits’ ability to purchase them, according to Rebecca Allen, director of recovery advocacy for the Connecticut Community for Addiction Recovery (CCAR).

“We support anything that can get naloxone out to the people that need it absolutely,” Allen said. “Something is better than nothing.”

“If this is going to cost an organization or a business five grand plus the cost of the Narcan too, absolutely it will be a barrier,” Allen said. “The vending machines are really for organizations, businesses, places where people gather, and those people aren’t usually typically in this (addiction recovery) space.”

Allen said that perhaps a large public venue like the Xfinity Center might be willing to pay for a temperature-controlled machine, but smaller organizations might not be able to foot the bill. The outdoor boxes help ensure 24/7 access in areas where there may not be Narcan access through a nonprofit, particularly during hours when no one is available at those sites to give it out. 

Additionally, the need for electricity means those vending machines cannot be placed in remote areas and must be installed by professionals.

“If you’re talking some of the smaller organizations and stuff, that’s a lot of money to spend on something and I can’t see them wanting to foot the bill for that,” Allen said. “If there’s some assistance from the state for individuals, businesses to purchase these vending machines, that’s one thing, but if they have to come out of pocket for it, I don’t see that happening.”

Sue Willette, founder and president of The Roadway of Hope CT, a nonprofit that supports families and those suffering from mental health issues and addiction, says she doesn’t believe the Narcan will stay in the boxes long enough to become ineffective.

“I’ve been pushing for vending machines,” Willette said. “Why can’t we just stick them anywhere? I think if it was available and readily available to anybody that it wouldn’t last very long in any container that it’s in, or vending machine or whatever you want to call it.”

“If people see it, they’re going to use it,” Willette said, adding that she would place the non-temperature-controlled boxes anywhere that would allow it. “I think the stigma of wanting it or needing it prevents a lot of people from seeking it out and I think if it was there and people knew about it, it would be gone before long.”

Brian Merlen, an activist out of Stamford who is pushing against this requirement made by the Department of Consumer Protection, says other states, including next door neighbors like Massachusetts and New York, do not place such requirements on naloxone vending machines.

“The issue is these 49 other states require machines that don’t use electricity, they’re like newspaper dispensers, there’s nothing that breaks on them, there’s no electricity needed,” Merlen said. “None of it makes sense. There’s going to be very few distribution devices in Connecticut, frankly.”

The Connecticut Department of Consumer Protection (DCP), which advocated for the legislation and climate-controlled vending machines, says the requirement is necessary to ensure the Narcan doesn’t degrade in very high or low temperatures. 

“DCP has concerns about the efficacy of this medicine when being stored in extreme cold or hot temperatures, which our state experiences in both the summer and winter months,” wrote Kaitlyn Krasselt, director of communications for DCP, in an email. “The concern is that medicine retrieved from an environment that is not temperature controlled would be rendered ineffective.”

“While making these products more easily accessible is a DCP priority and critical to fighting the opioid epidemic, we remind the public that they should call 9-1-1 immediately even if they are able to access and administer the opioid antagonist, as there is not a guarantee the product will work if it has been exposed to extreme temperatures or has otherwise been tampered with,” Krasselt continued. “Storing naloxone in a temperature controlled environment increases the likelihood the product will be effective in an emergency situation.”

A 2019 study published in the Harm Reduction Journal found that naloxone remained “chemically stable following exposure to heat or freeze-thaw cycles after 28 days,” and would be effective if stored in non-ideal conditions, although the authors said pharmacists should continue to store the drug at the recommended temperature. Unlike water, Narcan doesn’t freeze until it hits 5 degrees below zero.

According to emails forwarded to Connecticut Inside Investigator (CII), however, DCP said the data was inconsistent and that other studies have shown significant degradation following extreme temperatures. But other states, including nearby New York, are not quite as cautious.

Monroe County, New York, for example, purchased and installed 307 naloxone distribution boxes, including 241 located indoors and 56 located outside, all purchased in bulk from Illinois Supply Company, according to emails forwarded to CII from Tisha Smith, of the Monroe County Department of Public Health, who says her team approaches businesses in hot-spot areas to see if they can install a naloxone box.

“Our outreach team knows the hot spots and we just set about asking businesses, libraries, community centers, housing programs, and convenience stores in those areas,” Smith wrote. “We also use some information about where overdoses are occurring and if it is a commercial establishment, we approach them for both naloxone distribution and we introduce the Naloxbox idea.”

Brandon Wilson, co-owner of Illinois Supply Company says that while he has supplied outdoor boxes for states across the country, with every kind of climate, he has yet to sell a single temperature-controlled machine.

“The cost of the non-climate-controlled ones is so affordable that it’s just a better use of taxpayer dollars or grant dollars since it’s widely known that Narcan still works after it has frozen,” Wilson said. “It’s become best practice to put it in small quantities outside to maximize the access and count on rapid turnover instead of climate control.”

Wilson says that states like his home-state of Illinois, which can endure brutal winters, allows outdoor, non-temperature-controlled Narcan boxes for distribution. “They’re selling across the country,” Wilson said. “Every day, we get orders for these.”

“What we’re seeing is when you put public access Narcan out in the environment it turns over very quickly because people need it. A big area of concern is people who are homeless or who are economically disadvantaged and maybe even people living out of their cars,” Wilson said. “A lot of times, they don’t have the luxury of climate control, if you’re taking Narcan back to a tent or a police car or an automobile, it’s not going to be climate controlled after you take it anyway.”

Merlen says that adding to the overall cost of getting these machines and naloxone out into the public is the fact that the Food and Drug Administration (FDA) has only approved Narcan nasal spray for over-the-counter distribution, which costs roughly $48 per bottle, and did not approve an injectable Pfizer product which sells for $10 or lower for nonprofits.

“It’s the same thing again, the FDA has only approved the very cost-prohibitive nasal one instead of the injection and then Connecticut is only approving these very cost prohibitive boxes that are roughly 15 times the cost per unit,” Merlen said. “In the end it’s like both decisions are horrible, it’s going to prevent the U.S. from getting saturation in terms of naloxone access.”

According to an annual report by Connecticut’s Office of the Chief Medical Examiner, opioid-related deaths have increased from 298 in 2012 to 1,339 in 2022 and deaths from Fentanyl rose from 14 to 1,253. According to the Centers for Disease Control, Connecticut had 42.3 drug overdose deaths per 100,000 of population in 2021, one of the higher rates in the country.

“I think [Narcan] should just be anywhere, I don’t think it should be about money,” Willette said. “I really wish it would stop being about monetary problems and it would start being about being readily available for anybody who needs it and as easy as possible to get it.”

“In an environment where you’re trying to get as much Narcan into the hands of people who are suffering from the throes of addiction and you know that these people are out on the streets, it really is a good idea to reflect on the risk of them dying is bigger than the risk of the Narcan going bad,” Wilson said.

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