New Mexico Naloxone Legislation: Targeting those Most in Need

Background: Drug overdose deaths due to heroin and prescription opioids are a public health crisis in the United States (US) and throughout much of the world. New Mexico (NM) has led the US for many years in opioid overdose deaths. Naloxone is the most effective harm reduction tool to reduce overdose deaths. Methods: New Mexico House Bill 370 (2017) was strategically drafted to target the populations most able to utilize naloxone and reduce opioid overdose deaths: 1) The patients and social contacts at opioid treatment programs (OTP). 2) All law enforcement officers. 3) Inmates just released from all correctional facilities with a history of opioid use disorder. NM House Bill 370 requires two doses of naloxone, opioid overdose education, and a prescription to be given to all patients at any NM federally qualified OTP and for all inmates upon release from correctional facilities. All New Mexico law enforcement officials must carry two doses of naloxone as well. Results: New Mexico House Bill 370 (2017) passed unanimously in both the NM State House and Senate, and became effective July 1, 2017. Conclusion: Targeted naloxone legislation, such as NM House Bill 370, may help to curb the epidemic of drug overdose deaths.


Introduction
Deaths due to heroin and prescription opioid analgesics are increasing in the United States (US) and internationally and represent a global public health epidemic [1]. In 2015, the US Centers for Disease Control and Prevention (CDC) reported over 50 thousand drug related deaths, which exceeded gun violence and motor vehicle accidents as the leading cause of accidental death in the US [2]. The resolution to the opioid epidemic requires a multi-pronged, targeted approach including: 1) understanding social networks related to drug use [3], 2) reform of re-entry from correctional facilities for inmates with opioid use disorder (OUD) [4], 3) requiring all first responders, including law enforcement officials (LEOs) to carry naloxone [5], and 4) increasing access to medication assisted treatment (MAT) [6].
According to the National Conference of State Legislators [7], New Mexico became the first state to enact the Good Samaritan Law in 2007. Now, a decade later, in April 2017, New Mexico has passed new naloxone legislation. By targeting individuals in opioid treatment programs (OTPs), those recently released from incarceration, and law enforcement officers (LEOs) state wide, New Mexico House Bill 370 (2017) strategically provides opioid overdose education and naloxone distribution (OEND) to populations that will benefit most based on contemporary social psychological paradigms. This new law, effective July 1, 2017, mandates: 1) all LEOs in New Mexico carry two doses of naloxone; 2) all federally qualified OTPs provide overdose education, two doses of naloxone, and a prescription for naloxone to every patient; and 3) all inmates with an OUD receive overdose education, two doses of naloxone, and a prescription for naloxone upon discharge from a correctional facility. By taking these steps, a community can reduce overdose deaths and encourage treatment for OUDs while safeguarding the legitimate use of medically necessary medications for those who truly need them.

New Mexico House Bill 370 Part 1: Federally Qualified Opioid Treatment Programs must provide Opioid Overdose Education, Two Doses of Take-Home Naloxone and a Prescription for Naloxone to All Patients being treated by the Facility for OUD
There is much evidence that patients in active treatment for OUD, along with their social contacts, benefit significantly from the harm reduction components of OEND [3]. This underscores the notion that social networks are one of the largest determinants of health; and an individual's health is significantly correlated and interdependent with the health of others around them [8]. Additionally, previous research suggests that those who have been saved by naloxone are more likely to seek treatment for their OUD [9].
A critical component of NM House Bill 370 is the integration of descriptive and prescriptive social norms, so that these "norms" can work together [10]. Descriptive norms reflect the social behavior that is occurring in the community at large, whereas prescriptive norms demonstrate the desired behavior change. Through opioid overdose educational campaigns and naloxone availability (descriptive norms), individuals within social networks become active in performing overdose reversals. This changes the social milieu from descriptive to prescriptive so that using naloxone is a positive behavior change that alters the social norm. Both qualitative and quantitative research validates that people will administer naloxone if the drug is made accessible to them. This may change the norms within a social network and allow for more overdose reversals to be performed if naloxone is made easily available to patients being treated in an OTP [11].

New Mexico House Bill 370 Part 2: All New Mexico Law Enforcement Officers must Carry Two Doses of Naloxone
For decades, emergency medical services (EMS), such as 911 first responders in ambulances and fire units, across the U.S. have carried naloxone to treat unresponsive patients in the field. In largely rural areas, however, EMS may take hours to arrive at the scene of a medically ill patient, meaning that someone overdosing on heroin and/or prescription opioids may die before EMS arrives to assist. In addition, overdose reversal outcomes directly correspond to the level of first responder training [12].
On October 21 st 2015 [13], the Obama administration urged law enforcement agencies across the US to equip their officers with naloxone to prevent unnecessary drug overdose deaths. Increasingly, LEOs in various cities and counties throughout the US now carry naloxone to perform overdose reversals and most LEOs who carry naloxone are performing overdose reversals safely and with increasing self-efficacy [5]. In New Mexico, all LEOs will now carry naloxone without exception.

New Mexico House Bill 370 Part 3: Every Inmate Released from a Correctional Facility in New Mexico with an OUD must Receive Opioid Overdose Education, Two Doses of Take-Home Naloxone and a Prescription for Naloxone
Incarcerated individuals with an OUD (who have not been treated with MAT while in correctional facilities) are at a substantially higher risk of drug overdose deaths for at least one month after release from a correctional facility compared to any other time [4]. The New England Journal of Medicine (2003) reported a retrospective study of 30,237 former inmates and described a 12.7 times increased risk of death, with drug overdose as the primary risk factor [14]. Inmates often leave correctional facilities homeless and without treatment for neither psychiatric nor medical conditions. If they suffer from an OUD, they are at great risk for overdose with opioids to which they are no longer tolerant.

Conclusion
New Mexico House Bill 370 [15] is the first highly tailored naloxone legislation in the US aimed at reducing drug overdose deaths by targeting those populations that are most likely to be affected. Through a multi-pronged deliberate approach that utilizes social psychological paradigms, and addresses the populations most in need of harm reduction tools for opioid overdose, this targeted approach may further decrease the numbers of New Mexicans dying each year. An evaluation of this legislation is needed to understand the full impact for patients and society.
There are many other opportunities to reduce opioid overdose death. These include improving access to MAT for the millions of Americans suffering with opioid use disorder and mandating education related to pain management and safe opioid prescribing for clinicians with prescriptive authority.