Missouri naloxone distribution 2017-2023: Evaluation and implications of applying a naloxone saturation model

Overdose deaths have increased sharply in the past five years. States have implemented overdose education and naloxone distribution (OEND) initiatives to mitigate overdose deaths at a population level. Irvine et al. (2022) proposed a model to estimate amounts of naloxone needed to meaningfully reduce opioid overdose mortality (defined as naloxone saturation) by distributing it through: 1) community-based, 2) pharmacy-initiated, and 3) provider-based access points. In the most recent rounds of State Opioid Response grant applications, the Substance Abuse and Mental Health Services Administration (SAMHSA) required plans to reach naloxone saturation. Though SAMHSA funding has supported the growth of Missouri-based OEND, the outcomes of applying such a model are yet to be evaluated.

We used descriptive statistics and visual inspection to evaluate Missouri's naloxone distribution across agency types and years. Missouri's naloxone output was compared to observed opioid overdose fatalities and the naloxone need estimated by the model, which was at least 31,000 two-dose kits distributed through community-based settings to reach saturation.

Missouri distributed over 400,000 naloxone kits from 2017 to 2023. In 2021, Missouri distributed 32,486 kits, passing the annual saturation threshold. Overall, street outreach/harm reduction services received the most naloxone (38.9 %), followed by treatment providers (13.6 %), recovery community centers (12.6 %), and social service providers (11.6 %). Missouri's opioid overdose death rate slowed in 2022 and began to discernibly decrease in 2023.

Missouri's naloxone distribution exceeded established saturation targets and evolved to include a wide variety of community access points, eventually coinciding with opioid overdose mortality reductions. Given the significant variability in overdose risk across populations and regions, the increasingly potent and volatile drug supply emerging since 2017, and the persistent risk of solitary drug use, more comprehensive response strategies are needed and saturation models should be updated to incorporate more specific geographic, racial/ethnic, and programmatic distribution targets.