By delivering free naloxone and other harm reduction supplies discreetly and confidentially to people’s homes, what arrives in the mail could save a life. That’s the take-home message from an innovative approach to reducing opioid overdose deaths in Philadelphia, where the fatal overdose rate surpasses that of other large U.S. cities. Mailing is an effective yet largely underutilized strategy for increasing access to life-saving harm reduction supplies, one that policymakers should explicitly support given the urgent need.

In a recently published paper in International Journal of Drug Policy, we evaluated a partnership between NEXT Harm Reduction, the Philadelphia-based harm reduction group SOL Collective, and the Philadelphia Department of Public Health that provides free mailed naloxone to any Philadelphian who requests it. We analyzed the 422 naloxone requests received in Philadelphia from March 2020 through January 2021, throughout the pandemic.

We found that COVID-related barriers accounted for nearly a third of reasons that individuals cited for not being able to access naloxone in person. Many individuals lacked knowledge about how to access naloxone, even though all pharmacies across Philadelphia are required to carry it. Consistent with other studies, cost, supply issues, and stigma also emerged as barriers to in-person naloxone access.

The free mailed naloxone program is targeted to people with personal proximity to overdose (broadly defined as personally overdosing or witnessing/worrying about others overdosing). We found that only three-fifths of the requestors in our study identified as such, suggesting that better dissemination efforts are needed to reach this target audience—perhaps by increasing the presence of online content that is easily searchable.

Additionally, further efforts are needed to reduce racial disparities in naloxone access. Only 13.6% of naloxone-by-mail requestors were Black, despite the fact that 40% of Philadelphians are Black. As opioid overdose death rates rise among Black Americans and drug overdoses kill more Black than white Philadelphians amidst the COVID-19 pandemic, these findings reveal that even well-intentioned initiatives can perpetuate racial disparities. NEXT Harm Reduction and SOL Collective are actively working to address these disparities by partnering with individuals and organizations rooted in Philadelphia communities most in need of services.

The reach and impact of mail-based harm reduction efforts could be amplified by mailing supplies beyond naloxone, especially in Philadelphia where fentanyl has infiltrated the entire drug supply, including heroin, pills pressed to look like prescription opioids or benzodiazepines, and cocaine. Despite fentanyl’s leading role in overdose deaths, fentanyl test strips are difficult to obtain because of legal barriers at the federal level. Local policymakers in Philadelphia and elsewhere should explicitly support and fund the mailing of safe use kits that include fentanyl test strips, syringes, and other infection-prevention supplies.

We know that mail-based harm reduction efforts save lives, prevent injection-related disease transmission, and improve the lives of people who use drugs. There are encouraging signs from the Biden administration, which has included harm reduction and advancing racial equity issues in its first-year priorities for national drug policy. This may signal a much-needed shift away from The War on Drugs and criminalization of people who use substances, which has not succeeded in promoting health; in fact, it continues to do the opposite. Emphasizing harm reduction and racial justice is a step in the right direction.

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The study, A Free Mailed Naloxone Program in Philadelphia Amidst the COVID-19 Pandemic, was published online in March 2021 in the International Journal of Drug Policy.  Authors are Rachel French, Jamie Favaro, and Shoshana Aronowitz.