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The purpose of this document is to provide Tennessee county, city and local government leaders with an overview of naloxone and the types of distribution and promotion strategies for the overdose-reversal medication that are available and evidence-based, with estimates for cost, time, stakeholders, and expected impact. For more information on a specific strategy, please contact smart@tennessee.edu or visit smart.tennessee.edu.
Naloxone Safety and Efficacy
Naloxone is an opioid antagonist, meaning that it binds to the same receptors in the nervous system and blocks opioids from working, meaning it can reverse an opioid overdose and save a life. It also prevents the person from feeling the euphoric effects (or “high”) of an opioid. Naloxone itself is non-intoxicating, non-addictive, and other than a very rare chance of an allergic reaction (like any medication) it has no noticeable effect on people who do not have opioids in their system. It is not itself harmful to adults or children. However, it only reverses the effects of opioids, and cannot prevent or reverse an overdose due to methamphetamine, cocaine, xylazine, or other non-opioid drugs (NIDA, 2022).
Why Naloxone?
Data shows a 20-30% decrease in fatal overdose deaths in 2024 (CDC 2025b), meaning that 27,000 fewer people compared to 2023. While the overdose rate still remains higher than when the opioid epidemic was declared to be a national emergency in October 2017 (CDC, 2025a), this is still the most dramatic reduction in overdose deaths since the opioid crisis began.
Data points to numerous potential contributors to this reduction in deaths, including harm reduction practices (i.e., smoking instead of injecting (Cariné, 2024)), changes and disruptions to the drug supply (DEA, 2024), and epidemiological factors (such as increased metabolic tolerance to fentanyl among the drug use population (MacMillan, 2024) and the deaths of those who were at the greatest risk (Dasgupta, Miller & Sibley, 2024). However, the evidence overwhelmingly points to widespread and easy access to naloxone as the largest causal contributor to this massive reduction in overdose fatalities (CDC, 2025b; Dasgupta, Miller & Sibley, 2024).
High Risk Populations that Benefit from Naloxone
Having naloxone as widely available as possible improves the chances that it will be used to save lives, but some populations need to be prioritized by naloxone distribution and promotion programs due to a number of factors that place them at particularly elevated risk of relapse and overdose. One of the biggest risk factors for overdose death is returning to drug use after a period of voluntary or involuntary sobriety, which can occur during jail or when attempting to quit using drugs. When this happens, metabolic tolerance for the drug decreases, and using the same dose as before can result in unintentional overdose, which is often fatal, particularly when the drug in question involves highly potent fentanyl.
Such high-risk/high-need populations include but are not limited to:
- People leaving jail and re-entering the broader community
- People discharged from emergency rooms/hospitals after receiving treatment for overdose
- Homeless/transient people
- People living in recovery residences
- Rural people with lower income
- Friends and families of people with substance use disorder (they are more likely than the average person to be nearby when an overdose occurs)
Naloxone Legality in Tennessee
Tennessee’s “Good Samaritan” law, passed in 2014, protects anyone administering naloxone to someone they reasonably believe is experiencing an overdose from civil litigation (except for gross negligence or willful misconduct).
A licensed healthcare provider may prescribe naloxone directly or by standing order to (1) an individual; (2) a family, friend or other individual in a position to assist an individual experiencing an overdose; and (3) any organization, municipal or county entity including, but not limited to, a center, recovery organization, hospital, school, harm reduction organization, homeless services organization, county jail, shelter, AIDS service organization, federally qualified health center, rural health clinic, health department, or treatment resource, for the purpose of providing an opioid antagonist to (1) or (2) (citation).
Put simply: essentially anyone in Tennessee is legally permitted to acquire, store and use naloxone to prevent opioid overdose.
Obtaining Naloxone in Tennessee
- Naloxone is available as a nasal spray like Narcan, Kloxxado or a generic naloxone nasal spray (of which there are multiple varieties), as well as a similar array of intramuscular formulations. Nasal spray is the most widely known and understood by the general public, but intramuscular is far less expensive and studies suggest it adequately meets the needs of those most at risk of overdose death (Cid, Mahajan & Wong, 2024).
- Tennessee has a statewide collaborative practice agreement, meaning that any licensed and practicing pharmacist in Tennessee can be an access point for naloxone to an individual or organization and no prescription is required. Because of this, it can be acquired in bulk directly from pharmaceutical manufacturers, wholesalers and even online pharmacies.
- Governmental and Public Service entities are eligible for a discounted price for bulk naloxone purchases.
- The Regional Overdose Prevention Specialists (ROPS) program is the most essential distribution pointfor naloxone in Tennessee. From Oct 2017 to June 2024, ROPS distributed 854,000 units of naloxone, saving a documented 103,000 lives (the actual number is believed to be much higher, as reporting is voluntary). ROPS provides naloxone and training at no cost to:
- first responders,
- individuals at high risk of overdose as well as their friends and family and
- agencies and organizations that provide treatment and recovery services or community resources.
- Naloxone is available to purchase at pharmacies over the counter, meaning no prescription is required. This is a good option for individuals interested in being “Good Samaritans” who have the ability to pay for naloxone.
- Tennessee Harm Reduction is a nonprofit based in West Tennessee that mails both nasal spray and intramuscular naloxone products to all 95 counties for free, as well as other harm reduction products such as fentanyl test strips. This is a good option for individuals who want naloxone but cannot easily afford it.
Paying for Naloxone
Some of the sources of naloxone identified in the above section are available at no cost, such as through ROPS or Tennessee Harm Reduction. Similarly, naloxone can often be sourced from other local organizations including drug prevention coalitions, syringe service programs, and other similar entities.
Opioid settlement funds can be spent on naloxone. This includes the subdivision funds administered by BrownGreer as well as the Opioid Abatement Trust Fund, either through the direct payments to counties or through the community grants.
The State Opioid Response (SOR) grants from the federal government fund much of Tennessee’s naloxone availability, such as the ROPS program. A county program should coordinate or leverage these resources when launching a new program.
Other grants from both public and private sources, including foundations, may pay for naloxone.
Naloxone Distribution and Promotion Programs
Naloxone distribution and promotion takes many forms, and deciding which program to use should involve consideration (1) accessibility of the naloxone to those who need it, (2) which stakeholders are involved, (3) cost of implementation, (4) time involved in launching the program and (5) maintenance considerations.
First Responder/EMS Naloxone Leave Behind Programs
Accessibility: Controlled. Targets only people at high risk of overdose.
Stakeholders: First Responders/EMS providers, as well as a local service provider such as an anti-drug coalition or treatment provider, preferably with a certified peer recovery specialist on staff.
Cost: Low (approx. a few hundred to about $1,000, depending on size and accreditation of first responder personnel). The TN Dept. of Mental Health and Substance Abuse Services (TDMHSAS) will provide the naloxone itself, as well as training for first responders at no charge. However, the cost of overtime pay for staff to receive training may need to be reimbursed—fortunately this is an allowable expense through the opioid settlements.
Estimated time to launch: 3-6 months, depending on personnel time for training, identifying local partners, and granting reimbursement for overtime pay. 
Where EMS has responded to an overdose and administered naloxone, successfully reversing that overdose and saving a life, a naloxone leave behind program would involve providing to the patient an overdose reversal kit that contains 1-2+ additional doses of naloxone so that the patient may have it on hand in case they experience another overdose after EMS leaves.
It is not uncommon that patients who have overdosed refuse to be transported to the hospital after EMS has revived them (Bergstein et al., 2021), so leave behind programs increase the likelihood that a patient known to be at high risk of overdose (evidenced by having just experienced one) will have a greater chance of having naloxone nearby should they continue to use drugs.
Naloxone leave behind programs are most likely to be effective if the kits also involve a connection to local resources, especially if those resources include certified peer recovery specialists. As such, a successful naloxone leave behind program would involve an agreement between the EMS provider and a local anti-drug coalition or treatment program, or some other local service that can connect a patient to follow-up long-term treatment as soon as possible.
Importantly, TDMHSAS has begun placing care coordinators across the state specifically to work with first responders in implementing leave behind programs, and as of May 2025 is serving 39 counties with this program.
Finally, as some counties do not have an active anti-drug coalition or a care coordinator, consider TDMHSAS’ Project Lifeline, which employs certified peer recovery specialist coordinators across the state whose primary responsibility is routing people to treatment and recovery resources.
Public Distribution Points, or Naloxone Housing Units (NHU)
Accessibility: Open or controlled to specific populations, depending on the NHU type, location and program goals.
Stakeholders: Depends on location chosen, population targeted, involvement in research or other collection of usage data, and (most importantly) volume of supply needed for stocking the NHU.
Cost: Approximately $99-$12,000, depending on device, use volume and accessibility.
Estimated time to launch: 1-6 months, depending on chosen device, naloxone supply required, funding stream and stakeholder involvement.
Although naloxone is more accessible than ever in Tennessee due to our Good Samaritan laws, collaborative practice agreement, standing orders for organizations and the fact that naloxone is now available over the counter and can even be purchased in some major grocery store chains, it can still be difficult for the people at greatest risk of an overdose to obtain a dose. First and foremost is cost: a pack of generic naloxone nasal spray can still cost $30-40. Even more so, though they can be purchased at greater accessibility, that does not necessarily equate to the product being close at hand during an emergency or getting in the hands of those that need it the most.
Numerous companies have thus stepped up to create devices for public distribution, sometimes known as naloxone housing units (NHU), intended for use in geographic areas known to have a high rate of overdose or be accessed by people at high risk of overdose. Options range from low cost and simple (such as repurposed newspaper stands, public-facing cabinets, or boxes mounted to the wall alongside first aid kits or AEDs), to the complex and expensive, such as vending machines (which can also store a variety of useful items like fentanyl test strips, wound care kits, etc., and are also capable of collecting data if desired). Regardless of the NHU chosen, the desired impact is the same: placing these devices in areas where overdose deaths are known to have occurred—or are accessed by people at risk of overdose—anyone in these areas who needs naloxone can simply open the device and get it.
The options for public distribution range from simple and low cost to complex and expensive.
On the lower cost end ($50-$500) are the newspaper stands, mounted boxes and simple cabinets, which are usually branded in purple—the color of recovery—and stamped with announcements of the naloxone inside. Some have a degree of technology to them, such as the ONEbox, which has a video player inside that can provide on-the-spot naloxone training for those who do not know how to effectively use the nasal spray. These have become popular devices in Nashville, Knoxville, Chattanooga and other cities for their practical usefulness in music venues and bars as part of the venues’ first aid response. The downside to these options is that their storage capacity is smaller, so doses may need to be replaced more often, depending on use.
The smaller devices are also commonly intended for use in emergency situations by staff. For example, in Nashville, while some of the ONEboxes® have been placed in locations where anyone can access them, some venues have chosen to keep them accessible only to staff, where they can be accessed like an AED or first aid kit in an emergency. The doses of naloxone can be accessed for free through ROPS, who can also provide overdose response training to staff.
On the more costly end ($5,000-$12,000) are vending machines, which can hold a very large quantity of naloxone as well as other harm reduction tools like fentanyl test strips and wound care kits. Some programs also offer other supplies based on their target population. For example, gun locks may be included in machines targeting veterans at risk of suicide as well as overdose, or condoms for populations at risk of transmitting HIV (a disease also often transmitted by sharing drug needles). It all depends on the target population and goals of the device. These machines also often allow for instructions, have ample space for signage and instructions, advertisements for local recovery resources and services, and may even help directly track data on use volume and more.
Common locations where public access boxes and devices are placed: harm reduction services, treatment clinic lobbies, recovery community centers, places where homeless people at risk of overdose are known to pass through, jails, libraries, hotels, motels, music venues, bars, and even street corners; wherever overdoses are known to occur with great frequency.
Important considerations:
- Naloxone supply chains. Once the naloxone inside is used, who will restock the boxes or machines, where will they source the replacement doses, and how often will the devices be checked and restocked?
- Data collection. Funders may want to know how many doses are used, how often the devices are accessed, and even potentially demographics of those who access the devices. Determining who will be in charge of data collection and reporting will be important.
- Using local, timely data to determine placement. It's critical to ensure that these devices are placed in areas where people at risk of overdose are actually likely to encounter and use them. Local EMS or first responder data, ODMAP, police response calls, and other sources of information will be crucial in determining where these devices will be placed. From there, additional local stakeholders can be identified.
- Concerns that doses may be stolen are valid—stocking these devices can be expensive—but overdose response experts have said that people who “steal” naloxone probably need it for its intended purpose anyway, so having a point of access where naloxone is literally free for the taking is indeed highly likely to be used by people who need it for overdose reversal.
- NHU programs that are operated in-house by a county are typically more cost-effective than outsourcing to a contracted external overdose prevention program. Furthermore, NHU programs that include overdose education may be more effective at reaching target populations (Starbird et al., 2024). As such, it is highly advisable that an NHU program coordinate with ROPS (see Obtaining Naloxone in Tennessee above).
Naloxone Promotion and Anti-Stigma Media Campaigns
Accessibility: Typically broad and open, but can be controlled to specific populations.
Stakeholders: Media and marketing companies, local partners (coalitions, first responders, healthcare workers or others, depending on the goal of the media campaign) and the target audience.
Cost: $5,000-$95,000, depending on strategy, duration and media utilized (website, video, printed, billboards, etc.)
Estimated time to launch: 1-12 months or longer, depending on strategy, duration of campaign and media chosen.
Media campaigns can be effective at reducing stigma, normalizing behaviors, promoting particular products, and raising general awareness, as well as solidifying a consistent message across multiple stakeholders. As stigma remains a widespread concern in Tennessee, particularly towards naloxone (Kourvelas et al., 2021), media campaigns can enhance the effectiveness of outreach programs such as DEA drug take back days, naloxone leave behind, public distribution points, recovery community centers, new clinics, and other efforts (Yang & Mackert, 2023).
The cost of an effective media campaign can vary significantly, based mostly on the media type chosen and the duration of the campaign. For example, hiring a designer to add a page to an existing county website that has promotional messaging and lists local resources may only cost about $1,000, but launching a full-scale media campaign that includes a stand-alone website, billboards, outreach events, video products that air on television, social media and more, as well as printed materials that are disseminated throughout the community may run up to $100,000, if that campaign is expected to run for six months. As such, the scalability and customizability of media campaigns do make it an attractive strategy to consider, as they can fit nearly any opioid abatement budget.
Because naloxone is so readily available in Tennessee, and services to distribute naloxone exist in every county but awareness may be generally low among the population most at-risk for overdose, the best use for a media campaign in this state is to highlight existing services or promote new or expanded programs funded by the opioid abatement settlements.
References
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Cariné E. Megerian, Luka Bair, Jessica Smith, Erica N. Browne, Lynn D. Wenger, Laura Guzman, Alex H. Kral, Barrot H. Lambdin, Health risks associated with smoking versus injecting fentanyl among people who use drugs in California, Drug and Alcohol Dependence, Volume 255, 2024, 111053, ISSN 0376-8716, https://doi.org/10.1016/j.drugalcdep.2023.111053. (https://www.sciencedirect.com/science/article/pii/S0376871623012917)
Centers for Disease Control and Prevention. (2025, January 15). Vital Statistics Rapid Release: Provisional drug overdose death counts. National Center for Health Statistics. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
Centers for Disease Control and Prevention. (2025, February 25). CDC reports nearly 24% decline in U.S. drug overdose deaths. https://www.cdc.gov/media/releases/2025/2025-cdc-reports-decline-in-us-drug-overdose-deaths.html
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Dasgupta, N., Miller, C., & Sibley, A. (2024, September 18). Are overdoses down and why? Opioid Data Lab. https://opioiddatalab.ghost.io/are-overdoses-down-and-why/#5-depletion-of-susceptibles
Drug Enforcement Administration. (2024, November 15). DEA’s third annual National Family Summit on Fentanyl highlights progress in fight to save lives. https://www.dea.gov/press-releases/2024/11/15/deas-third-annual-national-family-summit-fentanyl-highlights-progress
Kourvelas, J. (Jeremy), Myers, C. R., Cahill, K., Derefinko, K. J., Pack, R., Moore, K. E., & Tourville, J. (2021, August 5). The Cost of Stigma. UT Institute for Public Service SMART Policy Network. Retrieved from https://smart.ips.tennessee.edu/index.php/drug-policy-analysis/cost-stigma
Little, Ken (2019, April). Health officials ramp up marketing, education on antidote. Greeneville Sun. Retrieved from https://www.greenevillesun.com/news/local_news/health-officials-ramp-up-marketing-education-on-antidote/article_e891d16b-377b-5e90-88e4-8d37e241fe7c.html
MacMillan, C. (2024, March 18). Why is fentanyl driving overdose deaths? Yale Medicine. https://www.yalemedicine.org/news/fentanyl-driving-overdoses
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The purpose of this document is to provide Tennessee county, city and local government leaders with an overview of naloxone and the types of distribution and promotion strategies for the overdose-reversal medication that are available and evidence-based, with estimates for cost, time, stakeholders, and expected impact. For more information on a specific strategy, please contact smart@tennessee.edu or visit smart.tennessee.edu.