Free Take-Home Naloxone at Emergency Departments
A Low-Burden, Hospital-Based Model for Direct Naloxone Dispensing
The Virginia Naloxone Project uses opioid settlement funds to buy naloxone for emergency departments, enabling clinicians to hand patients a take-home kit at discharge instead of a paper prescription that often goes unfilled. In its first year, it reached 54 emergency departments across the Commonwealth.
The Challenge They Were Addressing
Patients who come to an emergency department after an opioid overdose are among the most likely to overdose again. A study at VCU Health found that roughly 5 percent of patients who present to the ED for a nonfatal overdose die within a year of that visit. The emergency department is often the first and sometimes the only point of contact these patients have with the health system, which makes it one of the best places to put naloxone directly into their hands.
The standard practice was to send patients home with a paper prescription for naloxone. As the project team put it, that prescription rarely gets filled. Most state pharmacy rules also require specific storage, labeling, and dispensing steps, making it difficult to dispense naloxone directly to an at-risk patient before discharge. So the medicine that could prevent the next overdose rarely left the building with the person who needed it.
The reason hospitals had not solved this was money, not willingness. Payers do not reimburse take-home naloxone, so a health system that dispenses kits in the ED absorbs the cost of the medication and has no way to recover it. That single fact, described by the project lead as the primary barrier and the heaviest lift, kept most emergency departments from starting a program even when their clinicians wanted one.
What They Built
The Virginia Naloxone Project directly removes the cost barrier. It uses opioid settlement money to purchase naloxone and provides it free to any Virginia emergency department that enrolls. Once an ED is set up, a clinician can order a take-home kit in the electronic health record for any patient deemed at risk. A nurse retrieves the kit from the automated dispensing cabinet, labels it, counsels the patient on how to use it, and the patient walks out with naloxone in hand. Each kit holds two 4 mg intranasal naloxone spray devices and instructions for use.
The project began at VCU Health and Carilion Clinic and grew from there. With the settlement award in place, the team expanded to 54 additional emergency departments across the Commonwealth, working toward the goal of reaching every ED in Virginia. The team starts with the largest health systems first, because a single system can carry many sites at once: VCU runs seven emergency departments, Carilion ten, and Inova fourteen.
Enrollment is designed to be low-burden for the hospital. A participating ED receives free naloxone, a step-by-step implementation toolkit, technical assistance throughout setup, and monthly data reports on the number of kits it has dispensed. The toolkit is the part that carries most of the administrative weight. It walks a hospital pharmacist through the Virginia Board of Pharmacy rules, the statewide standing order, the labeling and recordkeeping requirements, and the steps to build the order set and stock the dispensing cabinet, so each site is not solving the legal questions on its own.
Reaching the systems where the team already had relationships was straightforward. The harder work is the long tail of roughly 40 remaining hospitals where the team does not yet have an agreement. That outreach runs on cold emails and a one-page summary that explains what the project is, that it comes at no cost to the hospital, and that a toolkit will guide the pharmacy team through setup.
Key Program Components
Who You Need at the Table
What made a willing partner essential vs. optional?
The required partners are those that supply, pay for, and dispense the medication. The Opioid Abatement Authority funds naloxone; The Naloxone Project buys and ships it; and each enrolling emergency department and its pharmacy team does the work of standing up the program and getting kits into patients' hands. Without any one of those, there is no program.
The helpful partners open doors. The Virginia Hospital and Healthcare Association and the Virginia College of Emergency Physicians lent the project legitimacy and access to systems and physicians it would not have reached on its own. The Naloxone Project, the national nonprofit that started in Colorado and counts Virginia as its first sibling chapter, provides the underlying model and public toolkits that a new state or a single hospital can adopt and adapt.
Budget Breakdown
What is the minimum viable budget to replicate this?
The medication is the budget. Because take-home naloxone is not reimbursed, the money has to cover the kits themselves; that is the spend that turns a willing hospital into an active one. A county or single hospital starting small does not need a large staff or new technology. With roughly $75,000, it could buy a real supply of naloxone, lean on the publicly available toolkit from The Naloxone Project for the legal and procedural steps, and run dispensing through the ED clinicians and pharmacists already on shift. The floor is a funded naloxone supply plus one ED willing to build the order set and dispense at discharge.
What Worked and Why
Specific decisions or design features that drove success
Buying the naloxone and giving it away free was the decision that made everything else possible. Hospitals were not refusing on principle; they were refusing because they would incur an unreimbursed cost. Offer them free naloxone, and the main reason to say no disappears. The project lead called the free medication the activation energy for the program and estimated it accounts for about 90 percent of what makes the work succeed.
Starting with the largest health systems gave the project scale quickly. One system enrollment can bring many emergency departments online at once, since VCU runs seven EDs, Carilion ten, and Inova fourteen. Beginning where the relationships already existed, let the team build volume and a track record before turning to the harder, one-at-a-time outreach.
Putting the administrative weight into a toolkit kept the lift light for each hospital. The heaviest non-cost work is meeting the Board of Pharmacy labeling and recordkeeping rules and building the order set. The Virginia-specific toolkit walks a pharmacist through those steps, so a new site is not interpreting regulations alone, and clinicians can focus on the patient in front of them.
Once the cost barrier is gone, clinician buy-in comes easily. The team expected pushback and skepticism and saw very little. Physicians and pharmacists generally see dispensing naloxone as plainly good for their patients, so many moved quickly within their own organizations to get a program running, even though they knew it meant some extra setup work.
Early outcomes and data
54 emergency departments were enrolled across Virginia in the first year, to reach every ED in the Commonwealth, leaving fewer than 50 to recruit.
More than 10,000 free naloxone kits sent to participating emergency departments.
Early systems, VCU, Carilion, UVA and Inova, together account for many of the enrolled sites, since each operates between seven and fourteen EDs.
A peer-reviewed VCU Health study found a 48 percent lower risk of a subsequent ED overdose and a 63 percent lower risk of death within six months among overdose patients after the ED take-home naloxone program started.
In that study, death within six months fell from 5.6 percent before the program to 2.0 percent after among patients who first presented with an opioid overdose.
Each enrolled ED receives a monthly report on the number of naloxone kits dispensed.
Lessons Learned
Pay for the medicine, and the rest will follow. The team learned that the one move that changes everything is removing the cost. Once the naloxone is free, hospitals that had hesitated for years are willing to do the setup work, because the clinical case was never the obstacle.
Start where the relationships already are. Enrolling large systems the team already knew, and where one system means many EDs, built scale and credibility quickly. The cold-contact hospitals can come once there is a track record to point to.
Expect less resistance than you fear. The team braced for skepticism about credentials and motives and met very little. Most clinicians saw dispensing naloxone as plainly good for patients and moved quickly once the cost was addressed.
Put the hard rules into a toolkit once. Writing the Board of Pharmacy and standing-order requirements into a single step-by-step guide spared every new site from having to interpret the regulations on its own and made the program an easy lift.
Plan the long tail of outreach early. Reaching the last 40 or so hospitals where the team has no contact is the slow part of going statewide. Budgeting time and a clear pitch for that outreach from the start would have smoothed the path.