Honolulu becomes first US city to mandate naloxone in high-risk locations

In response to opioid overdose concerns, Honolulu officials passed Bill 28, which requires that all Honolulu bars, nightclubs, and other high-risk venues keep two doses of naloxone spray (also known by the brand name Narcan), the lifesaving opioid reversal medication, on their premises. 

The requirement went into effect at the beginning of the new year, making Honolulu the first city nationwide to mandate the medication at high-risk locations. The law was preceded by an outreach campaign in which free doses were given out to affected businesses

In June 2023, a mass overdose at a resort in Waikiki resulted in two deaths and three hospitalizations. Police reported that fentanyl was found at the scene. 

The tragedy highlighted fentanyl overdose concerns in Hawaiʻi. According to health officials, cited in a recent Hawaiʻi News Now report, over the past five years, fatal fentanyl overdoses in Hawaiʻi increased around 400%.

“Naloxone is a necessary tool these days in light of the national opioid epidemic. It should be available and accessible in as many places as possible, in the same way we have fire extinguishers and defibrillators in case of emergencies,” said Honolulu Councilmember Tyler Dos Santos-Tam, who introduced Bill 28. “This new law will not only save lives – it will hopefully set an example for other cities throughout the United States.”

Background

Bill 28 was introduced on March 29, 2023 – the same day the FDA granted over-the-counter approval of Narcan, the life-saving opioid-reversal medication. It mandated that liquor-serving establishments carry Naloxone, including bars, nightclubs, brewpubs and cabarets.

The bill was initially conceptualized by local Honolulu bar and nightclub owners, who outlined a fear of overdoses occurring in their establishments, according to Dos Santos-Tam.

Health experts have often noted the negative effects of mixing opioids and alcohol – including impaired motor control, respiratory arrest and an increased chance of overdose. Business owners attested anecdotally to these findings, telling of accidental overdoses that occurred on their premises. 

“Overdoses happen, especially when mixed with alcohol,” said Robbie Baldwin, owner of Scarlet Honolulu, a Chinatown nightclub. “I do not want to see well-meaning and law-abiding business owners being punished for an overdose that occurs – beyond their control – on their property. This bill helps prevent this worst-case scenario.” 

To ease the financial impacts of Bill 28, the Honolulu Liquor Commission has agreed to provide free “starter doses” of Naloxone to all liquor-licensees, using portions of the nearly $1.4 million in opioid settlement monies for replacement doses.

Implications for tourism

Honolulu’s June 2023 mass overdose occurred in Waikīkī, at the heart of Oʻahu’s tourism district.  Local tourism experts spoke on the impacts of the event, and the importance of mitigating similar tragedies in the future.

“To be perfectly clear: a mass overdose like this has negative impacts on tourism and our quality of life in Hawaiʻi,” said Mufi Hannemann, former Honolulu Mayor and current President of the Hawaiʻi Lodging and Tourism Association. “Hawai‘i needs to be seen as a safe destination, and so reducing the risk of a disruptive emergency at a hotel, bar, or restaurant is critical.”

Hannemann continued: “The opioid crisis is hitting Hawaiʻi just like it’s hitting the mainland. We can’t let it put local people or our visitors at risk. We also can’t let it devastate Hawaiʻi’s tourism industry, which is critical to our economy.”

National trends

A March, 2023 study aggregated a number of the methods in which different states increase the supply of naloxone in their jurisdictions. These included third-party prescribing and prescription-free distribution, among other initiatives. 

With Bill 28, Honolulu is the first jurisdiction – state or municipal – to mandate the medication in certain places. But according to a news release issued by Dos Santos-Tam, the approach may have national implications.

In Tennessee, for example, State Senator London Lamar introduced SB0200 in early 2023, which would require establishments who gross more than $500,000 per calendar year on alcoholic beverages to keep one dose of Naloxone on the premises. 

Lamar said, “When it comes to the opioid epidemic, few states in the United States have been hit harder than Tennessee. In 2020 alone, 2,388 Tennesseans died from an opioid overdose. That’s why I introduced SB0200. Like Honolulu, we need to make Naloxone as accessible as possible – especially in those high-risk locations.”

Dos Santos-Tam represents Honolulu City Council District 6, which spans from Kakaʻako to Kalihi, and includes portions of Kakaʻako, Chinatown, Downtown, Punchbowl, Papakōlea, Pauoa Valley, Nu‘uanu, Iwilei, Liliha, ‘Ālewa Heights, Kalihi and Kalihi Valley.