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Marley GT, Annis IE, Egan KL, Delamater P, Carpenter DM. Naloxone Availability and Cost After Transition to an Over-the-Counter Product. JAMA HEALTH FORUM 2024; 5:e241920. [PMID: 39058509 PMCID: PMC11282446 DOI: 10.1001/jamahealthforum.2024.1920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 05/17/2024] [Indexed: 07/28/2024] Open
Abstract
Importance The US Food and Drug Administration approved Narcan, a nasal spray formulation of naloxone, for sale as an over-the-counter (OTC) medication in March 2023. The purpose of OTC approval was to improve naloxone accessibility to reduce opioid overdoses; however, research has not yet evaluated whether naloxone's availability and cost changed since this policy was implemented. Objective To evaluate whether the accessibility and cost of naloxone at North Carolina community pharmacies changed after OTC naloxone became available and whether cost and availability varied by pharmacy type and urbanicity. Design, Setting, and Participants This longitudinal telephone-based secret shopper survey study included a stratified sample of 202 North Carolina community pharmacies, including health department, independent, and chain pharmacies. There were 2 separate data collection efforts from March to April 2023 (before OTC naloxone could be sold at pharmacies) and November 2023 to January 2024 (after OTC naloxone was sold at pharmacies). Exposure OTC naloxone first became available for sale at community pharmacies in September 2023. Main Outcomes and Measures The main outcomes were same-day availability of naloxone without a clinician-issued prescription and the quoted out-of-pocket cost for cash-paying patients. Results Data were collected from 192 pharmacies. Same-day naloxone availability increased from 42.2% (81 of 192) before OTC naloxone availability to 57.8% (111 of 192) after (P < .001). The mean (SD) quoted out-of-pocket cost decreased from $90.93 ($42.6) pre-OTC availability to $62.67 ($41.0) post-OTC availability (P < .001). Independent pharmacies had higher mean (SD) costs than chain pharmacies in both the pre-OTC phase ($109.47 [$37.90] vs $86.40 [$35.70]; P < .001) and post-OTC phase ($77.59 [$38.90] vs $57.74 [$35.90]; P = .004). Out-of-pocket costs did not differ by urbanicity in the pre-OTC phase; however, mean (SD) costs were higher at suburban ($88.67 [$66.80]) and rural ($65.43 [$35.00]) pharmacies compared with urban pharmacies ($53.58 [$29.00]) in the post-OTC phase (P = .003). Conclusions and Relevance The Food and Drug Administration's approval of OTC naloxone nasal spray contributed to an increase in pharmacy-based availability of naloxone and a reduction of its cost for cash-paying patients. Cost was higher at independent pharmacies compared with chain pharmacies and lower in urban pharmacies compared with suburban and rural pharmacies.
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Affiliation(s)
- Grace T. Marley
- UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
- South East Area Health Education Center, Wilmington, North Carolina
| | - Izabela E. Annis
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
| | - Kathleen L. Egan
- Department of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Paul Delamater
- Department of Geography and Environment, University of North Carolina at Chapel Hill
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Marley G, Annis IE, Ostrach B, Egan K, Delamater PL, Bell R, Dasgupta N, Carpenter DM. Naloxone Accessibility by Standing Order in North Carolina Community Pharmacies. J Am Pharm Assoc (2003) 2024; 64:102021. [PMID: 38307248 PMCID: PMC11081860 DOI: 10.1016/j.japh.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND According to a standing order in North Carolina (NC), naloxone can be purchased without a provider prescription. OBJECTIVE The objective of this study is to examine whether same-day naloxone accessibility and cost vary by pharmacy type and rurality in NC. METHODS A cross-sectional telephone audit of 202 NC community pharmacies stratified by pharmacy type and county of origin was conducted in March and April 2023. Trained "secret shoppers" enacted a standardized script and recorded whether naloxone was available and its cost. We examined the relationship between out-of-pocket naloxone cost, pharmacy type, and rurality. RESULTS Naloxone could be purchased in 53% of the pharmacies contacted; 26% incorrectly noting that naloxone could be filled only with a provider prescription and 21% did not sell naloxone. Naloxone availability by standing order was statistically different by pharmacy type (chain/independent) (χ2 = 20.58, df = 4, P value < 0.001), with a higher frequency of willingness to dispense according to the standing order by chain pharmacies in comparison to independent pharmacies. The average quoted cost for naloxone nasal spray at chain pharmacies was $84.69; the cost was significantly more ($113.54; P < 0.001) at independent pharmacies. Naloxone cost did not significantly differ by pharmacy rurality (F2,136 = 2.38, P = 0.10). CONCLUSION Approximately half of NC community pharmacies audited dispense naloxone according to the statewide standing order, limiting same-day access to this life-saving medication. Costs were higher at independent pharmacies, which could be due to store-level policies. Future studies should further investigate these cost differences, especially as intranasal naloxone transitions from a prescription only to over-the-counter product.
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Affiliation(s)
- Grace Marley
- Grace T. Marley, PharmD, UNC Eshelman School of Pharmacy 201 Pharmacy Lane, CB 7355, Chapel Hill, NC 27599-7355, USA
| | - Izabela E Annis
- Izabela E Annis, MS, Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, NC 27599
| | - Bayla Ostrach
- Bayla Ostrach PhD, MA CIP, Medical Anthropology & Family Medicine, Boston University School of Medicine; Fruit of Labor Action Research & Technical Assistance, LLC, 608 Emmas Grove Rd., Fletcher, NC 28732
| | - Kathleen Egan
- Kathleen L Egan PhD, MS, Department of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine
| | - Paul L. Delamater
- Paul Delamater PhD, Department of Geography and Environment, University of North Carolina at Chapel Hill
| | - Ronny Bell
- Ronny Bell, PhD, Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 27599
| | - Nabarun Dasgupta
- Nabarun Dasgupta, MPH, PhD, Injury Prevention Research Center, 725 MLK Jr. Blvd, CB 7505, Chapel Hill, NC 27599
| | - Delesha M. Carpenter
- Delesha M. Carpenter MSPH, PhD, UNC Eshelman School of Pharmacy 220 Campus Drive CPO 2125 Asheville, NC 28804
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Zhang W, Wang D, Ostertag-Hill CA, Han Y, Li X, Zheng Y, Lu B, Kohane DS. On-Demand Opioid Effect Reversal with an Injectable Light-Triggered Polymer-Naloxone Conjugate. NANO LETTERS 2023; 23:10545-10553. [PMID: 37937844 PMCID: PMC10949359 DOI: 10.1021/acs.nanolett.3c03426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Misuse of opioids can lead to a potential lethal overdose. Timely administration of naloxone is critical for survival. Here, we designed a polymer-naloxone conjugate that can provide on-demand phototriggered opioid reversal. Naloxone was attached to the polymer poly(lactic-co-glycolic acid) via a photocleavable coumarin linkage and formulated as injectable nanoparticles. In the absence of irradiation, the formulation did not release naloxone. Upon irradiation with blue (400 nm) light, the nanoparticles released free naloxone, reversing the effect of morphine in mice. Such triggered events could be performed days and weeks after the initial administration of the nanoparticles and could be performed repeatedly.
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Affiliation(s)
- Wei Zhang
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Dali Wang
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Claire A. Ostertag-Hill
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Yiyuan Han
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Xiyu Li
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Yueqin Zheng
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Berwyn Lu
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Daniel S. Kohane
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
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Rawal S, Osae SP, Tackett RL, MacKinnon NJ, Soiro FD, Young HN. Community pharmacists' naloxone counseling: A theory-informed qualitative study. J Am Pharm Assoc (2003) 2023; 63:1743-1752.e2. [PMID: 37633453 DOI: 10.1016/j.japh.2023.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Opioid-related overdose (ORO) deaths have reached a record high in the United States. Naloxone is an opioid antagonist that can rapidly reverse an opioid overdose. Pharmacists are in an ideal position to provide naloxone and related counseling, given their accessibility and expertise. However, minimal research is available on community pharmacists' naloxone counseling. OBJECTIVES The aim of this study was to investigate Georgia community pharmacists' naloxone counseling as well as explore their attitudes, subjective norms, and perceived behavioral control toward counseling. METHODS Semi-structured telephone interviews were conducted to elicit pharmacists' beliefs and practices regarding naloxone counseling. The interviews were guided by open-ended questions based on the theory of planned behavior (TPB). Thematic analysis was performed to identify the modal salient beliefs expressed by the pharmacists. The Consolidated Criteria for Reporting Qualitative Research was used to report the study findings. RESULTS A total of 12 community pharmacists participated. Pharmacists held mixed attitudes toward naloxone counseling. While they recognized it as a vital part of their profession to prevent ORO deaths, they also expressed concerns about offending patients. Regarding normative beliefs, pharmacists identified several groups, including regulatory agencies (e.g., Board of Pharmacy, CDC), managers, news/media, patients, and doctors, influencing their provision of naloxone counseling. Facilitators to counseling included receiving naloxone training and having access to counseling guidelines and resources. Reimbursement issues, high costs of naloxone, and lack of patient awareness were the most commonly cited barriers. Pharmacists reported participating in counseling and providing information on identifying signs of opioid overdose and administering naloxone. CONCLUSIONS The TPB is a useful framework for understanding community pharmacists' beliefs and practices regarding naloxone counseling. Capitalizing on facilitators and targeting barriers related to pharmacists' reimbursement issues, high costs of naloxone, and increasing patients' awareness of naloxone use and benefits may enhance pharmacists' naloxone counseling.
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Sisson ML, Azuero A, Chichester KR, Carpenter MJ, Businelle MS, Shelton RC, Cropsey KL. Preliminary effectiveness of online opioid overdose and naloxone administration training and impact of naloxone possession on opioid use. Drug Alcohol Depend 2023; 249:110815. [PMID: 37336007 DOI: 10.1016/j.drugalcdep.2023.110815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Despite the demonstrated value of opioid overdose education and naloxone distribution (OEND) programs, uptake and utilization remains low. Accessibility to OEND is limited and traditional programs may not reach many high-risk individuals. This study evaluated the effectiveness of online opioid overdose and naloxone administration education and the impact of naloxone possession. METHODS Individuals with self-reported illicit use of opioids were recruited via Craigslist advertisements and completed all assessments and education online via REDCap. Participants watched a 20-minute video outlining signs of opioid overdose and how to administer naloxone. They were then randomized to either receive a naloxone kit or be given instructions on where to obtain a kit. Effectiveness of training was measured with pre- and post-training knowledge questionnaires. Naloxone kit possession, overdoses, opioid use frequency, and treatment interest were self-reported on monthly follow-up assessments. RESULTS Mean knowledge scores significantly increased from 6.82/9.00 to 8.22 after training (t(194)=6.85, p <0.001, 95% CI[1.00, 1.81], Cohen's d=0.85). Difference in naloxone possession between randomized groups was significant with a large effect size (p <0.001, diff=0.60, 95% CI[0.47, 0.73]). A bidirectional relationship was found between naloxone possession and frequency of opioid use. Overdoses and treatment interest were similar across possession status. CONCLUSIONS Overdose education is effective in online video format. Disparity in naloxone possession across groups indicates barriers to obtaining naloxone from pharmacies. Naloxone possession did not influence risky opioid use or treatment interest and its impact on frequency of use warrants further investigation. TRIAL REGISTRATION Clinitaltrials.gov-NCT04303000.
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Affiliation(s)
- Michelle L Sisson
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Andres Azuero
- Department of Nursing, Family, Community & Health Systems, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Keith R Chichester
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew J Carpenter
- Medical University of South Carolina, Hollings Cancer Center & Department of Psychiatry and Behavioral Sciences, Charleston, SC, USA
| | - Michael S Businelle
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Richard C Shelton
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Karen L Cropsey
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Winstanley EL, Thacker EP, Choo LY, Lander LR, Berry JH, Tofighi B. Patient-reported problems filling buprenorphine prescriptions and motivations for illicit use. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100091. [PMID: 36844166 PMCID: PMC9949336 DOI: 10.1016/j.dadr.2022.100091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
Background While barriers to accessing buprenorphine (BUP) therapy have been well described, little is known about pharmacy-related barriers. The objective of this study was to estimate the prevalence of patient-reported problems filling BUP prescriptions and determine whether these problems were associated with illicit use of BUP. The secondary objectives included identifying motivations for illicit BUP use and the prevalence of naloxone acquisition among patients prescribed BUP. Methods Between July 2019 and March 2020, 139 participants receiving treatment for an opioid use disorder (OUD) at two sites within a rurally-located health system, completed an anonymous 33-item survey. A multivariable model was used to assess the association between pharmacy-related problems filling BUP prescriptions and illicit substance use. Results More than a third of participants reported having problems filling their BUP prescription (34.1%, n = 47) with the most commonly reported problems being insufficient pharmacy stock of BUP (37.8%, n = 17), pharmacist refusal to dispense BUP (37.8%, n = 17), and insurance problems (34.0%, n = 16). Of those who reported illicit BUP use (41.5%, n = 56), the most common motivations were to avoid/ease withdrawal symptoms (n = 39), prevent/reduce cravings (n = 39), maintain abstinence (n = 30), and treat pain (n = 19). In the multivariable model, participants who reported a pharmacy-related problems were significantly more likely to use illicitly obtained BUP (OR=8.93, 95% CI: 3.12, 25.52, p < 0.0001). Conclusion Efforts to improve BUP access have primarily focused on increasing the number of clinicians waivered to prescribe; however, challenges persist with BUP dispensing and coordinated efforts may be needed to systematically reduce pharmacy-related barriers.
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Affiliation(s)
- Erin L. Winstanley
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States,Corresponding author at: Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States.
| | - Emily P. Thacker
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Lyn Yuen Choo
- West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, United States
| | - Laura R. Lander
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States
| | - James H. Berry
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States
| | - Babak Tofighi
- Department of Population Health, New York University School of Medicine, United States
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Lai RK, Friedson KE, Reveles KR, Bhakta K, Gonzales G, Hill LG, Evoy KE. Naloxone Accessibility Without an Outside Prescription from U.S. Community Pharmacies: A Systematic Review. J Am Pharm Assoc (2003) 2022; 62:1725-1740. [DOI: 10.1016/j.japh.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 10/16/2022]
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