Access to naloxone at community pharmacies under the Massachusetts statewide standing order

Naloxone Availability and Cost After Transition to an Over-the-Counter Product

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.

The association between naloxone claims and proportion of independent versus chain pharmacies: A longitudinal analysis of naloxone claims in the United States

BACKGROUND

Expanding access to naloxone through pharmacies is an important policy goal. Our objective was to characterize national county-level naloxone dispensing of chain versus independent pharmacies.

METHODS

The primary exposure in our longitudinal analysis was the proportion of chain pharmacies in a county, identified through the U.S. Department of Homeland Security 2010 Infrastructure Foundation-Level Data. We defined counties as having "higher proportion" of chain pharmacies if at least 50% of pharmacies were large national chains. The primary outcome was quarter-year (2016Q1-2019Q2) rate of pharmacy naloxone claims per 100,000 persons from Symphony Health at the county level. We compared the naloxone dispensing rate between county types using 2-sample t tests. We estimated the association between county-level chain pharmacy proportion and rate of naloxone claims using a linear model with year-quarter fixed effects.

RESULTS

Nearly one-third of counties (n = 946) were higher proportion. Higher proportion counties had a significantly higher rate of naloxone claims across the study period, in 4 of 6 urban-rural classifications, and in counties with and without naloxone access laws (NALs). The linear model confirmed that higher proportion counties had a significantly higher rate of naloxone claims, adjusting for urban-rural designation, income, population characteristics, opioid mortality rate, coprescribing laws, and NALs.

CONCLUSION

In this national study, we found an association between naloxone dispensing rates and the county-level proportion of chain (vs. independent) pharmacies. Incentivizing naloxone dispensing through educational, regulatory, or legal efforts may improve naloxone availability and dispensing rates-particularly in counties with proportionately high numbers of independent pharmacies.

Naloxone Accessibility by Standing Order in North Carolina Community Pharmacies

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.

The policy landscape for naloxone distribution in four states highly impacted by fatal opioid overdoses

Background

Expanding access to naloxone is one of the most impactful interventions in decreasing opioid-related mortality. However, state distribution rates of naloxone are insufficient to meet community need. The current study sought to better understand this gap by focusing on state policies that may facilitate or impede naloxone distribution in four states highly impacted by fatal opioid overdoses - Kentucky, Massachusetts, New York, and Ohio.

Methods

We provide a descriptive analysis of the policy landscape impacting naloxone distribution through pharmacy and community channels in the four states participating in the HEALing Communities Study (HCS). Publicly available data and the expertise of the research team were used to describe each state's naloxone access laws (NALs), Medicaid coverage of naloxone, and community overdose education and naloxone distribution infrastructure. Data presented in this study represent the most current policy landscape through September 2022.

Results

Variation exists between specific components of the NALs of each state, the structure of Medicaid coverage of naloxone, and the community distribution infrastructure networks. Massachusetts and New York have a statewide standing order, but other states use different strategies short of a statewide standing order to expand access to naloxone. Quantity limits specific to naloxone may limit access to Medicaid beneficiaries in some states.

Conclusion

States participating in the HCS have developed innovative but different mechanisms to ensure naloxone access. Policies were dynamic and moved towards greater access. Research should consider the policy landscape in the implementation and sustainability of interventions as well as the analysis of outcomes.

Availability of buprenorphine/naloxone films and naloxone nasal spray in community pharmacies in 11 U.S. states

BACKGROUND

Prompt access to prescribed buprenorphine/naloxone films (BUP/NX) and naloxone nasal spray (NNS) is vital for patients with opioid use disorder (OUD), but multiple studies have documented pharmacy-level barriers.

METHODS

A cross-sectional secret shopper telephone audit was conducted in a sample of 5734 actively licensed pharmacies in 11 U.S. states from May 2020-April 2021. Primary outcomes included availability of 14 generic BUP/NX 8/2 mg and one unit of NNS 4 mg. Outcomes were compared by pharmacy type, county metropolitan status, state Medicaid expansion status, and state drug overdose death rate.

RESULTS

Data from 4984 pharmacies (3402 chain and 1582 independent) were analyzed. Both medications were available in 41.2 % of pharmacies, BUP/NX was available in 48.3%, and NNS was available in 69.5%. Chain pharmacies were significantly more likely than independent pharmacies to have both medications available, to have each medication available individually, and to be willing to order BUP/NX. Pharmacies in metropolitan counties were more likely to have BUP/NX available than pharmacies in non-metropolitan counties, pharmacies in Medicaid expansion states were more likely to have both medications available and to have NNS available than pharmacies in non-expansion states, and pharmacies in states with high drug overdose death rates were more likely to have NNS available than pharmacies in states with low drug overdose death rates.

CONCLUSIONS

BUP/NX and NNS are not readily accessible in many U.S. pharmacies. Deficits in access are most pronounced in independent pharmacies, though county- and state-level factors may also influence availability of these essential medications.

Factors associated with naloxone availability and dispensing through Michigan's pharmacy standing order

Background: Pharmacy standing order policies allow pharmacists to dispense naloxone, thereby increasing access to naloxone. Objectives: To describe pharmacy standing order participation and associations of pharmacy and community characteristics that predict naloxone availability and dispensing across eight counties in Michigan. Methods: We conducted a telephone survey of 662 standing order pharmacies with a response rate of 81% (n = 539). Pharmacies were linked with census tract-level demographics, overdose fatality rates, and dispensing data. County maps were created to visualize pharmacy locations relative to fatality rates. Regression models analyzed associations between pharmacy type, neighborhood characteristics, fatality rates, and these outcomes: naloxone availability, having ever dispensed naloxone, and counts of naloxone dispensed. Results: The prevalence of standing order pharmacies was 54% (n = 662/1231). Maps revealed areas with higher fatality rates had fewer pharmacies participating in the standing order or lacked any pharmacy access. Among standing order pharmacies surveyed, 85% (n = 458/539) had naloxone available and 82% had ever dispensed (n = 333/406). The mean out-of-pocket cost of Narcan_® was $127.77 (SD: 23.93). National chains were more likely than regional chains to stock naloxone (AOR = 3.75, 95%CI = 1.77, 7.93) and to have ever dispensed naloxone (AOR 3.02, 95%CI = 1.21,7.57). Higher volume of naloxone dispensed was associated in neighborhoods with greater proportions of public health insurance (IRR = 1.38, 95%CI = 1.21, 1.58) and populations under 44 years old (IRR = 1.24, 95%CI = 1.04, 1.48). There was no association with neighborhood overdose fatality rates or race in regression models. Conclusion: As deaths from the opioid epidemic continue to escalate, efforts to expand naloxone access through greater standing order pharmacy participation are warranted.

If we build it, will they come? Perspectives on pharmacy-based naloxone among family and friends of people who use opioids: a mixed methods study

BACKGROUND

Expanding access to the opioid antagonist naloxone to reduce overdose mortality is a public health priority in the United States. Naloxone standing orders (NSOs) have been established in many states to increase naloxone dispensing at pharmacies, but increased pharmacy access does not ensure optimal uptake among those likely to witness an overdose. In a prior statewide purchase trial, we documented high levels of naloxone access at Massachusetts pharmacies under a statewide NSO. In this study, we characterize barriers to pharmacy-based naloxone uptake among potential opioid overdose "bystanders" (friends or family of people who use opioids) that may be amenable to intervention.

METHODS

Eligible bystanders were Massachusetts residents ≥ 18 years of age, did not use illicit opioids in the past 30 days, and knew someone who currently uses illicit opioids. We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N = 22) were conducted April-July 2018, to inform the development of a subsequent quantitative survey (N = 260), conducted February-July 2020.

RESULTS

Most survey participants (77%) reported ever obtaining naloxone but few (21%) attempted to purchase it at a pharmacy. Qualitative participants revealed that barriers to utilizing the NSO included low perceived risk of overdose, which was rooted in misconceptions regarding the risks of prescription opioid misuse, denial about their loved one's drug use, and drug use stereotypes; inaccurate beliefs about the impact of naloxone on riskier opioid use; and concerns regarding anticipated stigma and confidentiality. Many participants had engaged in mutual support groups, which served as a source of free naloxone for half (50%) of those who had ever obtained naloxone.

CONCLUSIONS

Despite high levels of pharmacy naloxone access in Massachusetts, few bystanders in our study had attempted to obtain naloxone under the NSO. Low perceived risk of overdose, misinformation, stigma, and confidentiality were important barriers to pharmacy naloxone uptake, all of which are amenable to intervention. Support groups provided a setting for addressing stigma and misinformation and provided a discreet and comfortable setting for naloxone access. Where these groups do not exist and for bystanders who do not participate in such groups, pharmacies are well-positioned to fill gaps in naloxone availability.

A qualitative examination of responses from a survey of pharmacy staff in Georgia regarding access to Narcan®

Georgia state lawmakers enacted legislation designed to reduce opioid overdose deaths by increasing public access to rescue products, such as Narcan®. This article explores whether pharmacy employees have effectively adopted such changes into pharmacy practice. We analyzed unsolicited remarks noted during a parent telephone survey of 120 Georgia pharmacy staff regarding price, availability and barriers to layperson purchase of Narcan®. Comments regarding dispensing requirements and challenges in obtaining inventory and changes in communication style were recorded. Around 15% were unfamiliar with Narcan® as an opioid overdose reversal agent or were unaware of their pharmacy's policies governing its sale. Nearly half of those contacted did not have Narcan® in stock with some reporting that receiving Narcan® would take several days after placing an order. Over half specified requirements for purchasing Narcan® not required by law. Fewer than 15% had Narcan® available and imposed no unnecessary requirements for its purchase. During approximately 10% of the survey calls, respondents used a tone of voice or made comments suggestive of bias. We conclude that non-compliance with current laws, lack of familiarity with Narcan® and negative communication tendencies that suggest implicit bias and stigmatizing behaviors could ultimately inhibit access to opioid overdose treatment.

Pharmacists' experiences with a statewide naloxone standing order program in Massachusetts: a mixed methods study

OBJECTIVES

In a prior statewide naloxone purchase trial conducted in Massachusetts, we documented a high rate of naloxone dispensing under the state's standing order program. The purpose of this study was to understand the factors that facilitate naloxone access under the Massachusetts naloxone standing order (NSO) program and identify any remaining barriers amenable to intervention.

DESIGN

Mixed methods design involving a pharmacist survey and 3 pharmacist focus groups.

SETTING AND PARTICIPANTS

Focus groups were conducted at 3 separate professional conferences for pharmacists (n = 27). The survey was conducted among Massachusetts pharmacists (n = 339) working at a stratified random sample chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019.

OUTCOME MEASURES

Facilitators and barriers to NSO implementation and naloxone dispensing and pharmacists' attitudes and beliefs regarding naloxone and opioid use.

RESULTS

Most pharmacists described NSO implementation as being straightforward, although differences were reported by pharmacy type in both the survey and focus groups. Facilitators included centralized implementation at chain pharmacies, access to Web-based resources, regularly stocking naloxone, and use of naloxone-specific intake forms. Barriers included patient confidentiality concerns and payment/cost issues. Only 31% of surveyed pharmacists reported always providing naloxone counseling; the most commonly cited barriers were perceived patient discomfort (21%) and time limitations (14%). Confidential space was also more of a concern for independent (vs. chain) pharmacists (18% vs. 6%, P = 0.008). A majority of pharmacists held supportive attitudes toward naloxone, although some reported having moral/ethical concerns about naloxone provision.

CONCLUSION

We documented several facilitators to NSO implementation and naloxone dispensing. Areas for improvement include addressing stigma and misconceptions around opioids and naloxone use. These remain important targets for improving pharmacy-based naloxone dispensing, although our overall positive results suggest Massachusetts' experience with NSO implementation can inform other states' efforts to expand pharmacy-based naloxone access.

Trends in State-Level Pharmacy-Based Naloxone Dispensing Rates, 2012-2019

INTRODUCTION

Improving access to naloxone is an important public health strategy in the U.S. This study examines the state-level trends in naloxone dispensing from 2012 to 2019 for all 50 states and the District of Columbia.

METHODS

Data from IQVIA Xponent were used to examine the trends and geographic inequality in annual naloxone dispensing rates and the number of naloxone prescriptions dispensed per high-dose opioid prescription from 2012 to 2019 and from 2016 to 2019 to correspond with the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain release. Annual percentage change was estimated using linear regression. Analyses were conducted in 2020.

RESULTS

Naloxone dispensing rates and the number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 2012 to 2019 across all states and the District of Columbia. Average state-level naloxone dispensing rates increased from 0.55 per 100,000 population in 2012 to 45.60 in 2016 and 292.31 in 2019. Similarly, the average number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 0.002 in 2012 to 0.24 in 2016 and 3.04 in 2019. Across both measures of naloxone dispensing, the geographic inequality gap increased during the study period. In 2019, the number of naloxone prescriptions dispensed per 100 high-dose opioid prescriptions ranged from 1.04 to 16.64 across states.

CONCLUSIONS

Despite increases in naloxone dispensing across all states, dispensing rates remain low, with substantial variation and increasing disparities over time at the state level. This information may be helpful in efforts to improve naloxone access and in designing state-specific intervention programs.

Naloxone availability in independent community pharmacies in Georgia, 2019

BACKGROUND

Increasing the availability of naloxone among people who use opioids, and friends and family of past and present people who use opioids is a vitally important mission to reduce the occurrence of opioid-related overdose deaths. The purpose of this study was to determine the availability of naloxone in independent community pharmacies in Georgia. Secondary objectives include determining pharmacists' knowledge regarding the standing order and ability to counsel regarding naloxone.

METHODS

A cross-sectional study using a secret shopper approach with phone contact was conducted over a period of 10 months. The study was population based and was conducted at all independent pharmacies in the state of Georgia. All independent community pharmacies in the state of Georgia were contacted and asked the naloxone questions with a 96% response rate (n = 520).

RESULTS

Five hundred fifty-eight independent community pharmacies were called, with a 96% response rate (n = 520 pharmacies). Two hundred-twenty pharmacies reported having naloxone in stock. Of the 335 pharmacists asked, 174 (51.9%) incorrectly said that a prescription was required. The mean (SD) cash price was $148.02 (27.40), with a range of $0 to $300. Of 237 pharmacists asked who had naloxone in stock or who stated they could get naloxone in stock, 212 stated that they could demonstrate how to use it, 8 stated they could not, and 17 said that they possibly could or were unsure how to use it.

CONCLUSIONS

This study provided insight into the limited availability of naloxone at independent community pharmacies in Georgia after the standing order was issued. The majority of pharmacists at independent pharmacies in Georgia were not using the publicly available state naloxone standing order. Additionally, the low availability of naloxone and its high cost for uninsured individuals are significant structural barriers for reducing opioid-related mortality.

Pharmacist furnishing of naloxone in California: A follow-up analysis

BACKGROUND

Increasing naloxone access in communities has been a priority to mitigate the increasing rate of opioid-related overdose deaths.

OBJECTIVES

The aims of this telephone survey were to estimate the availability of naloxone furnishing (provided without a prescription) by community pharmacists in California and examine the changes that occurred between 2018 and 2020.

METHODS

A telephone audit of a random representative sample of 1271 California licensed community pharmacies was conducted from January 22, 2020, to February 24, 2020. The results were compared with those of a survey of 1147 California licensed community pharmacies that was conducted from January 23, 2018, to February 28, 2018. The primary outcomes measured were naloxone availability without a prescription, information on formulations, cost, insurance billing, and stocking status.

RESULTS

There was a statistically significant increase in the furnishing of naloxone, as well as stocking and billing, in California from 2018 to 2020. Although fewer than half of the pharmacies were willing to provide naloxone without a prescription in 2020 (n = 487, 42.4%), this was an 80% increase from 2018 (P < 0.001). Of the pharmacies furnishing naloxone, many (n = 399, 81.9%) had nasal naloxone in stock, a large and statistically significant increase from 2018 when only 50.6% reported having it in stock (P < 0.001). In 2020, 90% of the pharmacies reported correctly that pharmacist-furnished naloxone could be billed to insurance compared with 56.9% in 2018 (P < 0.001). The median cash price of nasal naloxone (pack of 2) at chain pharmacies in 2020 was $131 (interquartile range [IQR] $129-$138) compared with $153 (IQR, $141-$163; P = 0.001) at independent pharmacies.

CONCLUSION

Community pharmacy-based access to naloxone increased in a statistically significant manner in California, although more than half of the pharmacies still do not provide such access. This study demonstrates the need for further efforts to expand community pharmacy-based access to naloxone.

Considering the Potential Benefits of Over-the-Counter Naloxone

Since 1999, annual opioid-related overdose (ORO) mortality has increased more than six-fold. In response to this crisis, the US Department of Health and Human Services outlined a 5-point strategy to reduce ORO mortality which included the widespread distribution of naloxone, an opioid antagonist that can rapidly reverse an opioid overdose. Increased distribution has been facilitated by the implementation of naloxone access laws in each US state aimed at increasing community access to naloxone. While these laws differ from state-to-state, most contain mechanisms to enable pharmacists to dispense naloxone without a patient-specific prescription. These laws have enhanced community naloxone distribution, both from pharmacies and overdose education and naloxone distribution programs, and produced positive effects on ORO mortality. However, a growing body of evidence has revealed that significant barriers to naloxone access from pharmacies remain, and annual ORO deaths have continued to climb. Given these concerns, there has been a push among some clinicians and policymakers for the US Food and Drug Administration to re-classify naloxone as an over-the-counter (OTC) medication as a means to further increase its accessibility. If an OTC transition occurs, educational outreach and funding for clinical innovations will continue to be crucial given the important role of health professionals in recommending naloxone to people at risk for experiencing or witnessing an ORO. Recognizing the severity of the ORO public health crisis, we believe transitioning formulations of naloxone approved for layperson use to OTC status would result in a net benefit through increased access. However, such a change should be combined with measures to ensure affordability.

Preparing pharmacists to increase naloxone dispensing within community pharmacies under the Pennsylvania standing order

PURPOSE

Opioid misuse and overdose deaths remain a public health concern in the United States. Pennsylvania has one of the highest rates of opioid overdose deaths in the country, with Philadelphia County's being 3 times higher than the national average. Despite several multimodal interventions, including use of SBIRT (screening, brief intervention, and referral to treatment) methods and naloxone distribution, the rate of overdose deaths remains high.

METHODS

To gain insights on strategies for improving access to naloxone and naloxone distribution by pharmacists in Philadelphia County, a study was conducted in 11 community pharmacies (chain and independent) in Philadelphia. Twenty-four pharmacists were recruited and completed SBIRT and naloxone trainings. Each pharmacy elected to have at least 1 pharmacy champion who received additional training on and helped develop pharmacy site-specific naloxone dispensing protocols.

RESULTS

Pre-post survey results showed a reduction in stigmatizing attitudes regarding naloxone dispensing and an increase in pharmacists' understanding of the standing order and appropriate naloxone use. There was an increase in pharmacists' self-reported confidence in their ability to appropriately identify, discuss, and dispense naloxone to patients. All pharmacies increased their average monthly dispensing rate following protocol implementation.

CONCLUSION

Pharmacists who received both trainings were more likely to change naloxone dispensing practices, leading to an overall increase in naloxone dispensing by community pharmacists. The study addressed overall gaps in pharmacists' knowledge, reduced stigma, and prepared pharmacists to address opioid use and overdose prevention with their patients. The described pharmacist-led patient counseling and intervention service for overdose prevention may be explored as a model for other community pharmacies to adopt to improve naloxone dispensing and similar interventions to reduce overdose deaths.

Pharmacologic Considerations for Opioid Use in Kidney Disease

Individuals with kidney disease have a high prevalence of chronic noncancer pain. Although opioids are not a recommended treatment option for chronic noncancer pain in the general population, a higher percentage of individuals with kidney disease receive opioid prescriptions for chronic pain. Individuals with kidney disease have an increased risk for opioid adverse events because of changes related to kidney disease progression, normative aging, and the pharmacology of opioid medications. Despite the frequent prescription of opioids for chronic noncancer pain among those with kidney disease, there are no guidelines for opioid management in this population. This article reviews the pharmacologic challenges of opioid use in relation to the physiologic changes occurring in kidney disease and normative aging. We highlight how understanding opioid pharmacology and human physiology can support safe practices of opioid management in patients with kidney disease who require opioids for chronic noncancer pain.

Systematic review of the emerging literature on the effectiveness of naloxone access laws in the United States

BACKGROUND AND AIMS

Naloxone access laws (NALs) have been suggested to be an important strategy to reduce opioid-related harm. We describe the evolution of NALs across states and over time and review existing evidence of their overall association with naloxone distribution and opioid overdose as well as the potential effects of specific NAL components.

METHODS

Descriptive analysis of temporal variation in US regional adoption of NAL components, accompanied by a systematic search of 13 databases for studies (published between 2005 and 20 December 2019) assessing the effects of NALs on naloxone distribution or opioid-related health outcomes. Eleven studies, all published since 2018, met inclusion criteria. Study time-frames spanned 1999-2017. Opioid-related overdose mortality, emergency department episodes and naloxone distribution were correlated with the presence of a NAL and, where data were available, NAL components.

RESULTS

Existing evidence suggests mixed, but generally beneficial, effects for NALs. Nearly all studies show that NALs, particularly those that permit naloxone distribution without patient-specific prescriptions, are associated with increased naloxone access [incidence rate ratios (IRR) range from 1.40, 95% confidence interval (CI) = 1.15-1.66 to 7.75, 95% CI = 1.22-49.35] and increased opioid-related emergency department visits (IRR range from 1.14, 95% CI = 1.07-1.20 to 1.15, 95% CI = 1.02-1.29). Most studies show NALs are associated with reduced overdose mortality, although findings vary depending on the specific NAL components and time-period analyzed (IRR range from 0.66, 95% CI = 0.42-0.90 to 1.27, 95% CI = 1.27-1.27). Few studies account for the variation in opioid environments (i.e. illicit versus prescription) or other policy dimensions that may be correlated with outcomes.

CONCLUSIONS

The existing literature on naloxone access laws in the United States supports beneficial effects for increased naloxone distribution, but provides inconclusive evidence for reduced fatal opioid overdose. Mixed findings may reflect variation in the laws' design and implementation, confounding effects of concurrent policy adoption, or differential effectiveness in light of changing opioid environments.

Using the behaviour change wheel to understand and address barriers to pharmacy naloxone supply in Australia

BACKGROUND

There has been low community pharmacy-based naloxone supply in Australia despite its over-the-counter status. The Behaviour Change Wheel (BCW) is a method used to understand individual and system-level barriers and facilitators to a particular behaviour to inform program implementation. The BCW is focused on three essential conditions of behaviour change (capability, opportunity, and motivation (termed the COM-B)) which we use to assess pharmacists perceptions and experiences of naloxone provision with the aim of using informing targets for interventions to improve naloxone distribution.

METHOD

Qualitative interviews with community pharmacists (n = 37) from four Australian jurisdictions explored naloxone knowledge, expectations and experiences dispensing the medicine. Audio-recorded interviews were transcribed verbatim and coded against the a priori domains in the COM-B (capability, opportunity, and motivation). Results were analysed to identify key barriers and facilitators to naloxone provision within each domain. Finally, we mapped our analysis against the intervention functions and policy-level strategies provided in the BCW to identify example intervention strategies.

RESULTS

Underlying all pharmacists' descriptions of naloxone were structural impediments to dispensing including poor communication regarding pharmacists' role and disrupted supply chains. Mapped across the three COM-B domains, we find two divergent groups of pharmacists. Pharmacists' capability and motivation to supply naloxone was higher amongst those who did not problematize people who inject drugs and who worked in pharmacies already supplying harm reduction services. Pharmacists were less likely to discuss capabilities and opportunities for naloxone dispensing when harm reduction was not normalised in their workplace and/or they described people who inject drugs using negative and stigmatising language.

CONCLUSIONS

Analysis using the COM-B framework reveals key areas where implementation and policy strategies are needed to increase naloxone supply. Individual- and structural-level supports are needed to improve pharmacists' knowledge of naloxone and address other logistical and cultural barriers that limit naloxone provision in pharmacy settings.

Pharmacist counseling when dispensing naloxone by standing order: A secret shopper study of 4 chain pharmacies

BACKGROUND

Texas has passed legislation to increase access to naloxone, the opioid overdose antidote, allowing pharmacists to dispense by standing order without an outside prescription. Given this added responsibility, there is a need to assess real-world counseling provided by pharmacists when dispensing naloxone.

OBJECTIVES

Assess naloxone accessibility and counseling provided by community pharmacists when dispensing naloxone by standing order.

METHODS

A total of 11 student pharmacists (mean age 25 years; 63.6% female; primarily Hispanic [36.4%], Asian [27.3%], and white [27.3%]) audited community pharmacies by presenting to purchase naloxone. Variables included naloxone availability and price, counseling duration, and whether 13 predetermined counseling points were provided unprompted. Shoppers were prepared with a background story if asked so that each answered questions consistently. All shoppers participated in two 1-hour training sessions, including verification of their ability to accurately assess naloxone counseling. Pharmacies in Bexar County, TX were selected randomly from 4 pharmacy chains, each of which have implemented statewide standing orders within their chain. Descriptive statistics were calculated. A Fisher exact test and linear mixed-effects regression model were used to assess variation across chains in whether naloxone was dispensed and the mean total number of counseling points provided, respectively.

RESULTS

The shoppers audited 45 pharmacies. Naloxone was dispensed in 31 of 45 (68.9%) encounters (mean cost: $129.59). The mean counseling duration was 89 seconds. The most common counseling points included: administration technique (24 of 31), readministration of second dose (22 of 31), and calling 9-1-1 (20 of 31). All other points were included in less than one-third of pharmacists' counseling. Across the 4 chains, there was significant variation in naloxone dispensing and the number of counseling points provided.

CONCLUSION

Secret shoppers were unable to access naloxone from nearly one-third of pharmacies. Counseling often excluded concepts pertinent to patient safety and effectiveness, suggesting opportunities remain to promote consistent, high-quality naloxone counseling in community pharmacies.

Geographic variation in the provision of naloxone by pharmacies in Ontario, Canada: A population-based small area variation analysis

BACKGROUND

Regional variation in pharmacy-dispensed naloxone rates could create access disparities that undermine the effectiveness of this approach. We explored individual and public health unit (PHU)-level determinants of regional variation in naloxone distribution through the Ontario Naloxone Program for Pharmacies.

METHODS

We conducted a population-based study between April 1, 2017 and March 31, 2018. We calculated age- and sex-standardized pharmacy-dispensed naloxone rates for the 35 Ontario PHUs, and identified determinants of these rates using generalized estimating equations negative binomial regression.

RESULTS

The age- and sex-standardized pharmacy-dispensed naloxone rate in Ontario was 5.5 (range 1.8-11.6) kits per 1000 population. Variables associated with higher naloxone dispensing rates included opioid use disorder history [rate ratio (RR) 2.27; 95% confidence interval (CI) 1.75-2.96], opioid agonist therapy (RR 11.17; 95% CI 7.15-17.44), and PHU opioid overdose rate (RR 1.09 per 10 deaths; 95% CI 1.06-1.13). Pharmacy-dispensed naloxone rates were lower in rural areas (RR 0.83; 95% CI 0.73-0.94) and among individuals dispensed one (RR 0.72; 95% CI 0.65-0.79), two to five (RR 0.67; 95% CI 0.54-0.84) or 6-10 (RR 0.92; 95% CI 0.74-1.14) opioids in the prior year relative to those receiving no opioids.

CONCLUSION

Pharmacy-dispensed naloxone programs are important components of a public health response to the opioid overdose crisis. We found considerable variation in pharmacy-dispensed naloxone rates that could limit program effectiveness, particularly in rural settings with limited access to health and harm reduction services..

Assessing pharmacy-based naloxone access using an innovative purchase trial methodology

OBJECTIVES

Massachusetts was among the first states to allow standing orders to facilitate pharmacy-based naloxone purchases and reduce opioid overdose deaths. We conducted a unique purchase trial to establish a valid measure of standing order naloxone in Massachusetts, using purchasers from 2 high priority populations to determine whether naloxone is less accessible to those who use illicit opioids than other potential purchasers.

DESIGN

Purchase trial.

SETTING AND PARTICIPANTS

The study used a stratified random sample of 200 chain and independent retail pharmacies across Massachusetts. Each pharmacy underwent 2 purchase attempts-1 by a person who used illicit opioids (PWUIO) and 1 by a potential bystander who did not use illicit opioids but had a relationship with someone at risk of opioid overdose.

OUTCOME MEASURE

Successful or unsuccessful naloxone purchase attempt.

RESULTS

Overall, 322 of 397 purchase attempts (81%) were successful, with no statistically significant difference between PWUIO and bystanders (P = 0.221). Most purchases (93%) resulted in the acquisition of single-step nasal naloxone (Narcan; median cost $133.38). Forty percent of the purchases included state-mandated verbal counseling, and PWUIO were significantly less likely to receive counseling than bystanders (30% vs. 51%, P < 0.001). Common reasons for failed purchase were not stocking naloxone (47%), price > $150 (25%), and requiring a prescription (15%). Chain pharmacies were significantly more likely to sell naloxone than independent pharmacies (86% vs. 53%, P < 0.001).

CONCLUSION

We documented high levels of naloxone access for both PWUIO and bystanders, suggesting Massachusetts could serve as a model for states seeking to improve pharmacy-based naloxone access. Additional implementation efforts should focus on expanding availability at independent pharmacies and supporting pharmacies in proactively offering naloxone to PWUIO and other high-risk individuals.