Pharmacy naloxone codispensing: A mixed methods study of practices and perspectives under a statewide standing order program

Pharmacy Naloxone Standing Order and Community Opioid Fatality Rates Over Time

Importance

Despite the proliferation of pharmacy standing-order naloxone dispensing across many US states before the change to over-the-counter status, few policy analyses have evaluated the implementation of pharmacy naloxone standing orders in addressing opioid overdose fatality among communities.

Objective

To determine whether the implementation of pharmacy standing-order naloxone was associated with lower opioid fatality rates compared with communities without pharmacies with standing-order naloxone.

Design, Setting, and Participants

This retrospective multisite study was conducted with an interrupted time series analysis across 351 municipalities in Massachusetts over 24 quarters (from January 1, 2013, through December 31, 2018). Standing-order naloxone dispensing data were collected from 2 sources for all major chain pharmacies and many independent pharmacies, covering 70% of retail pharmacies in Massachusetts. Municipalities had various standing-order naloxone implementation inceptions during the study period. Data were analyzed from December 2021 to November 2023.

Exposure

The main exposure was measured by the first quarter with standing-order naloxone dispensation as the actual implementation inception.

Main Outcomes and Measures

The primary study outcome was municipal opioid fatality rate per 100 000 population obtained from the Massachusetts Registry of Vital Records and Statistics.

Results

The median (IQR) population size across 351 municipalities was 10 314 (3635 to 21 781) people, with mean (SD) proportion of female individuals was 51.1% (2.8 percentage points). Pharmacies from 214 municipalities (60.9%) reported dispensing standing-order naloxone over the study period. At the baseline of the first quarter of 2013, municipalities that eventually had standing-order naloxone had greater quarterly opioid fatality rates compared with those that never implemented standing-order naloxone (3.51 vs 1.03 deaths per 100 000 population; P < .001). After adjusting for municipal-level sociodemographic and opioid prevention factors, there was significant slope decrease of opioid fatality rates (annualized rate ratio, 0.84; 95% CI, 0.78-0.91; P < .001) following standing-order naloxone dispensing, compared with the municipalities that did not implement standing-order naloxone. There were no significant level changes of opioid fatality rates in the adjusted models. Sensitivity analyses yielded similar and significant findings.

Conclusions and Relevance

These findings suggest that community pharmacy dispensing of naloxone with standing orders was associated with a relative, gradual, and significant decrease in opioid fatality rates compared with communities that did not implement the standing-order naloxone program. These findings support the expansion of naloxone access, including over-the-counter naloxone as part of a multifaceted approach to address opioid overdose.

Pilot study of a community pharmacist led program to treat hepatitis C virus among people who inject drugs

Background

People who inject drugs (PWID) are a key population for treatment with direct-acting antiviral medications (DAAs) to eliminate hepatitis C virus (HCV). We developed a Pharmacist, Physician, and Patient Navigator Collaborative Care Model (PPP-CCM) for delivery of HCV treatment; this study describes clinical outcomes related to HCV treatment (initial evaluation, treatment initiation, completion, and cure), as well as patient satisfaction.

Methods

We conducted a single-arm prospective pilot study of adult PWID living with HCV. Participants completed baseline and six-month follow-up surveys, and treatment and outcomes were abstracted from electronic health records. Primary outcome was linkage to pharmacist for HCV evaluation; secondary outcomes included DAA initiation, completion, and cure, as well as patient-reported satisfaction.

Results

Of the 40 PWID enrolled, mean age was 43.6 years, 12 (30 %) were female, 20 (50 %) were non-white, and 15 (38 %) were unhoused. Thirty-eight (95 %) were successfully linked to the pharmacist for initial evaluation. Of those, 21/38 (55 %) initiated DAAs, and 16/21 (76 %) completed treatment. Among those completing treatment who had viral load data to document whether they achieved "sustained virologic response", i.e. cure, 10/11 (91 %) were found to be cured. There was high satisfaction with 100 % responding "agree or strongly agree" that they had a positive experience with the pharmacist.

Conclusion

Nearly all participants in this pilot were successfully linked to the pharmacist for evaluation, and more than half were started on DAAs; results provide preliminary evidence of feasibility of pharmacist-led models of HCV treatment for PWID.

Clinicaltrialsgov registration number

NCT04698629.

State Laws That Require Coprescribing Opioids and Naloxone and Codispensing Practices

INTRODUCTION

Coprescribing naloxone with opioids could reduce the risk of overdose. By the end of 2020, 8 U.S. states implemented coprescribing laws requiring the prescription of naloxone alongside certain opioid prescriptions. This study examined the impacts of state laws that require coprescribing opioids and naloxone on codispensing practices.

METHODS

Data included opioid prescriptions for commercially insured adults between 2014 and 2020. Augmented synthetic control analyses were used to examine the impacts of 8 coprescribing requirement laws implemented between 2017 and 2020 on the proportion of opioid prescription fills with a naloxone coprescription fill. Analyses were completed in spring 2023.

RESULTS

Changes in the proportion of opioid prescription fills with a naloxone coprescription fill attributable to the laws varied across states. In 4 states (New Jersey, New Mexico, Rhodes Island, and Virginia), laws were associated with 0.8 (95% CI=0.3, 1.3) to 4.4 (95% CI=3.4, 5.4) percentage point increases in the proportion of opioid prescriptions with a naloxone coprescription fill (p<0.05). There were no statistically significant changes attributable to the other state laws (Arizona, Florida, Vermont, Washington).

CONCLUSIONS

Laws requiring coprescribing naloxone with certain opioid prescriptions are associated with small-in-magnitude increases in codispensing in some states. Broadening the categories of opioid prescriptions covered in naloxone coprescribing requirement laws and implementing health system strategies to encourage providers to coprescribe naloxone could help to magnify the impacts of these laws.

Impact of a statewide community pharmacy approach to opioid harm reduction

BACKGROUND

The past several years have seen sharp increases in opioid overdose mortality. Harm reduction resources, such as nonprescription syringes and naloxone, are used to save lives.

OBJECTIVES

To develop a statewide approach to increase the use of opioid harm reduction services through community pharmacies.

PRACTICE DESCRIPTION

The North Carolina Association of Pharmacists was awarded a grant to address opioid mortality across the state, using community pharmacies to address opioid use disorder.

PRACTICE INNOVATION

A statewide, standardized approach was implemented to increase knowledge and use of opioid harm reduction resources in the community pharmacy setting.

EVALUATION METHODS

Pharmacies were offered training related to harm reduction. Participating pharmacies provided monthly updates related to staff training, syringe access status, naloxone kits distributed, and comments about how the training was changing their practice. At the project conclusion, pharmacies provided retrospective naloxone dispensing data along with naloxone dispensing during the intervention period. Pharmacies shared the greatest benefit of the program, a potential change to make implementation simpler, and the biggest change in the pharmacist(s) as a result of the project. Descriptive statistics were used to analyze data.

RESULTS

A total of 58 pharmacies across 33 counties participated in the harm reduction project. Of the 100 North Carolina counties, 15 counties were identified as high-need, and 14 of the 15 high-need counties (93%) participated in this project. Of the 58 participating pharmacies, 40 pharmacies (69%) had or implemented a nondiscriminatory nonprescription syringe policy within their pharmacy. During the baseline period (January 1, 2018, to June 15, 2018), 177 prescriptions for naloxone were dispensed by participating pharmacies. During the intervention period (January 1, 2019, to June 15, 2019), 639 prescriptions for naloxone were dispensed, representing a 361% increase in naloxone dispensing.

CONCLUSION

The successful implementation of a standardized, statewide approach increased access to harm reduction services.