Naloxone Accessibility Under the State Standing Order Across Mississippi

Over-the-counter naloxone availability: Insights from rural community pharmacists in the Southern United States

BACKGROUND

Previous work has found that naloxone availability without a prescription in the Southern United States is highly varied, with 37% of Mississippi pharmacies and 53% of North Carolina pharmacies having naloxone available without a prescription in 2022 and 2024, respectively. The United States Food and Drug Administration approved Narcan nasal spray for over-the-counter (OTC) availability in 2023. However, limited information exists on the uptake of OTC naloxone across the United States, especially in rural spaces across the Southern United States.

OBJECTIVES

This study aimed to describe the availability and cost of OTC naloxone at rural community pharmacies across the Southern U.S. Secondary outcomes included pharmacists' perceived barriers to OTC naloxone for both pharmacists and patients.

METHODS

This study employed a cross-sectional survey study design of community pharmacists enrolled in the Rural Research Alliance of Community Pharmacies practice-based research network. Data were descriptively analyzed using IBM SPSS Statistics.

RESULTS

There were N = 47 responses to the survey, yielding a response rate of 34.8%. Of the responding community pharmacists, 40% indicated that their pharmacy carried OTC naloxone at the time of the survey (n = 18/47, 38.3%). Among these pharmacies, the median cost of OTC naloxone was $50.00 (interquartile range $46.25-$64.25, range $43.00-$123.20).

CONCLUSION

Despite OTC Narcan nasal spray being available in pharmacies as of September 2023, availability of this life-saving medication remains less than ideal in rural and Southern pharmacies. These findings emphasize the need for further educational and policy interventions to improve naloxone availability.

Pharmacy harm reduction practices to help reduce opioid overdoses, Arizona 2023

BACKGROUND

Characterizing pharmacies based on their practices, community need for such practices and pharmacy type could advance pharmacy-based intervention precision to reinforce or increase pharmacy practices related to reducing opioid overdose deaths.

OBJECTIVE

To measure a combination of 3 pharmacy practices focused on opioid overdose death reduction and explore whether there are discernable groupings related to practices, pharmacy characteristics, and community characteristics.

METHODS

A telephone survey was conducted between August 1, 2023 and October 8, 2023 with the pharmacist on duty at 921 Arizona community pharmacies. The survey measured pharmacy characteristics, buprenorphine stocking, buprenorphine and naltrexone dispensing, likelihood of methadone dispensing for opioid use disorder (OUD) when legally permitted, and interest in state-subsidized naloxone dispensing.

RESULTS

A response rate of 22.6% was achieved (N = 208). The vast majority (93.8%) of pharmacies stocked buprenorphine and dispensed buprenorphine or naltrexone. About half (47.6%) were very likely or somewhat likely to dispense methadone for OUD when permitted. Metropolitan pharmacies were less likely to dispense methadone compared to rural pharmacies (45.1% Vs. 75.0%). Among pharmacies not likely to dispense methadone, 85.3% were located in counties with opioid overdose death rates above the national average. About half of pharmacies indicated interest in enrolling as a distributor of state-subsidized naloxone. When considered together as pharmacy practices, 26% of pharmacies reported frequent buprenorphine or naltrexone dispensing, expressed interest in subsidized naloxone dispensing and a likelihood of methadone dispensing. Latent class analysis yielded 4 distinct groups of pharmacies ranging from those only dispensing buprenorphine or naltrexone frequently to adopters of the 3 pharmacy practices related to opioid overdose reduction in the community. The 'adopters' who frequently dispensed buprenorphine or naltrexone, who had interest in subsidized naloxone, and would likely dispense methadone for OUD tended to be in metropolitan or small/rural areas but tended not to be mass merchandizers.

CONCLUSION

An emerging group of pharmacies shows potential for greater adoption of pharmacy practices to reduce opioid overdose. Larger, multistate studies will help verify pharmacy latent class groups for greater precision of pharmacy practice interventions to reduce opioid overdose in communities. It is crucial to explore why pharmacies in higher need counties are not likely to adopt practices related to opioid overdose reduction.

Over-the-counter naloxone availability at North Carolina community pharmacies: A secret shopper study

BACKGROUND

Over-the-counter (OTC) naloxone became available for sale at community pharmacies in September 2023. This study examines whether naloxone availability and cost are associated with pharmacy type (independent vs chain), pharmacy rurality, and their interaction.

METHODS

Using a cross-sectional secret shopper study design, data were collected by phone from a stratified random sample of 600 community pharmacies in North Carolina from November 2023 to January 2024. Trained secret shoppers enacted a standardized script and documented whether the pharmacy: dispensed naloxone, sold OTC naloxone, and offered same-day pick-up. Shoppers also documented the location of OTC naloxone and out-of-pocket cost. Generalized Estimating Equations (GEEs) were used to examine whether naloxone availability and cost varied by pharmacy type (independent vs chain), rurality (urban, suburban, rural), and a rurality*type interaction.

RESULTS

Sampled pharmacies were 48.5 % urban, 11.7 % suburban, and 39.7 % rural, with 50.4 % being chain, 48.2 % independent, and 1.4 % health department pharmacies. Among the 500 pharmacies that sold naloxone, 57.4 % sold the OTC product, which was primarily stored behind-the-counter (62.5 %). Same-day pick-up was available at 82.8 % of pharmacies. In GEE models, rurality was not significant. However, independent pharmacies were significantly less likely than chain pharmacies to sell naloxone, have same-day pick-up, and store OTC naloxone on-the-shelf. Interaction terms were not significant, suggesting that the effect of pharmacy type on naloxone availability and cost did not vary by rurality.

CONCLUSIONS

Pharmacy type, not rurality, was consistently associated with naloxone access and out-of-pocket cost. Interventions should address barriers to naloxone access and cost at independent pharmacies.

Fentanyl harm reduction strategies among Latinx communities in the United States: a scoping review

PURPOSE

Fueled by the prescription opioid overdose crisis and increased influx of illicitly manufactured fentanyl, fentanyl overdoses continue to be a public health crisis that has cost the US economy over $1 trillion in reduced productivity, health care, family assistance, criminal justice, and accounted for over 74,000 deaths in 2023. A recent demographic shift in the opioid crisis has led to a rise in overdose deaths among the Latinx population. Harm reduction interventions, including the use of naloxone and fentanyl test strips, have been shown to be effective measures at reducing the number of opioid overdose deaths. The aim of this scoping review is to summarize naloxone and fentanyl test strip interventions and public health policies targeted to Latinx communities.

METHODS

PubMed, CINHAL, Web of Science, Embase, and PsycINFO research databases using the keywords "fentanyl," "Latinx," "Harm Reduction," "Naloxone," and "Fentanyl Test Strips'' to identify studies published between January 1, 2013 and December 31, 2023. Endnote and Covidence software were used to catalog and manage citations for review of studies. Subsequently, studies that met inclusion criteria were then summarized using resulting themes.

RESULTS

Twenty-seven articles met the inclusion criteria and were further abstracted for the scoping review. Of these articles, 77.7% (n = 21) included a naloxone intervention, while only 11.1% (n = 3) included a fentanyl test strip intervention. Furthermore, 30.1% (n = 8) of these studies were Latinx targeted, and 7.7% (n = 2) of the studies were adapted for Latinx populations. Four themes, including an overall lack of knowledge and awareness, a lack of access to harm reduction or opioid overdose prevention resources, an overall lack of culturally adapted and/or targeted interventions, and restrictive and punitive policies that limit the effectiveness of protective factors were highlighted in this scoping review.

CONCLUSION

Limited published research exists on the use of emerging harm reduction behaviors, such as the use of naloxone and fentanyl test strips as community intervention strategies to prevent opioid overdose deaths. Even fewer publications exist on the targeting and cultural adaptation of harm reduction interventions responsive to Latinx communities, especially those using theoretical approaches or frameworks to support these interventions. Future research is needed to assess the unique needs of Latinx populations and to develop culturally responsive programs to prevent opioid-related overdose deaths among this population.

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.

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.