Naloxone availability and dispensing in Indiana pharmacies 2 years after the implementation of a statewide standing order

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.

Price Sensitivity and Information Barriers to the Take-Up of Naloxone

We conducted a field experiment that randomized advertisements, advertisement content, and prices across 2,204 counties in the United States to study the impacts on online purchases of naloxone, an opioid overdose reversal drug. Advertising increased website users but only impacted purchases when combined with a price reduction. Messages emphasizing the discreet nature of online sales had no additional impact on purchases. Comparing counties with advertisements featuring a highly discounted price to those featuring the full price, we estimate a price elasticity of demand for online naloxone of -1.3. Price is a significant barrier to online purchases of this lifesaving medication.

Investigating the complexity of naloxone distribution: Which policies matter for pharmacies and potential recipients

Despite efforts to expand naloxone access, opioid-related overdoses remain a significant contributor to mortality. We study state efforts to expand naloxone distribution through pharmacies by reducing the non-monetary costs to prescribers, dispensers, and/or potential recipients of naloxone. We find that laws that only address liability costs have small and insignificant effects on the volume of naloxone dispensed through pharmacies. In contrast, we estimate large effects of laws removing the need for patients to obtain prescriptions from traditional prescribers (e.g., primary care physicians): laws authorizing non-patient-specific prescription distribution and laws granting pharmacists prescriptive authority. We test whether areas designated as primary care shortage areas-where it would be costlier to obtain a prescription-were disproportionately impacted. Shortage areas experienced sharper growth in pharmacy naloxone dispensing in states adopting prescriptive authority policies. These gains were primarily due to those facing low out-of-pocket costs, suggesting that price barriers also must be addressed to increase naloxone purchases.

Implementation Documentation and Process Assessment of the PharmNet Intervention: Observational Report

BACKGROUND

The number of overdose deaths in the United States involving opioids continues to exceed 100,000 per year. This has precipitated ongoing declarations of a public health emergency. Harm reduction approaches, such as promoting awareness of, ensuring access to, and fostering willingness to use naloxone to reverse opioid overdose, are a key component of a larger national strategy to address the crisis. In addition, overdose reversal with naloxone directly and immediately saves lives. Because of pharmacies' ubiquity and pharmacists' extensive clinical training, community pharmacies are well-positioned, in principle, to facilitate naloxone access and education.

OBJECTIVE

In 2022, a single-site pilot study of PharmNet, a community pharmacy intervention incorporating naloxone distribution, awareness building, and referral, showed promising outcomes for both naloxone and resource distribution in the community. As a next step, this study was intended to be a pilot randomized controlled trial of PharmNet in 7 pharmacies. However, due to circumstances outside of the study team's control, data collection was unable to be fully completed as planned. In keeping with open research standards, we transparently report all available data from the study and discuss trial barriers and processes. We do so both to provide insights that may inform similar studies and to avoid the "file-drawer" (publication bias) problem, which can skew the aggregated scholarly literature through nonpublication of registered trial results or selective publication of findings affirming authors' hypotheses.

METHODS

This paper reports an in-depth implementation study assessment, provides the available observational data, and discusses implementation considerations for similar studies in independent (eg, nonchain) community pharmacies.

RESULTS

Retrospective assessment of study outcomes and fidelity data provided for robust discussion around how resource differences in independent community pharmacies (vs well-resourced chain pharmacies), as well as high demands on staff, can affect intervention implementation, even when leadership is highly supportive.

CONCLUSIONS

Community pharmacies, particularly independent community pharmacies, may require more support than anticipated to be successful when implementing a new intervention into practice, even if it might affect estimates of real-world effectiveness. Further implementation science research is needed specific to independent community pharmacies. All study elements are outlined in the International Registered Report Identifier (IRRID) PRR1-10.2196/42373. Although this paper reports results associated with that registration, results and conclusions should not be given the weight assigned to findings from a preregistered study.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/42373.

Come back when you're infected: pharmacy access to sterile syringes in an Arizona Secret Shopper Study, 2023

BACKGROUND

Pharmacies are critical healthcare partners in community efforts to eliminate bloodborne illnesses. Pharmacy sale of sterile syringes is central to this effort.

METHODS

A mixed methods "secret shopper" syringe purchase study was conducted in the fall of 2022 with 38 community pharmacies in Maricopa and Pima Counties, Arizona. Pharmacies were geomapped to within 2 miles of areas identified as having a potentially high volume of illicit drug commerce. Daytime venue sampling was used whereby separate investigators with lived/living drug use experience attempted to purchase syringes without a prescription. Investigator response when prompted for purchase rationale was "to protect myself from HIV and hepatitis C." A 24-item instrument measured sales outcome, pharmacy staff interaction (hostile/neutral/friendly), and the buyer's subjective experience.

RESULTS

Only 24.6% (n = 28) of 114 purchase attempts across the 38 pharmacies resulted in syringe sale. Less than one quarter (21.1%) of pharmacies always sold, while 44.7% never sold. Independent and food store pharmacies tended not to sell syringes. There emerged distinct pharmacy staff interactions characterized by body language, customer query, normalization or othering response, response to purchase request and closure. Pharmacy discretion and pharmacy policy not to sell syringes without a prescription limited sterile syringe access. Investigators reported frequent and adverse emotional impact due to pharmacy staff negative and stigmatizing interactions.

CONCLUSIONS

Pharmacies miss opportunities to advance efforts to eliminate bloodborne infections by stringent no-sale policy and discretion about syringe sale. State regulatory policy facilitating pharmacy syringe sales, limiting pharmacist discretion for syringe sales, and targeting pharmacy-staff level education may help advance the achievement of public health goals to eliminate bloodborne infections in Arizona.

Naloxone Accessibility Under the State Standing Order Across Mississippi

Importance

Naloxone is a life-saving medication for individuals experiencing an opioid overdose. Naloxone standing orders aim to make naloxone more available by allowing patients improved access to this medication at community pharmacies; however, lawful availability does not mean that this life-saving intervention is accessible to patients.

Objective

To characterize naloxone availability and out-of-pocket cost under the state standing order in Mississippi.

Design, Setting, and Participants

This telephone-based, mystery-shopper census survey study included Mississippi community pharmacies open to the general public in Mississippi at the time of data collection. Community pharmacies were identified using the Hayes Directories April 2022 complete Mississippi pharmacy database. Data were collected from February to August 2022.

Exposures

Mississippi House bill 996, the Naloxone Standing Order Act, signed into law in 2017, allowing pharmacists to dispense naloxone under a physician state standing order at a patient's request.

Main Outcomes and Measures

The main outcomes were naloxone availability under Mississippi's state standing order and the out-of-pocket cost of available formulations.

Results

There were 591 open-door community pharmacies surveyed for this study, with a 100% response rate. The most common pharmacy type was independent (328 [55.50%]), followed by chain (147 [24.87%]) and grocery store (116 [19.63%]). When asked, "Do you have naloxone that I can pick up today?" 216 Mississippi pharmacies (36.55%) had naloxone available for purchase under the state standing order. Of the 591 pharmacies, 242 (40.95%) were unwilling to dispense naloxone under the state standing order. Among the 216 pharmacies with naloxone available, the median out-of-pocket cost for naloxone nasal spray (n = 202) across Mississippi was $100.00 (range, $38.11-$229.39; mean [SD], $105.58 [$35.42]) and the median out-of-pocket cost of naloxone injection (n = 14) was $37.70 (range, $17.00-$208.96; mean [SD], $66.62 [$69.27]).

Conclusions and Relevance

In this survey study of open-door Mississippi community pharmacies, availability of naloxone was limited despite standing order implementation. This finding has important implications for the effectiveness of the legislation in preventing opioid overdose deaths in this region. Further studies are needed to understand pharmacists' unwillingness to dispense naloxone and the implications of lack of availability and unwillingness for further naloxone access interventions.

Pilot implementation of the PharmNet naloxone program in an independent pharmacy

BACKGROUND

The U.S. overdose epidemic has continued to escalate with more than 100,000 deaths per year in the past several years, most of which involve opioids. Widespread availability of naloxone is part of a national solution to the crisis, and community pharmacies are well-poised to facilitate such distribution and provide additional harm reduction services.

OBJECTIVES

The primary objectives of this study were to (a) examine the usability of each of the separate intervention components prepared for PharmNet, (b) observe intervention fidelity through regularly scheduled site visits, and (c) explore the association between PharmNet implementation and the volume of naloxone sales and distribution in the pilot site.

PRACTICE DESCRIPTION

Here, we describe a carefully designed and tailored pharmacy harm reduction intervention called PharmNet that is designed to maximize harm reduction impact while minimizing utilization of pharmacist resources. It is a pragmatic awareness, service provision, and referral program that was developed through careful, iterative feasibility studies with pharmacists.

PRACTICE INNOVATION

PharmNet procedures include tools and steps to create awareness (e.g., yard signs and messaging for patients, reminder tools for pharmacists), facilitation of naloxone delivery from nonprofits, and provision of referral cards featuring local resources.

EVALUATION METHODS

Evaluation included direct data collection and randomly scheduled fidelity site visits.

RESULTS

The intervention was associated with an increase of 3.33 naloxone doses/mo being dispensed at cost (34.4% relative increase) and an overall increase of 9.33 naloxone doses/mo being dispensed via any mechanism (96.48% relative increase). Around 2.85 referral cards were issued to patients daily. Intervention fidelity was moderate, and the study provides valuable information for how to modify the study prior to a randomized trial.

CONCLUSION

With modifications informed by this pilot study, the PharmNet intervention merits a randomized trial to determine whether it causes increased naloxone dispensing in independent community pharmacies.

The PharmNet Harm Reduction Intervention for Community Pharmacies: Protocol for a Pilot Randomized Controlled Trial

Background

The overdose epidemic in the United States has continued to worsen despite substantial efforts to mitigate its harms. The opioid antagonist naloxone has been identified as a key means of reducing the prevalence of fatal overdoses. An important evidence-based approach to optimizing naloxone’s impact is to seed it throughout the community, because bystanders are often able to reverse overdoses more quickly than first responders and sometimes are the only possible means of overdose reversal. As part of a multipronged approach to distributing naloxone nationwide, community pharmacies have been identified as ideal venues for naloxone dispensing, especially under standing orders. However, dispensing rates remain surprisingly low, and there is a need to understand how best to engage community pharmacies in naloxone-based harm reduction services.

Objective

The objective of this trial is to determine whether a tailored, pragmatic pharmacy intervention (PharmNet) results in greater naloxone dispensing relative to baseline (the prior 3 months) compared to a control condition. This pilot trial is intended to determine whether it is appropriate to invest the substantial resources that would be required to conduct a full-scale, randomized controlled study of PharmNet.

Methods

We will conduct a 3-month randomized controlled pilot trial consisting of 2 parallel groups with a 4:3 allocation ratio. A group of 7 independent pharmacies from rural areas in Indiana will be randomly assigned to either the PharmNet intervention arm (n=4) or the control arm (n=3). The primary outcome will be overall naloxone dispensing (both at cost and free), and secondary outcomes will include the distribution of referral cards and multiple variables at the level of individual staff members. Dispensing data will be collected for the 3 months prior to the intervention and the 3 months of the intervention, and all other data will be collected using a pretest-posttest design. The primary analysis will be a generalized linear mixed model with a Poisson distribution with fixed effects for group, time, and their interaction and a random effect for pharmacy ID to account for repeated measures within pharmacies.

Results

This study was approved by the Indiana University institutional review board in 2 phases (August 2, 2021, and April 26, 2022) and was funded by the Indiana University Grand Challenge: Responding to the Addictions Crisis.

Conclusions

If this study produces evidence that the PharmNet intervention results in increased naloxone dispensing relative to control pharmacies, it will be both appropriate and important to study it in a large, full-scale randomized controlled trial.

International Registered Report Identifier (IRRID)

PRR1-10.2196/42373

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.

A qualitative examination of naloxone access in three states: Connecticut, Kentucky, and Wisconsin

BACKGROUND

Prevention of opioid-involved overdose deaths remains a public health priority in the United States. While expanding access to naloxone is a national public health strategy, it is largely implemented at the state and local level, where significant variability in policies, resources, and norms exist. The aims of the current study were to examine the social context of naloxone access in three different states (Connecticut, Kentucky, Wisconsin) from the perspectives of key informants (first responders, harm reduction personnel, and pharmacists), who play some role in dispensing or administering naloxone within their communities.

METHODS

Interviews were conducted with key informants who were in different local areas (urban, suburban, rural) across Connecticut, Kentucky, and Wisconsin. Interview guides explored the key informants' experiences with administering or dispensing naloxone, and their perspectives on opioid overdose prevention efforts in their areas. Data analysis was conducted using multistage inductive coding and comparative methods to identify dominant themes within the data.

RESULTS

Key informants in each of the three states noted progress toward expanding naloxone access, especially among people who use opioids, but also described inequities. The key role of harm reduction programs in distributing naloxone within their communities was also highlighted by participants, as well as barriers to increasing naloxone access through pharmacies. Although there was general consensus regarding the effectiveness of expanding naloxone access to prevent overdose deaths, the results indicate that communities are still grappling with stigma associated with drug use and a harm reduction approach.

CONCLUSION

Findings suggest that public health interventions that target naloxone distribution through harm reduction programs can enhance access within local communities. Strategies that address stigmatizing attitudes toward people who use drugs and harm reduction may also facilitate naloxone expansion efforts, overall, as well as policies that improve the affordability and awareness of naloxone through the pharmacy.

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.

Trends in pharmacy-based dispensing of buprenorphine, extended-release naltrexone, and naloxone during the COVID-19 pandemic by age and sex - United States, March 2019 - December 2020

BACKGROUND

COVID-19 stay-at-home orders may reduce access to substance use treatment and naloxone, an opioid overdose reversal drug. The objective of this analysis was to compare monthly trends in pharmacy-based dispensing rates of medications for opioid use disorder (MOUD) (buprenorphine and extended-release [ER] naltrexone) and naloxone in the United States during March 2019-December 2020 by age and sex.

METHODS

We calculated monthly prescription dispensing rates per 100,000 persons using IQVIA New to Brand. We used Joinpoint regression to calculate monthly percent change in dispensing rates and Wilcoxon Rank Sum tests to examine differences in median monthly rates overall, and by age and sex between March 2019-December 2019 and March 2020-December 2020.

RESULTS

Buprenorphine dispensing increased among those aged 40-64 years and ≥ 65 years from March 2019 to December 2020. Median rates of total ER naltrexone dispensing were lower in March 2020-December 2020 compared to March 2019-December 2019 for the total population, and for females and males. From March 2019 to December 2020, ER naltrexone dispensing decreased and naloxone dispensing increased for those aged 20-39 years.

CONCLUSIONS

Dispensing ER naltrexone declined during the study period. Given the increase in substance use during the COVID-19 pandemic, maintaining equivalent access to MOUD may not be adequate to accommodate rising numbers of new patients with opioid use disorder. Access to all MOUD and naloxone could be further expanded to meet potential needs during and after the public health emergency, given their importance in preventing opioid overdose-related harms.

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.

Exploration of pharmacist comfort with harm reduction behaviors: Cross-sectional latent class analysis

BACKGROUND

Pharmacists are positioned to play important roles in implementing evidence-based prevention and harm reduction approaches for opioid misuse and related health care outcomes such as human immunodeficiency virus (HIV) and hepatitis C. More research is needed to understand how best to facilitate harm reduction practices among pharmacists.

OBJECTIVES

This hypothesis-generating study investigated (1) whether subgroups (latent classes) were observable among pharmacists based on self-reported comfort with specific harm reduction behaviors, (2) whether having reported expertise in key content areas was associated with any latent classes that might be identified, and (3) whether comfort and training were associated with actually having dispensed syringes for likely nonprescription drug use.

METHODS

This was a statewide census of community managing pharmacists in Arizona conducted from December 2018 to May 2019. Participants reported their degree of comfort with 10 harm reduction behaviors, their expertise (e.g., recent continuing pharmacy education or specialization) in selected content areas, and their syringe dispensing behavior. Additional sociodemographic information was also collected. Subgroups related to harm reduction were computed using latent class analysis, and associations between study variables were assessed using the Fisher's exact tests.

RESULTS

Data suggested the existence of 4 latent, comfort-based harm reduction classes: high comfort, moderate comfort, and clinical comfort, and opioid prevention only. Reported expertise in pre-exposure prophylaxis for HIV was likely associated with harm reduction class. However, class membership was not associated with reporting having dispensed nonprescription syringes, although the single comfort item for syringe dispensing, by itself, was associated therewith.

CONCLUSION

Comfort with harm reduction likely clusters, so pharmacists may be broadly comfortable with topics or methods of harm reduction; however, comfort with a specific harm reduction pharmacy practice may be a better predictor of engaging in that behavior than harm reduction comfort class. In contrast, strategies to improve comfort, such as intervention development, might successfully be informed by pharmacists' latent class.

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.

Investigating Community Pharmacy Take Home Naloxone Dispensing during COVID-19: The Impact of One Public Health Crisis on Another

A recent report found that the number of opioid-related deaths in Ontario in the first 15 weeks of the COVID-19 pandemic was 38.2% higher than in the 15 weeks before the pandemic. Our study sought to determine if pharmacy professionals self-reported an increase or decrease in naloxone provision due to the pandemic and to identify adjustments made by pharmacy professionals to dispense naloxone during the pandemic. A total of 231 Ontario community pharmacy professionals completed an online survey. Pharmacy professionals' barriers, facilitators, and comfort level with dispensing naloxone before and during the pandemic were identified. The sample consisted of mostly pharmacists (99.1%). Over half (51.1%) reported no change in naloxone dispensing, while 22.9% of respondents reported an increase and 24.7% a decrease. The most common adjustments made during the pandemic were training patients how to administer naloxone over video or phone, delivering naloxone kits, and pharmacy technicians offering naloxone at prescription intake. Over half (55%) of participants said the top barrier for dispensing was that patients did not request naloxone. Naloxone distribution through pharmacies could be further optimized to address the increased incidence of overdose deaths during the pandemic. Future research should investigate the reasons for changes in naloxone dispensing.

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.

Community pharmacists in Virginia dispensing naloxone under a standing order: A qualitative study

BACKGROUND

In 2016, the Virginia Health Commissioner signed a standing order into law allowing licensed pharmacists to dispense opioid receptor antagonists (ORAs) for overdose reversal.

OBJECTIVES

Using the theory of planned behavior as an initial guide to study development, the aim of this qualitative study was to explore community pharmacists' attitudes, subjective norm, perceived behavioral control, and behavioral intention toward dispensing ORAs under a standing order in Virginia.

METHODS

Semi-structured interviews were conducted with community pharmacists across the Commonwealth between June 2018 and October 2019. Interviews were recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Twenty-one community pharmacists were interviewed. Pharmacists were confused about the specifics and the processes involved with dispensing naloxone under the standing order. Furthermore, many recognized the underuse of the standing order. Positive attitudes focused on the life-saving action of ORAs. Negative attitudes included encouraging risky behaviors by patients, negatively affecting the patient-pharmacist relationship, offending or contributing to stigmatizing patrons, and having liability issues to the pharmacy. Subjective norms regarding dispensing of ORAs under the standing order were perceived to be favorable among peer pharmacists and primary care and emergency department physicians but may be seen as profit-seeking by patients. Barriers to service provision included lack of guidance from corporate offices (in chain pharmacies), inadequate training, patient out-of-pocket costs, reimbursement issues, inadequate staffing and time, and stigma. Facilitators comprised the existence of practice site-specific protocols, the REVIVE! training, technician support, increased community awareness, physician collaboration, pharmacist training, and employer guidance. Whereas some pharmacists intended to become more familiarized with the standing order, others did not intend to actively identify patients who were at risk of an opioid overdose.

CONCLUSION

Pharmacists expressed mixed behavioral intention toward dispensing ORAs under the standing order. Future research should focus on quantifying the uptake of the standing order at the state level.

Availability of buprenorphine/naloxone films and naloxone nasal spray in community pharmacies in Texas, USA

BACKGROUND AND AIMS

Patients with opioid use disorder (OUD) must be able to obtain prescribed buprenorphine/naloxone films (BUP/NX) and naloxone nasal spray (NNS) from a pharmacy promptly to reduce risk for a recurrence of use and subsequent morbidity and mortality. Telephone audits have identified concerning gaps in availability of NNS within US pharmacies, but the availability of BUP/NX has not been rigorously evaluated. This study estimated the availability of BUP/NX and NNS in the US state of Texas and compared availability by pharmacy type and metropolitan status.

DESIGN

A cross-sectional telephone audit with a secret shopper approach conducted from 18 May 2020 to 7 June 2020. Setting and Participants A random sample of 800 of 5078 (16%) community pharmacies licensed with the Texas State Board of Pharmacy.

MEASUREMENTS

Primary outcomes included availability of a 1-week supply of generic BUP/NX 8/2 mg films and a single unit of NNS 4 mg, overall and by pharmacy type. Secondary outcomes included willingness and estimated time-frame to order BUP/NX if unavailable.

FINDINGS

Data from 704 pharmacies (471 chain, 233 independent) were included for analyses. Of these, 34.1% of pharmacies (45.0% of chains versus 12.0% of independents, P < 0.0001) were willing and able to dispense a 1-week supply of generic BUP/NX and a single unit of NNS. BUP/NX alone was available in 42.2% of pharmacies (52.4% of chains versus 21.5% of independents, P < 0.0001). NNS alone was available in 60.1% of pharmacies (77.9% of chains versus 24.0% of independents, P < 0.0001). Of the 397 pharmacies with generic BUP/NX unavailable, 62.2% of pharmacies (73.9% of chains versus 48.0% of independents, P < 0.0001) indicated willingness to order.

CONCLUSIONS

Most pharmacies in Texas do not appear to be willing and able to dispense prescribed buprenorphine/naloxone films and naloxone nasal spray to patients with opioid use disorder in a timely manner. Deficiencies in availability are markedly more pronounced in independent pharmacies compared with chain pharmacies.

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.

What Is Known about Community Pharmacy-Based Take-Home Naloxone Programs and Program Interventions? A Scoping Review

A variety of new sources describing community pharmacy-based take-home naloxone (THN) programs have emerged recently in the literature. There is a need to define the types of take-home naloxone programs being offered to support future research designs in implementing and evaluating standardized programs that fill pharmacist and patient knowledge gaps and lift current barriers for optimal community pharmacy naloxone provision. The objective of this paper is to summarize the literature on community pharmacy-based THN programs, including specific program interventions used to increase naloxone dispensing, naloxone availability and dispensing patterns, facilitators and barriers for the THN programs, and knowledge gaps. Online databases such as PubMed, EMBASE, Scopus, and International Pharmaceutical Abstracts (IPA) and a search of the grey literature were used to identify eligible sources. Sources were screened by two reviewers for eligibility in COVIDENCE software. Both reviewers compared screening results and resolved conflicts through discussion. A data extraction form for all identified full texts was completed by both reviewers and results were compiled through reviewer discussion. Fifty-two sources met the eligibility criteria. The top three barriers identified were: cost/coverage of naloxone, stigma, and education/training for pharmacists. THN program interventions included screening tools, checklists, pocket cards, patient brochures, and utilizing the pharmacy management system to flag eligible patients. Patient knowledge gaps included naloxone misinformation and lack of awareness, while pharmacists demonstrated administrative, clinical, and counselling knowledge gaps. Naloxone availability was found to be highly variable, where independent and rural pharmacies were less likely to stock or dispense naloxone. Further, pharmacies located in districts with higher rates of opioid overdose deaths and lower household income were also less likely to have naloxone available. This review identified multiple new programs, showcasing that the implementation and evaluation of THN programs are an expanding area of research. Future research should focus on implementing and evaluating a THN program through a randomized controlled trial design that incorporates solutions for the barriers and knowledge gaps identified in this study.

Impact of naloxone education for patients receiving buprenorphine-containing prescriptions indicated for opioid use disorder at an independent community pharmacy

OBJECTIVES

A pilot study was conducted to identify whether an opioid education and naloxone distribution (OEND) service affected (1) willingness to accept naloxone; (2) naloxone dispensation; and (3) patient knowledge about opioids, overdose symptoms, and naloxone in patients receiving buprenorphine prescriptions for opioid use disorder (OUD).

METHODS

Participants were enrolled from January 2, 2019, to February 15, 2019, in this prospective noncontrolled study when receiving a buprenorphine prescription at the study site. The exclusion criteria included prescriptions being picked up by someone other than the patient and those who were below 18 years of age. The participants completed a written pre- and postsurvey containing "Yes" or "No," "Select all that apply," and open-ended questions assessing (1) willingness to accept naloxone and (2) change in opioid and naloxone knowledge.

RESULTS

Fifty-two participants were enrolled, and all completed the pre- and postsurveys. After the education, there was a not statistically significant change in the proportion of participants willing to accept naloxone from the pharmacy (28.8% vs. 36.5%; P = 0.31). In addition, there was an improvement in the proportion of participants believing that they need to carry naloxone with them (15.4% vs. 40.4%; P < 0.001). Naloxone dispensing increased 400% after the intervention implementation. Improvements in opioid knowledge also occurred. More participants correctly identified buprenorphine as an opioid (48.1% vs. 86.5%; P < 0.001), and correctly identified that methamphetamine (19.2% vs. 3.8%; P = 0.02) and cocaine (17.3% vs. 3.8%; P = 0.03) are not opioids. Of the 52 participants enrolled, 11.5% correctly identified all opioids on the presurvey, whereas 50% correctly identified all opioids on the postsurvey.

CONCLUSION

Patients diagnosed with OUD who are prescribed buprenorphine may be at high risk of an overdose if they return to use; yet, few OEND programs specifically target this population. This study suggests that OEND based in community pharmacies may be a strategy to increase naloxone access among these patients.