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

Pharmacist furnishing of hormonal contraception in California's Central Valley

BACKGROUND

In the United States, more than 19 million people of reproductive age need access to publicly funded hormonal contraception or live in areas where it is not readily available. These include rural areas of the country, commonly known as contraception deserts. Pharmacist prescribing has been proposed to increase access, but little is known about its implementation in such areas.

OBJECTIVE

This study quantified the extent of pharmacists' furnishing (prescribing) of hormonal contraception in California's Central Valley community pharmacies and identified barriers and facilitators to implementation.

METHODS

The researchers conducted a cross-sectional, mixed methods, observational study by (1) contacting all community pharmacies in the 11 counties of the Central Valley to determine furnishing rates and (2) surveying and interviewing pharmacies that indicated they furnished hormonal contraception.

RESULTS

Overall, 13% of pharmacies within the Central Valley reported that they furnished hormonal contraception. Pharmacists reported that barriers to furnishing included costs to patients and the pharmacy, lack of time and staff, lack of training and certifications, limited patient awareness of pharmacists' ability to furnish, pharmacists' limited confidence in furnishing, and patient use of emergency contraception as an alternative to hormonal contraception. Pharmacists reported that patients often sought hormonal contraception from pharmacists owing to ease of accessibility to a pharmacist; some other facilitators included advertising, confidentiality, low cost to patients, and referrals from other providers.

CONCLUSIONS

Common barriers were identified across pharmacies that furnished hormonal contraception, indicating the need for strategies that reduce these barriers to help expand patient's access to these services and to increase pharmacists' ability and confidence to prescribe.

Impact of California Statute on Naloxone Availability and Opioid Overdose Rates

Introduction

Ensuring that people at risk of overdosing on opioids have easy access to naloxone is an essential part of the fight against the opioid crisis. This study evaluates the impact of the 2016 California law (CA AB1535) permitting pharmacies to dispense this life-saving medication without a physician's prescription.

Methods

California counties were categorized on the basis of population density (rural, suburban, urban), rate of opioid-related deaths by population density (high, medium, low), and rate of opioid prescriptions by population density (high, medium, low). Ten diverse pharmacies from each category were selected for inclusion. In a brief 1-minute interview conducted between July and August 2021, pharmacists from 146 California pharmacies were surveyed regarding their knowledge of CA AB1535, their practice of dispensing naloxone without a physician's prescription, and whether they normally stock naloxone. Chi-square tests were used to compare responses.

Results

Although almost all pharmacies interviewed (94%) were aware of the law and most of them (64%) dispensed naloxone without a physician's prescription, few statistically significant differences were found between surveyed categories. There were no significant relationships between naloxone availability at pharmacies and overdose death rates.

Conclusions

Our results suggest that the number of California pharmacies dispensing naloxone without a physician's prescription has continued to increase since the implementation of CA AB1535. However, despite increased access to naloxone at pharmacies, opioid overdose rates have continued to rise since 2016, indicating the need for a multifaceted harm reduction approach.

Effectiveness of an Advanced Naloxone Training, Simulation, and Assessment of Second-Year Pharmacy Students

Background: Opioid overdoses continue to be one of the most urgent public health priorities. In 2020, reported overdose deaths in the United States reached a high of over 93,000 cases. As the COVID-19 pandemic and opioid crisis continues to be addressed, life-saving agents must be more widely accessible to those with a high overdose risk. An essential step to increasing access is to train student pharmacists to dispense naloxone. Once licensed, the number of personnel authorized to dispense naloxone can increase. Objectives: To design a training program to educate second-year pharmacy (P2) students on furnishing naloxone under a state protocol. Methods: A multi-phased curriculum-based naloxone training program was delivered to P2 students and included lecture-based education, team-based learning (TBL) applications, case-based scenarios, and summative assessments to improve student knowledge and confidence in furnishing naloxone. Students were surveyed on their knowledge and confidence with naloxone prior to training, after the in-class training and TBL applications and after three assessments. Assessments included simulated patient counseling, case-based scenarios, and proper dispensing of naloxone in a community pharmacy simulation lab. Results: A total of 185 student pharmacists completed the naloxone training program and 68 completed all three surveys. Average scores for naloxone assessments were 83% for the APPS lab patient case, 90.5% for the prescription label typed for the naloxone product, and 88.5% for patient counseling. Statistically significant increases in knowledge-based quiz-like scores (42.1% after training vs. 7.2% after assessment) and in the proportion of students affirmatively answering survey questions after training and assessment was observed. Conclusion: Multi-phase curriculum-based naloxone training program improved pharmacy student knowledge and confidence in furnishing naloxone under a state BOP protocol.

An observational study of the extent of naloxone furnishing in California Central Valley community pharmacies

BACKGROUND

California has sought to expand medication access and improve public health by authorizing pharmacists in California to prescribe certain medications since 2014. Medications with pharmacist-initiated prescribing, or furnishing, include naloxone, hormonal contraception, postexposure prophylaxis/preexposure prophylaxis, and nicotine replacement therapy. In light of the United States' opioid epidemic, naloxone, an opioid antagonist, this study considered furnishing rates in urban areas of California. Research from 2020 found 42.5% of pharmacies furnished naloxone. However, there has been limited study of furnishing outside of urban areas.

OBJECTIVE

This study assessed pharmacist furnishing rates of naloxone in California's Central Valley and identified barriers and facilitators to implementation.

METHODS

From April to May 2022, the researchers first conducted a cross-sectional, observational study of community and mail-order pharmacies in California's largely rural Central Valley, then collected interview data from a subset of pharmacists in stores that indicated they furnished naloxone.

RESULTS

Forty-three percent of Central Valley pharmacies reported that they furnished naloxone. Interview respondents reported that barriers to furnishing included time restrictions, cost to patients, stigma, and language barriers.

CONCLUSIONS

Furnishing rates in the Central Valley were slightly higher (43.4%) than those reported in previous research focusing on urban areas of California (42.5%). Identified barriers to furnishing were consistent with those identified in previous research. These findings suggest that further policy interventions may be needed to reduce out-of-pocket costs, establish stronger pharmacist-provider relationships, and provide education combatting stigma against opioid users to increase naloxone furnishing.

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.