Naloxone Accessibility by Standing Order in North Carolina Community Pharmacies

Marley, Grace; Annis, Izabela E.; Ostrach, Bayla; Egan, Kathleen; Delamater, Paul L.; Bell, Ronny; Dasgupta, Nabarun; Carpenter, Delesha M.

doi:10.1016/j.japh.2024.01.017

Cited by 2 publications

(24 citation statements)

References 24 publications

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“…As such, community pharmacists are theoretically well-positioned to improve harm reduction education and accessibility of related supplies. At the same time, recent studies also continue to suggest that naloxone remains unavailable for purchase in some community pharmacies and may be less likely to be available in independent pharmacies compared to chain pharmacies [ 29 ].…”

Section: Introductionmentioning

confidence: 99%

“…Further, there was variability in the a priori intervention components that would be available at different pharmacy types. For example, a systematic review [ 36 ] in addition to our own earlier research in Indiana [ 33 ] and a recent study in North Carolina [ 29 ] identified independent pharmacies as being significantly less likely to stock or dispense naloxone compared to chain pharmacies (eg, ability to dispense naloxone, even at cost, could not be assumed). While independent pharmacies are, in theory, more likely to be able to participate in a small intervention implementation program (eg, they do not need to seek approval from a large bureaucracy associated with a national or international chain), they also lack the financial and systemic resources that are available to chain pharmacies, which can have implications for stocking and dispensing of products, as well as pharmacists’ availability to undertake additional work.…”

Section: Introductionmentioning

confidence: 99%

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

Eldridge,

Meyerson,

Agley

2024

JMIR Form Res

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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

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Eldridge,

Meyerson,

Agley

2024

JMIR Form Res

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“…[4][5][6][7][8][9][10][11][12][13] When comparing naloxone access by pharmacy type, independent pharmacies, or pharmacies that follow the small owner/operator model, have lower naloxone availability compared with chain pharmacies, or pharmacies that are part of a corporation or have more than 5 locations. 4,6,9,[15][16][17][18][19][20] Urban pharmacies demonstrated higher accessibility to naloxone compared with rural pharmacies. 8 Pharmacy-based access to naloxone is important in rural areas because harm reduction organizations that distribute naloxone for free are often less accessible.…”

Section: Introductionmentioning

confidence: 99%

“…23,24 Secret shopper studies have documented high out-of-pocket costs for naloxone nasal spray, averaging more than $125, with elevated out-of-pocket costs at independent pharmacies compared with chain pharmacies and in rural areas compared with urban areas. 4,5,9,10,15,[23][24][25][26] North Carolina has a high opioid overdose death rate, particularly in rural areas. 1,27 In 2019, a secret shopper study of North Carolina pharmacies found that 61.7% were willing to dispense naloxone without a prescription, in accordance with the statewide standing order.…”

Section: Introductionmentioning

confidence: 99%

“…12 Moreover, the results of the first phase of this study conducted in 2023 found that only 53% of pharmacies were willing to dispense naloxone without a prescription, with an average cost of $96.27. 12,15 In an effort to increase the public's access to naloxone, the US Food and Drug Administration approved Narcan (Emergent BioSolutions), a nasal spray formulation of naloxone, for sale as an overthe-counter (OTC) product in March 2023, with the product first becoming available at pharmacies in September 2023. 28 The suggested manufacturer's retail price for 2 doses of OTC naloxone nasal spray, 4 mg, was $45.99.…”

Section: Introductionmentioning

confidence: 99%

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

Marley,

Annis,

Egan

et al. 2024

JAMA Health Forum

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ImportanceThe 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.ObjectiveTo 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 ParticipantsThis 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).ExposureOTC naloxone first became available for sale at community pharmacies in September 2023.Main Outcomes and MeasuresThe main outcomes were same-day availability of naloxone without a clinician-issued prescription and the quoted out-of-pocket cost for cash-paying patients.ResultsData 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 &lt; .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 &lt; .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 &lt; .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 RelevanceThe 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.

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Naloxone Accessibility by Standing Order in North Carolina Community Pharmacies

Cited by 2 publications

References 24 publications

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

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

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

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