Claremont, CA—For nearly 3 years, California law has allowed trained pharmacists to furnish naloxone without a physician’s prescription. Under a Board of Pharmacy protocol, naloxone is available by patient request or pharmacist suggestion.

Pharmacists must screen and educate patients on opioid-overdose prevention, recognition, and response, and, with patient consent, they are required to notify the patient’s primary care physician that naloxone was furnished.

A recent research letter in JAMA estimated the availability of pharmacist-furnished naloxone 2 years after implementation. To do so, Keck Graduate Institute School of Pharmacy–led researchers conducted an anonymous telephone survey of a 20% random sample of California community pharmacies between January 23 and February 28, 2018.

Posing as potential customers were 30 trained interviewers who used a standardized script to ask any pharmacy staff member, “I heard that you can get naloxone from a pharmacy without a prescription from your doctor. Can I do that at your pharmacy?”

If the answer was “yes,” interviewers asked what formulations were available, the cash price, and whether naloxone could be billed to insurance, also recording additional unsolicited information.

Ultimately, data was collected from 1,147 pharmacies, most of them urban (98.7%), and part of a chain (66.2%). Results indicate that pharmacist-furnished naloxone was available at 23.5% (95% CI, 21.0%-26.0%) of pharmacies.

While no difference was detected between urban and rural locations, researchers note a significant variation by pharmacy type, with 31.6% (95% CI, 28.3%-35.1%) of chain pharmacies versus 7.5% (95% CI, 5.1%-10.6%) of independent pharmacies furnishing naloxone (P <.001).

Of the 269 pharmacies able to provide naloxone, 225 (83.6%) offered a nasal formulation, while 14 (5.2%) offered combination buprenorphine-naloxone tablets used for treatment of opioid-use disorder, not opioid overdose.

Of pharmacies furnishing naloxone, 50.6% had nasal naloxone in stock, with chain pharmacies significantly more likely to have nasal naloxone in stock (52.3%; 95% CI, 46.3%-59.4%) compared with independents (31.0%; 95% CI, 15.3%-50.8%) (P = .03), the study team points out.

As for knowledge of insurance billing, 59.9% of pharmacies replied correctly that pharmacist-furnished naloxone could be billed, with no significant difference by pharmacy type, the study states. The median cash price of nasal naloxone (pack of two) at chain pharmacies was $136 (IQR, $120-$143.50) compared with $150 (IQR, $138.50-$170) (P = .04) at independents.

On the other hand, researchers reveal that several erroneous statements were made by respondents, including that naloxone was a controlled substance, that a tablet formulation was available, and that injectable formulations not appropriate for layperson use were available.

“Two years after implementation, only 23.5% of a representative sample of California retail pharmacies were furnishing naloxone to patients without a physician prescription,” study authors conclude. “Reasons the practice was not being implemented may include lack of knowledge of legislation, lack of required training, stigma about substance use disorder, and time.”

A similar survey was conducted in Texas from May 22, 2018, to June 29, 2018, although only pharmacists were surveyed; CVS, Walgreens, HEB, and Walmart pharmacies throughout Texas were included. Based on data from 2,317 pharmacists, 83.7% (95% CI, 82.2%- 85.2%) indicated they would dispense naloxone without a prescription, and 76.4% (95% CI, 74.7%-78.1%) said they currently stocked naloxone. In addition, according to University of Texas College of Pharmacy researchers, most (79.9% [95% CI, 78.3%- 81.6%]) would allow the purchase of naloxone for someone else, but only 49.7% (95% CI, 47.8%-51.9%) would be willing to bill the purchaser’s insurance for this third-party prescription.

The survey also found that 69.4% (95% CI, 67.5%-71.2%) stocked naloxone and would dispense it under the standing order. The Texas study also found some confusion regarding standing orders: 40 pharmacists stated that the orders only applied during acute overdoses.

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