Naloxone
Loren Bonner
Over the past 5 years, states have adopted pharmacy-based naloxone laws at rapid-fire pace, allowing pharmacists to dispense the opioid overdose antidote without a prescription. All states give pharmacists this authority through either statewide protocols, standing orders, or direct prescriptive authority.
Despite this progress, gaps still exist, especially in rural communities, according to CDC.
The agency found that rural counties were almost three times more likely to be low-dispensing areas compared with metropolitan counties. Nationwide, CDC investigators found that only one naloxone prescription was dispensed for every 70 high-dose opioid prescriptions. Coprescribing naloxone is recommended for patients at high risk for an opioid overdose.
Although many reasons can prevent a rural pharmacy—especially an independent one—from dispensing naloxone, Jeffrey Bratberg, PharmD, FAPhA, clinical professor at the University of Rhode Island College of Pharmacy in Kingston, said it will most likely be due to an economic issue or a shortage of personnel who are needed to help order, stock, and educate patients about naloxone.
“Rural areas are not increasing in population,” Bratberg said. “You often have less help [and] fewer customers, and that means clinical services that are perceived as time-consuming are not something you can do easily. While negative public and professional attitudes play a role in limits to overdose and opioid use disorder treatment, I don’t think it’s entirely related to stigma. Also, people are not making money purely from naloxone dispensing, so it’s an economic issue, too.”
Proactive process
Bratberg is coauthor of a new study that highlights how important it is to have all the pieces in place for more ubiquitous naloxone dispensing in pharmacies.
“Naloxone is so different from other drugs [in the pharmacy]—which is generally a reactive process. With naloxone, it’s a proactive process,” said Bratberg.
First, laws have to be in place that allow pharmacists to dispense naloxone without a provider’s prescription. Next, a pharmacy has to have the product available, which Bratberg said sets up an environment for pharmacists to confidently and universally recommend naloxone.
The study, published online November 19, 2019, in the Journal of the American Pharmacists Association, examined the attitudes of pharmacists toward dispensing naloxone in their pharmacy.
“Our most significant finding was that pharmacists who worked in settings that stocked naloxone [and] had either a standing order or collaborative practice agreement allowing them to dispense naloxone without a prescription had better attitudes toward opioid overdose prevention and public health prevention in general,” said Dina Burstein, MD, MPH, lead author of the study and a research scientist at the Injury Prevention Center at Rhode Island Hospital.
A survey was e-mailed to approximately 2,900 licensed pharmacists from all practice settings in Massachusetts and Rhode Island over a 4-month period in 2016.
“A limitation of the study is that we only surveyed pharmacists from Rhode Island and Massachusetts, so we can’t generalize the results beyond this population,” said Burstein.
Despite this limitation, Burstein said the findings support increasing the number of pharmacies that participate in programs that allow them to dispense naloxone without a prescription.
“We have shown that having these programs in place improves prevention attitudes among these pharmacists, which may lead to increased dispensing of naloxone to at-risk individuals,” she said.
Of the 2,900 or so pharmacists who received the survey, 402 responded, and 245 were included in the analyses. “We had a modest response rate to the survey, which may limit the strength of the result,” added Burstein.
Does the type of naloxone matter?
A randomized trial in JAMA Network Open found that the same dose of naloxone given intranasally was not as effective as naloxone given intramuscularly in reversing an opioid overdose. Almost 200 people participated in the trial, which took place at a medically supervised injecting facility in Australia. Of note, however, is that lower doses of I.N. naloxone not available in the United States were used in the study.
Should pharmacists be concerned about these findings? Bratberg doesn’t think so.
“The best naloxone you have is the one you have—it doesn’t matter what it is. Both myself and the FDA support both of these forms of naloxone,” he said.