Pharmacists save lives when given authority to directly dispense naloxone

Laws that allow pharmacists to directly dispense naloxone may reduce fatal opioid overdoses, according to a summary and comment published on May 10 in the New England Journal of Medicine (NEJM) Journal Watch.  

In the summary, Ali S. Raja, MD, MBA, MPH, editor-in-chief of NEJM Journal Watch Emergency Medicine, cited a recent study by Abouk and colleagues that examined fatal and nonfatal overdoses in all 50 states and the District of Columbia after the implementation of three types of naloxone access laws—those that give pharmacists direct authority to dispense naloxone without a prescription, indirect authority to dispense the drug through a standing order or statewide protocol, and others.

The study, published on May 6 in JAMA Internal Medicine, found that the overall rate of fatal opioid overdoses from 2005 to 2016 was 0.59 per 100,000 people. Only laws allowing pharmacists to directly dispense naloxone without a prescription were effective in curbing overdose deaths, reducing the rate by 0.39 per 100,000 people in the 3 or more years since the law’s adoption. The other laws, including those that granted pharmacists indirect authority to dispense the drug, did not significantly impact the risk of fatal overdoses.

Every state and the District of Columbia have passed varying forms of naloxone access laws, and many are recognizing the vital role of pharmacists in expanding access to the drug. However, some states have been slow to implement these laws, and many pharmacists aren’t aware of them.

For instance, despite Pennsylvania being one of the first states to implement a statewide standing order to allow pharmacists to dispense naloxone without a prescription, a recent study by Guadamuz and colleagues found that only one-third of Philadelphia pharmacies carried naloxone nasal spray, and many also required a physician’s prescription.

In the survey study published June 7 in JAMA Network Open, researchers called all pharmacies in Philadelphia between February and August 2017 to assess the availability of naloxone nasal spray. Of the 418 pharmacies that participated in the survey (92.1% response rate), only 34.2% (n = 143) had naloxone nasal spray in stock. Of these pharmacies, 61.5% offered the drug without a physician’s prescription.

The study also found that chain stores were more likely to have naloxone in stock and available without a prescription than independent ones. Of the 275 pharmacies in the study that didn’t stock naloxone, 70.5% were able to order it. However, fewer independent stores (60.6%) than chain stores (91.8%) could order the drug.

Pharmacies located in predominantly minority and low-income neighborhoods were less likely to offer naloxone without a prescription, with only 51.2% of pharmacies in low-income areas able to directly dispense the drug compared with 75% in higher-income neighborhoods. Pharmacies in districts with high rates of opioid overdose death—where the life-saving drug is most needed—were also less likely to have naloxone available.  

Even in pharmacies that could dispense naloxone without a prescription, barriers to access still existed. The study found that the median out-of-pocket cost for the nasal spray was $145. In addition, 17.4% of these pharmacies had an age restriction of 18 years to receive the drug. The researchers noted, however, that these age restrictions were less common in districts with higher rates of fatal overdoses.

Given the mounting rate of opioid overdose deaths in the United States, naloxone has become a crucial tool in combatting the epidemic. The study by Abouk and colleagues shows that allowing pharmacists to directly dispense the drug may save many lives from being lost to opioid overdoses. Indeed, in states that granted direct dispensing authority to pharmacists, the rate of nonfatal overdoses in the emergency department (ED) increased by 45 per 100,000 people since the law’s adoption, implying that more patients survived overdoses.

Further efforts are needed to expand and strengthen pharmacists’ role in making naloxone accessible to patients, especially in communities with the highest rates of overdose deaths. “We may see more nonfatal overdoses in the ED when patients are given naloxone by family or friends, but I’d much rather see these patients in my ED than in the morgue,” said Raja.