Patients can get—and pharmacists can provide—naloxone at the pharmacy. Why don’t they?

Barriers range from patient cost to stigma

Several major chains have trained all their pharmacists on naloxone. Forty-eight states and Washington, DC, allow pharmacists to dispense naloxone without a physician’s prescription. Access to naloxone through pharmacists is a win for the pharmacy profession—the role pharmacists could play in resolving the opioid epidemic is a major plank in the argument for provider status. So why hasn’t access to naloxone at pharmacies brought more patients in to get it? Any why are many pharmacists reluctant to provide it?

“I would say the biggest barrier is cost,” said Anita Jacobson, PharmD, clinical assistant professor at University of Rhode Island School of Pharmacy. “People who use opioids recreationally or illicitly are the most likely to be in the position to use naloxone, but if they are coming into a pharmacy and there is a cost associated with it, unfortunately that is a big deterrent.”

There are also practical barriers. Policies governing pharmacists’ latitude to furnish naloxone without a prescription vary widely. Some states require pharmacists to undergo training, which may cost a few hundred dollars, or require patient screening, which can throw a wrench in a busy pharmacy’s workflow. Counseling patients on how to use naloxone may not be reimbursed. In some states, pharmacists must enter into collaborative practice agreements to provide naloxone. And while some states, like Rhode Island, require third-party insurers to cover naloxone, many don’t.

States also vary in their “Good Samaritan” laws. Those who report overdoses to 911 may be exempt from liability for naloxone but are not necessarily exempt from criminal prosecution for drug-related activities. “Like I said, people who use drugs themselves are most likely to witness an overdose, but less than half of the time do people actually call 911,” Jacobson said.

The words pharmacists use to recommend naloxone help destigmatize it. Jacobson encourages use of the term “breathing emergency” in lieu of “overdose.”

She urges pharmacists to remind patients that there are occasions to use naloxone that don’t involve misuse of the drug—accidents can happen. “People could forget they took a dose already and double-up; also, there is risk of accidental or recreational exposure among children and adolescents, even a pet potentially could get into unsecured medication.” Also, they may have loved ones who could require naloxone.

It’s a matter of being prepared. “If you have an allergy, you have an EpiPen. If you have opioids, you have naloxone.”

Patients with sleep apnea, COPD, or other respiratory conditions should also be offered naloxone. “And certainly, anyone who has what we call ‘patient-related factors.’ Maybe a patient has been in a rehabilitation facility or even a correctional setting and is now transitioning back to the home setting where there isn’t as much constant support.” Patients are at a high risk for relapse during these transitions, and they may overdose because of reduced tolerance.

Prescription opioids are associated with 40% of overdoses, while 60% of opioid overdoses are the result of illicit opioids like fentanyl. For at-risk patients whom pharmacists may not be able to identify by their prescriptions, “syringe purchases are an avenue for that intervention,” Jacobson said.

Many pharmacists who otherwise could dispense naloxone—either as part of a collaborative practice agreement, state law, or company policy—aren’t doing it. “I suspect they think it’s somehow enabling people to use drugs,” Jacobson said. The data do not back up their concerns. “When you get naloxone into a community, there is not a compensatory increase in heroin usage.”

Lucas Hill, PharmD, BCPS, BCACP, is clinical assistant professor at University of Texas at Austin (UT Austin) College of Pharmacy and clinical pharmacist at CommUnityCare Federally Qualified Health Centers. Hill also leads Operation Naloxone, an opioid overdose education and naloxone distribution program led by UT Austin College of Pharmacy in collaboration with the School of Social Work and Texas Overdose Naloxone Initiative.

Hill has some blunt words for pharmacists who are hesitant to provide naloxone. “Get over it,” he said.

He’s kidding. Or is he? “Pharmacists have a key role to play in public health and harm reduction. Nowhere is that more evident than in our current opioid crisis. However, moralistic humbuggery and a general lack of willingness to push past traditional boundaries may well bungle this unique opportunity to advance the role of the community pharmacist,” he said.

“Many pharmacists worry that naloxone will be a safety net, promoting more extreme drug misuse. This is not supported by a shred of evidence. Several analyses have demonstrated that increasing naloxone access leads to fewer overdose deaths and promotes entry into addiction treatment programs,” Hill added.

For the full article, visit www.pharmacytoday.org for the August 2018 issue of Pharmacy Today.