Naloxone Accessibility Without a Prescriber Encounter Under Standing Orders at Community Pharmacy Chains in Texas

Abstract

This study evaluated naloxone accessibility from chain pharmacies in Texas 32 months after state legislation allowing pharmacists to dispense naloxone under standing orders from authorizing prescribers.

In response to the opioid overdose epidemic, each US state has passed legislation to expand access to naloxone, the opioid overdose antidote.¹ Although naloxone access laws differ by state, one component of most laws is allowance for standing orders, whereby prescribers may authorize pharmacists to dispense naloxone without an outside prescription (ie, the standing order constitutes a prescription from the authorizing prescriber). Enacted in September 2015, Texas’ naloxone access law provides liability protection for prescribers, pharmacists, and overdose responders and permits third-party prescribing (ie, to non–opioid users), layperson possession and distribution, and standing order development.

However, previous reports identified slow adoption of naloxone access laws.^2,3 Thirty months after Indiana enacted legislation, 58% of Indiana pharmacies stocked naloxone,² while 3 years after New York legislation passed, 37.5% of New York City pharmacies stocked and would dispense naloxone under standing order.³ Given the magnitude of opioid overdose–related harm, assessment of whether risk mitigation policies are producing anticipated outcomes is important.

This study evaluated naloxone accessibility under standing order from chain pharmacies in Texas 32 months after enactment of Texas’ legislation.

Methods

This study was deemed nonregulated research by the University of Texas Health San Antonio Institutional Review Board.

Texas has not enacted a statewide standing order, requiring individual agreements between pharmacies/pharmacists and prescribers. Thus, only certain pharmacies have developed standing orders, each with different protocols. The Texas State Board of Pharmacy does not maintain an active record of pharmacies with naloxone standing orders, rendering identification of a complete list, particularly of individual independent pharmacies, unfeasible. However, several pharmacy chains, including CVS, Walgreens, HEB, and Walmart, among others, have publicized implementation of statewide standing orders, granting privileges to each pharmacist working within that organization in Texas. Although not encompassing of all Texas pharmacies with standing orders, these 4 chains were included based on authors’ awareness of their standing orders and pervasiveness across the state, comprising 44.3% of the 5230 Texas community pharmacies.

From May 22, 2018, to June 29, 2018, a telephone audit of all CVS, Walgreens, HEB, and Walmart pharmacies throughout Texas (identified through the Texas State Board of Pharmacy) was conducted. Trained interviewers spoke to a pharmacist at each pharmacy, representing themselves as potential overdose responders (ie, third-party patients) wishing to purchase naloxone to have on hand in the event of an overdose. Interviewers used a scripted interview and a corresponding data collection instrument to obtain information regarding naloxone accessibility (Table). To obtain the primary measure, interviewers asked: “Do I need a prescription to get naloxone or can I just come in and purchase it from you?” To ensure uniform reporting, interviewers contacted the lead author if uncertain how to document a response, and clarification was provided to all interviewers in real time. Data analysis was conducted using JMP version 13 (SAS Institute Inc). Data are presented descriptively.

Table. Telephone Audit Responses—Accessibility of Naloxone Under Standing Orders by Pharmacists in Chain Pharmacies in Texas (N = 2317 Pharmacies)^a.

Questions	Affirmative Responses, No./Total No. (%) [95% CI]
1. Would the pharmacist dispense naloxone without a prescription?	1940/2317 (83.7) [82.2-85.2]
2. Was the pharmacist aware of the standing order?	2041/2317 (88.1) [87.0-89.2]
3. Was at least 1 formulation of naloxone currently in stock at the pharmacy?	1771/2317 (76.4) [74.7-78.1]
4. If naloxone was not in stock …
I. Does the pharmacy typically have it in stock?	217/531 (40.9) [36.8-45.2]
II. Would the pharmacy order naloxone on request?	405/531 (76.3) [72.4-79.7]
5. What dosage form of naloxone was available?
I. Nasal form	1686/1771 (95.2) [94.1-96.1]
i. Narcan nasal spray only	1544/1686 (91.6) [90.2-92.8]
ii. Prefilled syringe with atomization device only	53/1686 (3.1) [2.4-4.1]
iii. Both nasal forms	82/1686 (4.9) [3.9-6.0]
iv. Unknown	7/1686 (0.4) [0.2-0.9]
II. Injectable form	365/1771 (20.6) [18.8-22.6]
i. Vial plus intramuscular syringe only	265/365 (72.6) [67.8-76.9]
ii. Evzio auto-injector only	50/365 (13.7) [10.5-17.5]
iii. Both injectable forms	22/365 (6.0) [4.0-9.0]
III. Both nasal and injectable forms	281/1771 (15.9) [14.2-17.7]
6. Would the pharmacist sell an intramuscular syringe without a prescription?	924/1237 (74.7) [72.2-77.0]
7. Would the pharmacist dispense naloxone to a third party (ie, to non–opioid user to use for someone else)?	1852/2317 (79.9) [78.3-81.6]
8. Would the pharmacist bill a third party’s insurance if purchasing the naloxone for someone else (eg, to have on hand for emergencies or because of concern for a family member or friend)?	1151/2317 (49.7) [47.8-51.9]
Assessment of combinations of audit questions to estimate immediate availability
What proportion of pharmacies were willing to dispense naloxone without a prescription AND currently had naloxone in stock?b	1607/2317 (69.4) [67.5/71.2]
What proportion of pharmacies were willing to dispense naloxone without a prescription AND currently had naloxone in stock OR were willing to order naloxone?c	1893/2317 (81.7) [80.1-83.2]
What proportion of pharmacies were willing to dispense naloxone without a prescription AND currently had naloxone in stock AND were willing to bill a third party’s insurance?d	959/2317 (41.4) [39.4-43.4]

^aSpecific questions asked to obtain answers 1-8: (1) “Do I need a prescription to get naloxone or can I just come in and purchase it from you?” (2) If response to question 1 was “no,” caller would ask “Oh, I was at a presentation recently and they said that pharmacists at CVS, Walgreens, Walmart, and HEB have a standing order to dispense naloxone. Is your pharmacy not included in that?” (3) “Do you have naloxone in stock right now?” (4) If response to question 3 was “no,” caller would ask “Are you just out of it or do you not normally carry it?” and “Would you be able to order some for me?” (5) If response to question 3 was “yes,” caller would ask “Which version?” (6) “If I want to get the vial and the intramuscular syringe, am I able to buy the syringe there or do I need a prescription for that?” (7) “Even if I don’t use an opioid, am I able to purchase naloxone for someone else as a precaution?” (8) “If I am getting the naloxone to use in case someone else overdoses, can I still use my own insurance to purchase the naloxone?”

^bThis question was not specifically asked during telephone audit. The numerator in question 9 includes stores with pharmacists answering affirmatively to both questions 1 and 3.

^cThis question was not specifically asked during telephone audit. The numerator in question 10 includes stores with pharmacists answering affirmatively to both question 1 and question 3 or 4.

^dThis question was not specifically asked during telephone audit. The numerator in question 11 includes stores with pharmacists answering affirmatively to all 3 of questions 1, 3, and 8.

Results

One pharmacist from each of the 2317 CVS, Walgreens, HEB, and Walmart pharmacies in Texas responded (100% response). The proportion of audited pharmacies in urban settings (92%; n = 2127) was similar to the overall proportion of urban Texas community pharmacies (89.6%; n = 4686).

Among audited pharmacies, 83.7% (95% CI, 82.2%-85.2%) indicated they would dispense naloxone without prescription, and 76.4% (95% CI, 74.7%-78.1%) currently stocked naloxone (Table). Most (79.9% [95% CI, 78.3%-81.6%]) would allow 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. As a marker of immediate availability, 69.4% (95% CI, 67.5%-71.2%) stocked naloxone and would dispense under standing order. Qualitatively, confusion regarding standing orders remained (eg, 40 pharmacists stated that they only applied during acute overdoses).

Discussion

The present study identified that among Texas chain pharmacies with standing orders, most stocked naloxone and would dispense it without a prescription. However, access barriers remain.

The study was limited by interviewing only 1 pharmacist per pharmacy and including only Texas chain pharmacies. These data cannot be extrapolated to independent pharmacies or areas lacking chain pharmacies.

Consistent naloxone supply in all pharmacies, improved pharmacist understanding of naloxone standing orders, and ubiquitous insurance coverage for third-party purchasers may further improve access.

Section Editor: Jody W. Zylke, MD, Deputy Editor.