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.
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.
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).
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.
Accepted for Publication: September 20, 2018.
Corresponding Author: Kirk E. Evoy, PharmD, BCACP, BC-ADM, CTTS, Pharmacotherapy Education and Research Center, College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Dr, MC 6220, San Antonio, TX 78229 (evoy@uthscsa.edu).
Author Contributions: Drs Evoy and Reveles had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: Evoy, Hill, Groff, Mazin, Reveles.
Drafting of the manuscript: Evoy, Hill, Groff, Mazin, Reveles.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Mazin, Reveles.
Administrative, technical, or material support: Groff, Mazin, Carlson.
Supervision: Evoy, Hill, Groff, Mazin, Carlson.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Evoy reported receipt of grant funding from the University of Texas Health San Antonio Institute for Integration of Medicine and Science, the Kleberg Foundation, and Texas Health and Human Services to conduct opioid overdose prevention and response training, including providing education on proper use of naloxone and distribution of naloxone within the community. All formulations of naloxone are discussed in these trainings. The trainings conducted are solely for the purposes of reducing opioid overdose harm in the community. Dr Hill reported previously receiving donations of branded formulations of naloxone from Kaléo Pharma and Adapt Pharma for community distribution in support of efforts to reduce opioid overdose harm in the community. He received a donation of Evzio Auto-Injectors from Kaléo Pharma immediately following Hurricane Harvey for distribution to people who use illicit opioids whose risk of overdose was increased by a destabilized supply chain. He also received a donation of Narcan nasal spray from Adapt Pharma to distribute on campus in support of overdose preparedness efforts at The University of Texas at Austin. No other disclosures were reported.
Additional Contributions: We acknowledge the following PharmD candidates from The University of Texas at Austin College of Pharmacy who assisted with data collection: Ashley Dinh, Judy Chan, Ravi Gandhi, My Tran, Ashly Daioub, Alyeshka L. Jusino-Acosta, Rubya Khalid, Will Godinez, Kallie Erickson, Jillian Contreras, Judith Rendon, Brian Olivares, Suman Augsteen, Kimberly Nguyen, Brian Jermain, Uzma Ahmed, Sophie Tabe, Any Jivan, Michelle Tran, Melissa Evens, Ryan Ung, Baneen Noorali, Ryan Izadi, Mandy Renfro, Jennifer Ngoc La, Maddie Burgess, Sajidah Marwat-Khan, Noor Atiyah, Sara Smith, Eli Aggor, Shelby Humpert, Sarvnaz Sadrameli, Hannah Mucha, Nishat Huq, Shelly Goyal, Miriam Easo, Randi Braak, Itzel Alfaro-Rivas, Ashley Abraham, Samantha Le, Emma Gugala, Lindsey Loera, Jonathan Patterson, Ashley Sotoodeh, Sarah Piccuirro, Alexis Alba, Karen Aymá, Chenyuan Zhou, Hannah Spencer, James Hsu, Jessica Arianna Galindo, Kayla Kotara, Cameron Roy, Mariela Silva, David Giang, Kenny Nguyen, and Yi Kee Poon. They were not compensated for this role.