In 2016, unintentional injuries (UIs) became the third leading cause of death in the United States for the first time among all ages with a crude death rate of 49.9 deaths per 100 000 population.1,2 Of the 161 374 UI deaths in 2016, drug-induced deaths represented one-third (34%, or 54 793), an increased proportion of these deaths (12% in 2000 and 22% in 2006). Among adults 19 to 64 years of age, drug-induced UI deaths also represented a proportional increase during more than a decade, including from 2016 to 2018 when one-half of UI deaths were drug induced.1,2 Furthermore, more than one-half of those drug-induced UI deaths among adults 19 to 64 years of age in 2018 were caused by narcotics such as opioid overdoses.1,2 During 2019, any opioid overdose deaths among all ages increased to 82% of drug deaths.3
There are several reasons for the substantial increases in opioid overdose deaths during more than a decade. One reason is the proliferation of “illicitly made fentanyl and other highly potent synthetic opioids” mixed with substances leading to unknown amounts of opioids in those products.3,4 This situation has led to an increased risk of fatal overdoses.3,4 Another reason is the increasing number of patients receiving higher doses of prescription opioids for pain management.4
Naloxone, as an opioid antagonist, reverses an opioid overdose.4 The US Department of Health & Human Services (HHS) endorses naloxone dispensing by pharmacies as a key strategy for addressing the opioid epidemic.4,5 By 2017, all US states and territories had some form of naloxone access law; and by 2017, barring the state of Nebraska, pharmacists have been allowed to dispense or distribute naloxone without a patient-specific prescription in all of the other states including Georgia.6 Despite these laws, patients continue to face various barriers in gaining access to naloxone. Some barriers are due to the stigma that naloxone use will lead to riskier behaviors, and other barriers include the lack of knowledge among health care providers and pharmacists, limited availability of naloxone in pharmacies, and the cost of naloxone.4,7
Similar to other states, drug overdoses in Georgia have had a profound impact in communities. The annual drug overdose death rate more than doubled in Georgia from 4.7 deaths per 100 000 population in 2000 to 10.0 deaths per 100 000 in 2009; this death rate continued to increase through 2019 (Figure 1).2,8 In addition, the 2019 drug overdose death rate for Georgia was 13.1 per 100 000; nearly two-thirds of drug deaths were due to opioid overdoses.2,8 In 2014, Georgia practitioners were authorized to issue prescriptions for opioid antagonists, and a naloxone prescription did not have to be issued to a particular person but could be in the name of a first responder agency such as emergency medical services, a law enforcement agency, a concerned family member of a person with a substance use disorder, or an organization serving persons with a substance use disorder.9 This law was subsequently amended to expand naloxone availability through a standing order issued and renewed in 2019 to ensure that “Eligible Persons or Entities” such as family members, friends, and coworkers of persons with an opioid use disorder and first responders could use this order as a prescription to obtain naloxone from a pharmacy in any of the approved forms.10 Despite these laws, expanding accessibility to naloxone via pharmacies in underserved (low resourced) communities has been unclear, although counties with high-risk opioid prescribing are those with a high proportion of uninsured and unemployed populations.11 Findings from a recent study conducted in Georgia in 2017 cause further concern, because only one-third of community pharmacies had same-day availability of naloxone for purchase and two-thirds did not have naloxone in stock.12. Our objective in this qualitative study is to explore further the current availability of naloxone in selected underserved communities, including those that are predominantly African American.
Methods to Assess Naloxone Availability to Prevent Opioid Overdose
To prevent opioid use disorder overdose in underserved communities, the Public Health and Preventive Medicine Residency Program (PHPMRP) of Morehouse School of Medicine (MSM) leveraged interventions of the Health Promotion and Resource Center at MSM by adapting its comprehensive prevention model that includes community members and sectors (Figure 2). The model seeks to implement multiple community strategies, including increasing naloxone availability in pharmacies and community-based organizations. The innermost circles of the diagram (eg, individual with opioid use disorder, families and friends, emergency medical services, law enforcement) show typical sectors targeted for naloxone education, prescriptions, and dispensing. The behavioral health department in the diagram represents a public health agency with behavioral services and the outer circle designated as local public health represents the other services available in a public health agency and should be included in opioid overdose prevention.
To examine naloxone availability in underserved communities, an assessment of pharmacies was conducted as part of the Social-Cultural-Behavioral Determinants of Health Longitudinal Rotation of the MSM PHPMRP.13 This service-learning rotation was created to provide PHPM residents with the knowledge and skills to collaborate with partnering metropolitan Atlanta faith-based organizations (FBOs) by assessing the needs and assets of the community and to use these findings for implementing and evaluating health promotion interventions in the particular community. Community assessment methods include windshield surveys, key informant interviews, and focus groups. Faith-based organizations are in communities designated as health professions shortage areas for primary care or mental health.
During the 2019-2020 academic year, pharmacists or pharmacy staff were interviewed as key informants (see Appendix). All pharmacies in the same zip codes as the 2 partnering FBOs were identified using Google Maps and entering the zip code and the key word “pharmacy.” Only pharmacies located in the same zip code as the FBO were selected for the key informant interviews. Interviews were conducted by telephone from May to June 2020 and lasted no more than 10 to 15 minutes per participant. Key informants were asked about naloxone availability in the pharmacy, specific naloxone requests by individuals, naloxone-dispensing practices to individuals at risk for overdose, knowledge and skills in offering naloxone to individuals at risk, and if time permitted, strategies to enhance community awareness of naloxone (see Appendix).
Answers to interview questions were documented by note taking. All interview data were compiled and organized into one master document and manually categorized into themes. Confidentiality of key informants was maintained by storing identifying information on a password-protected computer and removing identifying information from the final compiled document. As part of an educational rotation, the study underwent an administrative review by the Institutional Review Board of MSM, which determined that the study was not research in this context.
Two communities were examined: one in DeKalb County with 103 drug overdose deaths in 2019 (50% among African Americans and 59 opioid-only overdoses) and one in Fulton County with 142 drug overdose deaths (62% among African Americans and 74 opioid-only overdoses).8 Nine pharmacies were found in the selected zip codes: 4 pharmacies in the Dekalb community and 5 in the Fulton community. In the DeKalb community in 2017, of the 45 893 residents, 91% were African Americans, the median age was 37.6 years, and 91% of adults 25 years of age or older had at least a high school education (28% had a college degree or more).15 The median household income was $50 120 (which is lower than $56 183 for Georgia), 10% of residents were unemployed, 16% had incomes below the federal poverty level, and 20% were uninsured.15 In the Fulton community, of 30 995 residents, 72% were African Americans, the median age was 35.4 years, and 79% of adults 25 years of age or older attained at least a high school education (19% attained college or more).15 The median household income was $29 652 (much lower than the state), 11% of residents were unemployed, 29% lived below the poverty level, and 17% were uninsured (2018).15,16
Among the 9 pharmacists interviewed, 3 themes emerged: low community awareness, availability, and accessibility of naloxone (Table). Several types of pharmacies were included in the study: retail chain pharmacies; retail, grocery store pharmacies; closed pharmacies; independent (compounding) pharmacies; or clinic-based pharmacies. Pharmacists indicated that individuals do not typically seek out naloxone, and they attributed the low naloxone–seeking behavior to the lack of awareness in the community. There were also inconsistent and limited community availability and accessibility of naloxone, as those pharmacies that had it in stock carried only 1 to 2 “Narcans” at a given time, even though it could certainly be ordered. Certain pharmacies in a grocery store or clinic did not report naloxone in stock. Pharmacies that had naloxone primarily stocked the nasal spray formulation and not Evzio, the autoinjector. In addition, 3 of the 4 grocery store pharmacies required a prescription before dispensing naloxone. Certain retail pharmacists also indicated that the cost of naloxone is expensive and not affordable for customers.
Responses of Community Pharmacists
About Community Awareness of Naloxone and Naloxone Availability and Accessibility in Pharmacies Located in 2 Urban, Underserved Communities in Georgia, March to April 2020
||Availability of Naloxonea
|Pharmacy 1 (retail- chain)
||Individuals do not come to or call the pharmacy to specifically ask for naloxone.
||Narcan is available ... exactly 1 Narcan behind the counter. Evzio is not available. It is a requirement that all pharmacies carry at least 1 Narcan.
||Narcan is expensive and people in the community cannot afford it.
|Pharmacy 2 (closed door pharmacy)
||The lack of people asking for Naloxone and the fact that this is a closed-door pharmacy impact the naloxone availability at this pharmacy. This pharmacy does not fill opioid prescriptions.
||An autoinjector(Evzio) is used in emergency situations. Pharmacy does not have or sell Narcan.
||This is a closed-door pharmacy, not accessible to the general public.
|Pharmacy 3 (retail pharmacy in a grocery store)
||Rarely do individuals show up and ask for Narcan. There has been zero in the last 3 mo at least. Individuals are not aware that this drug is available.
||Naloxone is available but only in the Narcan formulation. Pharmacy has 1-2 Narcans at any given time.
||The Narcan is located behind the counter but is available without a prescription for customers. Narcan is not affordable for customers.
|Pharmacy 4 (retail pharmacy in a grocery store)
||Individuals do not typically come and ask for Narcan. Pharmacy does not have any record of how many individuals have requested Narcan in the last 3 mo.
||Naloxone is not available in either formulation, and pharmacy has 1-2 Narcans at a given time. Pharmacy had placed an order for Narcan.
||The Narcan is available only by prescription and is not OTC.
|Pharmacy 5 (clinic pharmacy)
||Does not fill any class II drugs and that none of my patients to this point has requested naltrexone and/or naloxone in any of its formulations (nasal spray and/or autoinjector).
||Narcan is not readily available. However, it can be ordered.
||Patients do not require a prescription to have this medication ordered and/or filled.
|Pharmacy 6 (retail pharmacy in a grocery store)
||Does not believe that population is aware of Naloxone and/or naltrexone as it pertains to the ability to prevent opioid overdose.
||Neither naloxone (Narcan, Evzio) nor naltrexone is currently available in the pharmacy. However, this medication can be ordered with receiving a prescription from a licensed medical provider (primary care physician, pain management physician, etc).
||The Federal law prevents me from making this medication available to patients without receiving a prescription from a licensed health care provider. (False)
|Pharmacy 7 (compounding pharmacy/independent)
||Filling and/or providing this medication for a patient approximately once every 6 mo.
||This medication is located behind the pharmacy counter.
||Yes, there is a standing order for Narcan that I follow.
|Pharmacy 8 (retail-chain)
||Does not believe that many patients are aware of the availability of Narcan located in pharmacy.
||Yes, the medication is available. The pharmacy carries the Narcan spray. This medication is stored behind the pharmacy counter.
||Patients are not required to present a prescription to receive the medication. However, patients and I must sign a document before receiving this medication.
|Pharmacy 9 (retail pharmacy in a grocery store)
||Very few of the patients served are aware of naloxone and/or naltrexone and its use in terms of preventing opioid overdose.
||No, [Naloxone] is not available at this pharmacy without a prescription.
||Narcan, Evzio, and/or naltrexone are not available without a prescription based on the pharmacy protocol.
Abbreviation: OTC, over the counter.
aNaloxone availability is the presence of naloxone in the pharmacy on the day of the interview.
bNaloxone accessibility indicates whether pharmacist follows the Georgia state law of a standing order and there is not any barriers to public such as cost is affordable and pharmacy is open to public.
Discussion and Conclusions
Findings from this qualitative study of limited community awareness, availability, and accessibility of naloxone also have been found in a large quantitative study of naloxone dispensing in retail pharmacies from 2012 to 2018.17 The quantitative study found that although naloxone prescriptions increased during this time frame, only 1 naloxone was prescribed for every 69 high-dose opioid prescriptions.17 Although progress has been made in naloxone dispensing in retail pharmacies since that study, more efforts are needed in the face of a modest decline of opioid dispensing.17 A more recent 2017 quantitative study in Georgia demonstrates the need for community pharmacies to make available same-day purchase of naloxone by having it regularly in stock.12 All pharmacies examined the present study in 2 medically or mental health underserved urban zip codes in Georgia support the need for naloxone to be kept in stock and available for same-day purchase. According to the standing order in Georgia, either the nasal spray or autoinjector formulations of naloxone can be kept in stock, although a recent clinical trial in Australia found intranasal administration effective in reversing opioid overdose; however, that route was not as effective as an intramuscular injection of a comparable concentration.20 Pharmacists should stay up-to-date on which formulations should be stocked. This study also supports recommendations of the 2017 Georgia study to educate pharmacists about the Georgia standing order and law, particularly pharmacies in grocery stores.12 Next appropriate steps for future community assessments by our PHPM residents could be to examine further the knowledge, beliefs, and behaviors of pharmacists to prompt conversations with customers at risk for opioid overdose. This information can then be used to tailor education and training of pharmacists, particularly the grocery store pharmacists, and to improve availability and same-day purchase of naloxone in these underserved predominantly African American communities. Additional mixed-methods studies could obtain more information on the impacts that social determinants of health have on naloxone-dispensing habits of pharmacies in these areas, on access to naloxone due to costs among at-risk individuals to opioid overdose, and on practices of primary health care providers and social services. The assessment could also be expanded to examine community readiness to implement more widespread education about naloxone and its availability such as in the NaloxBox initiative by the Rhode Island Department of Health21 because of coexistence of illicit opioid use in communities. Educating all community members such as FBOs (particularly if they host substance use disorder support services), social services staff, and insurance companies (that could eliminate copays for naloxone) is also likely needed to combat premature mortality from opioid overdose in underserved African American communities.
Implications for Policy & Practice
- Assessment findings of limited community awareness, availability, and accessibility of naloxone in 2 predominantly African American communities in metropolitan Atlanta supported the call by the US Surgeon General in 2018 to improve awareness and availability of naloxone, and the HHS published guidance to expand naloxone prescribing to reach populations at high risk for opioid overdose.4,5,12
- Pharmacists play a key role in ensuring that naloxone is always available for dispensing in pharmacies.4,5,12
- Enhanced dispensing of naloxone could be improved by educating and training pharmacists on their role in preventing opioid overdose, patient identification of risk factors for opioid overdose, state regulations of naloxone dispensing, and the initiation of conversations about naloxone with patients.18
- Administrative, managerial, and institutional support of standing orders, as well as the availability of naloxone screening protocols and tools, is also needed to enable naloxone dispensing by pharmacists.19
1. National Center for Health Statistics. Health, United States, 2017: With Special Feature on Mortality. Hyattsville, MD: National Center for Health Statistics. https://www.cdc.gov/nchs/data/hus/hus17.pdf
. Published 2018. Accessed September 15, 2020.
2. Centers for Disease Control and Prevention. CDC WONDER: about the underlying cause of death, 1999-2018. https://wonder.cdc.gov/ucd-icd10.html
. Published 2020. Accessed September 15, 2020.
3. O'Donnell J, Gladden RM, Mattson CL, Hunter CT, Davis NL. Vital signs: characteristics of drug overdose deaths involving opioids and stimulants—24 States and the District of Columbia, January-June 2019. MMWR Morb Mortal Wkly Rep. 2020;69:1189–1197.
4. US Department of Health & Human Services. Office of the Surgeon General. US Surgeon General's Advisory on naloxone and opioid overdose. https://www.hhs.gov/surgeongeneral/priorities/opioids-and-addiction/naloxone-advisory/index.html
. Published April 2018. Accessed September 15, 2020.
5. US Department of Health & Human Services. Strategy to combat opioid abuse, misuse, and overdose. A framework based on the five part strategy. https://www.hhs.gov/opioids/sites/default/files/2018-09/opioid-fivepoint-strategy-20180917-508compliant.pdf
. Published 2017. Accessed September 15, 2020.
6. PDAPS. Naloxone overdose prevention laws. Temple University Center for Public Health Research. http://pdaps.org/datasets/laws-regulating-administration-of-naloxone-1501695139
. Published July 2017. Accessed September 15, 2020.
7. Centers for Disease Control and Prevention. Vital signs: life-saving naloxone from pharmacies. https://www.cdc.gov/vitalsigns/naloxone/index.html
. Published 2019. Accessed September 15, 2020.
8. Georgia Department of Public Health. OASIS: online analytical statistical information system. https://oasis.state.ga.us/
. Published 2020. Accessed September 15, 2020.
9. Georgia Drugs and Narcotics Agency. Naloxone (opioid antagonist) law now in effect. https://gdna.georgia.gov/press-releases/2014-06-23/naloxone-opioid-antagonist-law-now-effect
. Published June 23, 2014. Accessed September 15, 2020.
10. Georgia Board of Pharmacy. Notice regarding standing order for prescription of naloxone for overdose prevention. https://gbp.georgia.gov/press-releases/2017-06-28/notice-regarding-standing-order-prescription-naloxone-overdose-prevention
. Published 2017. Accessed September 15, 2020.
11. Centers for Disease Control and Prevention. Opioid prescribing, where you live matters. https://www.cdc.gov/vitalsigns/pdf/2017-07-vitalsigns.pdf
. Published 2017. Accessed September 15, 2020.
12. Stone RH, Hur S, Young HN. Assessment of naloxone availability in Georgia community pharmacies. J Am Pharm Assoc (2003). 2020;60(2):357–361.
13. Taylor BD, Buckner AV, Walker CD, Blumenthal DS. Faith-based partnerships in graduate medical education: the experience of the Morehouse School of Medicine Public Health/Preventive Medicine Residency Program. Am J Prev Med. 2011;41(4 suppl 3):S283–S289.
14. Carroll AM, Perez M, Toy P, Performing a community assessment—appendix A, Los Angeles: UCLA Center for Health Policy Research, Health DATA Program. http://healthpolicy.ucla.edu/programs/health-data/trainings/Documents/tw_cba4.pdf
. Published 2004. Accessed December 29, 2020.
15. Advameg. City-Data.com. http://www.city-data.com/zips
. Published 2020. Accessed September 15, 2020.
16. US Census Bureau. Selected characteristics of health insurance coverage in the United States. https://data.census.gov/cedsci/table?q=30310&tid=ACSST5Y2018.S2701&hidePreview=true
. Published 2020. Accessed September 15, 2020.
17. Guy GP Jr, Haegerich TM, Evans ME, Losby JL, Young R, Jones CM. Vital signs: pharmacy-based naloxone dispensing—United States, 2012-2018. MMWR Morb Mortal Wkly Rep. 2019;68(31):679–686.
18. Thakur T, Frey M, Chewing B. Pharmacist roles, training, and perceived barriers in naloxone dispensing: a systematic review. J Am Pharm Assoc 2020;60:178–194.
19. Taylor SR, Chaplin MD, Hoots K, Roberts C, Smith K. Effectiveness of implementing a naloxone screening tool in a community pharmacy. Addict Disord Their Treatment 2020;19:142–145.
20. Dietze P, Jauncey M, Salmon A, et al. Effect of intranasal vs intramuscular naloxone on opioid overdose: a randomized clinical trial. JAMA Network Open. 2019;2(11):e1914977.
21. Capraro GA, Rebola CB. The NaloxBox Program in Rhode Island: a model for community-access naloxone. Am J Public Health. 2018;108(12):1649–1651.
Key Informant (Pharmacist) Interview Guide
|Using the curriculum from the Health DATA Project Train the Trainer Project by the UCLA Center for Health Policy Research as a guide,14 3 public health and preventive medicine residents identified all pharmacies in same zip codes as the FBOs for community assessment. These residents developed a key informant tool, conducted the interviews, and compiled the data. Upon initial contact with the pharmacies by telephone, the residents first asked to speak to the pharmacist on-site. If this person was unavailable, they proceeded with interviewing the staff. The residents then introduced themselves, shared their affiliation with the MSM and the FBO, and explained the purpose of the assessment.
|Upon consent by the pharmacist or the pharmacy staff to participate in the interview, specific questions were asked as follows:
Is Naloxone available at this pharmacy? If so, what formulation? Narcan (nasal spray)? Evzio (autoinjector)? Both?
If available, where is it located in the pharmacy?
(If not available) Can you share the reason that it is not available?
Do individuals come to or call the pharmacy to specifically ask for either of the naloxone formulations?
If so, roughly how many individuals have made this request in the past 3 months? (Based on the participant's ability to recall these numbers, ask the number of individuals who have made this request in the past 1 month or 2 weeks as is applicable.)
Aside from filling naloxone prescriptions from other providers, do you offer naloxone to individuals who are at risk of overdose?
If so, roughly how many individuals were offered naloxone in the past 3 months? (Based on the participant's ability to recall this information, ask the number of individuals who were offered naloxone in the past 1 month or 2 weeks as is applicable.)
(If not) Can you share the reason that you do not offer naloxone?
Do you feel that you have sufficient knowledge and skills to comfortably offer naloxone to those at risk? To educate individuals on how to recognize opioid overdose.
(If not) What would be helpful to you to comfortably offer naloxone to those at risk?
|If time permits, ask:
4. What steps do you feel could be taken to make the availability of naloxone well known in the community?
Abbreviations: FBOs, faith-based organization; MSM, Morehouse School of Medicine.