The results of the secret shopper study confirm that structural factors at the provider level are a major barrier to increasing naloxone access and thus reducing mortality from the opioid epidemic in Georgia. The researchers found that, despite the standing order, less than half of independent retail pharmacies in Georgia stock naloxone. Further, the results show that there is a considerable knowledge gap in regards to the naloxone standing order in Georgia with 50.7% of pharmacists incorrectly answering the question regarding obtaining naloxone without a prescription, that 10.5% of pharmacists in independent pharmacies in Georgia do not feel comfortable providing counseling regarding naloxone’s use, and that 45.6% of pharmacists cannot adequately inform a patient where to obtain naloxone should they not have it in stock. This underscores that provider education continues to be a barrier for adequate access to naloxone. Because of naloxone’s ability to save lives, it is imperative that pharmacists are made aware of its benefits and the laws surrounding its dispensing.5
The richness of the data is brought on by the fact that independent pharmacies are not necessarily connected to one another; i.e., it is not likely to have multiple pharmacies respond in an extremely similar way. While a large chain may adhere to a corporate policy regarding the stocking and dispensing of Narcan, there is generally no such widespread policy among independent pharmacies. Thus, calls to independent pharmacies are better described as evaluations of pharmacists’ knowledge than of large corporations’ policies. Data are made still more robust by the variety in geographic location of the pharmacies.
Pharmacists who work in retail or community settings are in an especially useful position in helping patients access naloxone as they are one of the most accessible healthcare professionals and may be able to identify patients using high dose equivalents of opioids who are good candidates for naloxone.28 However, some retail pharmacists display a lack of understanding of the proper counseling points associated with dispensing naloxone to patients.28
Pharmacists dispensing naloxone, with or without a prescription, should not assume that the patients have been given any proper training or counseling about its use.19 Our study shows findings that having a naloxone standing order in place may not be as beneficial as intended given the lack of knowledge by the people who distribute the medication.
Additionally, cost may be a prohibitive factor for uninsured patients. The average cash price at the interviewed Georgia pharmacies currently stocking naloxone was $148.02, which is comparable to the national average of $150.29 As the average median annual household income in Georgia in 2018 is $55,67930, this may be viewed as a nonessential item for uninsured individuals in lower income brackets. This is particularly relevant, given that individuals who die by opioid overdose tend to be uninsured and of a lower socioeconomic status.31 Therefore, future studies should further investigate cost as a structural barrier to naloxone use as well as the impact of state-level policies to reduce its cost for uninsured individuals, as providing naloxone to patients has been shown to be a cost-effective practice.32
Limitations of this study include the lack of information gathered from each pharmacy. Callers did not collect information about the pharmacists themselves in terms of their age, gender, or experience working as a pharmacist in a retail environment. Age or time since graduation may affect the results, as recently graduated pharmacists are more likely to have had naloxone training as a part of their didactic curriculum. Callers also did not ask whether naloxone is generally stocked; it is possible that some stores normally stock it but were sold out on the day the call was placed. However, this is more than likely a minimal number of stores unlikely to affect the overall study results. There are other factors impacting naloxone acquisition and distribution that are not considered in this study. In particular, the social stigma surrounding naloxone usage and opioid use disorder may prevent someone from trying to obtain naloxone for themselves or for emergencies for others.8,9 Additionally, media coverage influences the public opinion of naloxone.33 This may mean that pharmacists’ perceptions of naloxone distribution are skewed, and would therefore directly impact the potential availability of naloxone at independent pharmacies as well as the depth and breadth of counseling provided by those respective pharmacists. Future studies should address these limitations to provide a more complete picture of the barriers to naloxone access. Future studies should also analyze how pharmacist education regarding naloxone use and distribution affects overall use and distribution in the state.