Stocking and supplying naloxone: Findings from a representative sample of community pharmacies in Victoria, Australia
Abstract
Introduction
Naloxone is an opioid receptor antagonist, which can rapidly reverse the effects of an opioid overdose. Community pharmacists may experience several barriers to stocking and supplying naloxone including a lack of confidence or knowledge and time constraints. The current study aimed to examine the extent to which Victorian community pharmacies stock and supply naloxone and determine specific characteristics associated with stocking naloxone.
Methods
A representative sample of community pharmacists (n = 558) in Victoria, Australia, were contacted between October and November 2020 and invited to participate in an online survey. Data related to pharmacy- and pharmacist-related characteristics, including stocking and frequency of supplying naloxone in the past year. Multivariate logistic regression analysis was performed to examine the effect of various covariates on stocking naloxone.
Results
The sample comprised 265 pharmacists (response rate 47%). Most pharmacies were located in Melbourne (the capital city of Victoria, 59.6%) and were part of a pharmacy chain (61.5%). In total, 100 (38%) pharmacies stocked naloxone, a third of whom did not supply it in the past year. Pharmacies that provided opioid agonist treatment had 2.4 times higher odds of stocking naloxone (95% confidence interval 1.425–4.136; p = 0.001).
Discussion and Conclusion
Less than half of Victorian community pharmacies stock naloxone, with even fewer actually supplying it in the past year. Future efforts are needed to increase the number of pharmacies that stock naloxone and the frequency in which it is supplied, while also addressing possible barriers to stocking and supplying naloxone among community pharmacists.
1 INTRODUCTION
Opioid-related harm is a significant public health concern in Australia and is often a result of increased opioid prescribing in recent decades [1]. In 2017, 3.1 million Australians were prescribed at least one opioid, of whom 715,000 used these opioids for non-medical purposes [2]. In this same year, opioids resulted in 1123 deaths throughout Australia, of which 58% were attributed to prescription opioids [3]. Prescription opioid-related overdoses requiring hospital admissions were more than double that for illicit opioids [2, 4]. This is vastly different to places like the United States and Canada, where opioid-related harms are largely driven by illicit fentanyl [5]. Irrespective of whether opioid-related harms are related to prescription or illicit opioids, there is a need for a multifaceted approach to mitigate these harms, including a range of demand, supply and harm reduction approaches.
There are various widely adopted, evidence-based harm reduction strategies to mitigate opioid-related harms, including opioid agonist treatment (OAT), used to treat opioid dependence and reduce harms associated with non-medical opioid use [6], supervised consumption clinics [7], drug checking facilities [8] and naloxone [9]. Naloxone is an opioid receptor antagonist, that rapidly reverses the effects of an opioid overdose when administered in a timely manner and is administered either as a nasal spray or injectable formulation [10]. Naloxone has been shown to successfully reduce opioid-related deaths, particularly in the United States, the United Kingdom and Canada [11-14].
In Australia, naloxone was originally only available via prescription, however, in 2016, naloxone was downscheduled to a ‘pharmacist only’ medicine so it could be purchased over-the-counter in pharmacies [15]. In July 2022, the Australian Government initiated the national Take Home Naloxone program, whereby naloxone was made available to patients at no cost, through participating pharmacies and other approved health services. As part of this program, pharmacies are provided a fee for naloxone supply, alongside being reimbursed for the cost of the naloxone provided [16, 17].
Pharmacists are the most easily accessible healthcare providers in Australia and are at the clinical interface between medicines and patients and, therefore, are ideally positioned to mitigate risk and reduce prescription opioid-related harms. They provide more free advice to patients than any other healthcare provider, without the need for an appointment [18]; however, a range of barriers have been cited which can impact pharmacists' decisions to stock and supply naloxone. These commonly include a lack of confidence and comfort to supply naloxone and counsel patients, a lack of knowledge of when to offer naloxone and pharmacists' negative perceptions, attitudes and stigma towards people who misuse opioids [19-21]. A range of system-level barriers, such as cost, lack of time, lack of remuneration and limited or no private space to engage in conversations within the pharmacy have also been identified. Furthermore, other factors such as the geographic location [20, 22] and whether the pharmacy is an independent enterprise or part of a chain [22, 23] have been reported to influence naloxone supply.
A 2015 national study exploring pharmacists' willingness to supply naloxone reported that the majority (at least 68%) of Australian pharmacists were willing to supply naloxone to individuals with varying circumstances (e.g., prescribed opioids, overdose history, substance use history, etc.); however, few pharmacies stocked naloxone and most pharmacists (68%) lacked confidence in counselling patients on its use [1]. Since then, little is known about whether there has been an increase in the number of pharmacies stocking and supplying naloxone. To address this gap, this study sought to (i) examine the extent to which Victorian community pharmacies stock naloxone and of those that do stock naloxone, how frequently naloxone has been supplied in the past year; and (ii) determine the pharmacy and pharmacist-related characteristics associated with stocking naloxone.
2 METHODS
2.1 Design and setting
Data were collected as part of a larger study examining the implementation of Victoria's Prescription Drug Monitoring Program [24, 25]. A representative sample of Victorian community pharmacists was invited to anonymously participate in an online cross-sectional survey. Ethics approval for this study was granted by the Monash University Human Research Ethics Committee (No: 20541).
2.2 Sampling of pharmacies
Maven Marketing and CoreList were used to identify Victorian pharmacies, with each list consisting of 1850 and 1819 pharmacies, respectively [26, 27]. After merging both lists, duplicates, non-community-based pharmacies, supply services and consultant services were removed which left 1240 community-based pharmacies. This list was then further merged with additional Victorian community pharmacies identified from Google Maps, resulting in a final list of 1400 pharmacies, of which half (n = 700) were approached. To ensure a representative sample of Victorian pharmacies were included, we randomly selected pharmacies using a random number generator and then cross-checked our recruited sample to confirm that it was representative across geographical remoteness categories using the Modified Monash Model, which defines whether a location is metropolitan, regional, rural and remote, using seven categories of remoteness and population size [28]. The final sample represented 19% of the 1400 identified pharmacies in Victoria, with the proportion of pharmacies in metropolitan/urban and rural/remote reflecting that of pharmacies in Victoria [29]. The ‘pharmacist in charge’ at each pharmacy was invited to participate to ensure that each pharmacy was only represented once. They were also considered to be best placed to represent the pharmacy and have the ability and knowledge to answer questions about naloxone and other services provided [30].
2.3 Participants and procedures
A structured telephone script was used to help ensure the key information about the study was provided in a consistent format to pharmacists, upon inviting them to participate in the study. The script briefly outlined the purpose of the call, the study aims and participation requirements, and where the pharmacist in charge was agreeable to participate, they were asked to provide an email address to which the survey link could be sent to. Between October and November 2020, 700 pharmacies were approached, including 15 that were found not to be community pharmacies, 4 duplicates, 1 located outside of Victoria and 77 that were deemed uncontactable. In addition, 34 pharmacists declined to participate due to insufficient time and a further 11 pharmacists declined due to a lack of interest and these pharmacies were not contacted again. After the exclusion of ineligible pharmacies, 558 agreed to be emailed the self-administered Qualtrics survey. Follow-up reminder emails were sent after 1 and 2 weeks.
2.4 Measures
- Individual pharmacists' demographic information, including gender and years of experience as a registered pharmacist.
- Pharmacy characteristics including location (i.e., capital city, urban centre, regional or remote) and pharmacy type (independent or chain pharmacy).
- Pharmacy services such as the frequency of dispensing any medications, frequency of dispensing opioid medications and whether the pharmacy provides OAT. OAT includes evidence-based treatments for opioid dependence, designed to prevent withdrawal, support retention in treatment and engagement with psychological therapies, which in Australia includes two medications, methadone and buprenorphine.
- Naloxone-specific characteristics, including whether the pharmacy stocks naloxone (i.e., is naloxone available within the pharmacy) and how frequently naloxone has been supplied (i.e., provided to a patient within the pharmacy) in the past year.
- Comfort to perform specific tasks, including intervening when concerned about an opioid prescription and comfort discussing overdose prevention and naloxone. These were captured on a 4-point Likert scale, ranging from very uncomfortable to very comfortable.
2.5 Statistical analysis
Descriptive statistics were used to characterise the sample, while chi-squared tests were used to examine the differences in pharmacy characteristics (pharmacy location and type) between those who supplied naloxone in the past year and those who did not. Multivariate logistic regression analysis was performed to examine the effect of various pharmacist (gender and years of pharmacy practice) and pharmacy-related (pharmacy location, pharmacy type, number of prescriptions dispensed per day, number of opioid prescriptions dispensed per day, whether the pharmacy provides OAT) covariates on the outcome of interest, stocking naloxone. All analyses used a p < 0.05 to denote statistical significance and were performed in SPSS V29.
3 RESULTS
The sample (n = 265, response rate = 47%) comprised equal representation by gender (50.6% female), with 38% reported to have 15 or more years of pharmacy practice experience (Table 1). Most pharmacies were located in Melbourne (the capital city of Victoria, 59.6%) and most were part of a pharmacy chain (61.5%). Just under half (44%) provided OAT.
| Sample and pharmacy characteristics | Overall (n, %) (n = 265) | Stock naloxone (n, %) (n = 100) | Do not stock naloxone (n, %) (n = 165) |
|---|---|---|---|
| Pharmacist-in-charge characteristics | |||
| Gender | |||
| Female | 134 (50.6%) | 53 (53%) | 81 (43%) |
| Male | 131 (49.4%) | 47 (47%) | 84 (57%) |
| Years of experience | |||
| 5 years or less | 59 (22.3%) | 22 (22%) | 37 (22.4%) |
| 6–15 years | 105 (39.6%) | 37 (37%) | 68 (41.2) |
| >15 years | 101 (38.1%) | 41 (41%) | 60 (36.4%) |
| Pharmacy characteristics | |||
| Pharmacy location | |||
| Capital city/urban | 189 (71.3%) | 69 (69%) | 120 (72.7%) |
| Rural/remote | 76 (28.7%) | 31 (31%) | 45 (27.3%) |
| Pharmacy type | |||
| Independent | 102 (38.5%) | 43 (43%) | 59 (35.8%) |
| Banner group/other | 163 (61.5%) | 57 (57%) | 106 (64.2%) |
| Number of prescriptions per day | |||
| 200 or less | 155 (58.5%) | 54 (54%) | 101 (61.2%) |
| >200 | 110 (41.5%) | 46 (46%) | 64 (38.8%) |
| Number of opioid prescriptions per day | |||
| 10 or less | 95 (35.8%) | 32 (32%) | 63 (38.2%) |
| 11–20 | 84 (31.7%) | 34 (34%) | 50 (30.3%) |
| >20 | 86 (32.5%) | 34 (34%) | 52 (31.5%) |
| Provide OAT | |||
| Yes | 117 (44.2%) | 59 (59%) | 58 (35.2%) |
| No | 148 (55.8%) | 41 (41%) | 107 (64.8%) |
| Comfort discussing overdose prevention and naloxone | |||
| Very uncomfortable/uncomfortable | 97 (36.6%) | 34 (34%) | 63 (38.2%) |
| Comfortable/very comfortable | 168 (63.4%) | 66 (66%) | 102 (61.8%) |
| Comfort intervening when concerned about an opioid prescription | |||
| Very uncomfortable/uncomfortable | 85 (32.1%) | 29 (26%) | 56 (34%) |
| Comfortable/very comfortable | 180 (67.9%) | 71 (71%) | 109 (66%) |
- Abbreviation: OAT, opioid agonist treatment.
3.1 Stocking and supplying naloxone
One hundred pharmacists (38%) indicated they stocked naloxone. Among these pharmacists, 34% indicated that although they stocked naloxone within their pharmacy, they had not supplied it in the past year, 43% supplied it up to four times in the past year, and the remaining 23% supplied naloxone five or more times in the past year. There was no significant difference in stocking naloxone by pharmacy location, that is, capital city/urban versus rural/regional (χ2 = 0.423; p = 0.515) or pharmacy type, that is, chain versus independent (χ2 = 1.379; p = 0.240). Similarly, there was no significant difference in supplying naloxone by pharmacy location (χ2 = 0.061; p = 0.805) or pharmacy type (χ2 = 1.030; p = 0.310).
3.2 Correlates of stocking naloxone
Table 2 reports the multivariate logistic regression results examining correlates of stocking naloxone. Pharmacies that provide OAT had 2.4 times higher odds of also stocking naloxone (95% confidence interval 1.425–4.136; p = 0.001). Other variables, including the pharmacists' gender or years of practice, the pharmacy location or type, and the number of overall scripts or opioid scripts dispensed per day, were not significantly associated with stocking naloxone.
| Odds ratio | 95% Lower CI | 95% Upper CI | p-value | |
|---|---|---|---|---|
| Pharmacist-in-charge characteristics | ||||
| Gender | ||||
| Male | Ref | |||
| Female | 1.224 | 0.717 | 2.089 | 0.458 |
| Years of practice | ||||
| ≤15 years | Ref | |||
| >15 years | 1.180 | 0.802 | 2.045 | 0.557 |
| Pharmacy characteristics | ||||
| Pharmacy location | ||||
| Capital city/urban | Ref | |||
| Rural/remote | 0.905 | 0.501 | 1.635 | 0.741 |
| Pharmacy type | ||||
| Independent | Ref | |||
| Banner group/other | 0.741 | 0.415 | 1.32 | 0.310 |
| Number of prescriptions per day | ||||
| 200 or less | Ref | |||
| >200 | 1.581 | 0.802 | 3.120 | 0.186 |
| Number of opioid prescriptions per day | ||||
| 10 or less | Ref | |||
| 11–20 | 1.153 | 0.590 | 2.257 | 0.678 |
| >20 | 0.905 | 0.400 | 2.045 | 0.810 |
| Provide OAT | ||||
| No | Ref | |||
| Yes | 2.615 | 1.533 | 4.462 | 0.001* |
- Abbreviations: CI, confidence interval; OAT, opioid agonist treatment; Ref, reference group.
- * Bold denotes significance.
4 DISCUSSION
The current study found that less than half of Victorian pharmacies stock naloxone, an opioid overdose reversal drug. This is despite an earlier study among a nationally representative sample of Australian pharmacists revealing that most were willing to supply naloxone, yet 60% were not comfortable with supplying it over the counter [1]. The current study found that while only 38% of pharmacists reported stocking naloxone, a third had not supplied it in the past year, and this is similar to findings of a recent review on pharmacy-based naloxone programs and interventions [22]. These findings suggest that whilst pharmacists may be willing to stock naloxone, they may not have the confidence to proactively identify at-risk patients who would benefit from naloxone, and initiate counselling on its use. Other research exploring Australian pharmacists' experiences and attitudes towards supplying over-the-counter naloxone reported additional training and education-related barriers, including limited knowledge and lack of experience [21]. This lack of confidence and comfort to stock naloxone are barriers to provision. Current findings corroborate those from an existing systematic review which reports a lack of confidence in dispensing naloxone as a major barrier to supply, highlighting the need for additional training and education for pharmacists to increase confidence in naloxone supply [19].
Negative beliefs and misconceptions about naloxone are also likely to be contributing factors to whether naloxone is stocked in pharmacies. For example, findings may reflect pharmacists' concerns about increased opioid use, attracting undesirable clientele or putting the pharmacist in an unsafe situation [19]. Furthermore, misconceptions that naloxone encourages people to take opioids at riskier levels than when they do not have naloxone [20], a concept known as a ‘moral hazard’ may also explain the current finding, although a recent systematic review, found no evidence of this [32]. Furthermore, modelling by Nielsen et al. found increasing naloxone availability to 90% of patients taking >50 mg of opioids per day had the potential to save 657 lives between 2020 and 2030 [33]. The same modelling study also suggested that this universal supply strategy could result in an estimated cost saving of $43,600 per life saved, demonstrating the importance of universal access to this life-saving, harm-reduction approach, which can be facilitated within community pharmacy settings.
Pharmacies that provided OAT had two and a half times higher odds of also stocking naloxone. This significant correlation between this treatment and harm reduction approach, was not surprising, with many pharmacies providing naloxone directly to people receiving methadone or buprenorphine as standard care, to prevent overdose [34]. The Victorian OAT policy also recommends providing naloxone to patients receiving OAT and may also explain this correlation between OAT and naloxone [35]. Finally, it may also reflect the higher percentage of pharmacies that stock naloxone and provide OAT (59%), which may be indicative of increased willingness and confidence to provide various opioid harm reduction services, including naloxone. For example, an earlier Australian study found more positive attitudes towards supplying naloxone were reported among pharmacists working in pharmacies that provided OAT [1].
Interestingly, other pharmacist and pharmacy characteristics were not significantly associated with stocking naloxone. For example, the number of opioid prescriptions dispensed per day was not a predictive indicator of stocking naloxone. This lack of correlation may partly be explained by the preconception that naloxone is predominantly for illicit opioid use, as opposed to prescription opioids [36]. For example, earlier take-home naloxone programs in Australia focused predominantly on people who inject drugs, with less emphasis on people prescribed opioids [37]. Alternatively, it could be that pharmacists do not perceive people prescribed opioids to be at risk of an overdose. This may further explain low levels of supply and is of concern, as 67% of opioid-related overdose deaths in 2021 were attributed to prescription opioids in Australia [38]. This systemic preconception of naloxone being a harm reduction approach predominantly targeted towards illicit opioid use may result in a large proportion of at-risk people failing to receive naloxone, highlighting the need to educate pharmacists on the range of patients who may benefit from naloxone. Specifically, future initiatives, targeting pharmacies that supply higher volumes of opioids, to simultaneously supply naloxone, for those on higher doses, is warranted.
4.1 Strengths and limitations
Strengths of the current study include a high response rate of 47%, among a sample of community pharmacies in Victoria, the second most populous state in Australia. The following limitations, however, should be considered. Personal demographic information such as ethnicity and race were not captured. Data relating to the supply of naloxone may be subjected to recall bias and rely on self-reported data. Survey data were also collected in 2020, before the implementation of the free take-home naloxone program in 2022. Therefore, little is known as to whether the stocking of naloxone increased after this initiative. Future studies should evaluate the impact of this initiative and determine whether rates of stocking and supplying naloxone have changed. Given that some pharmacies stocked naloxone, however, did not supply this in the past year, future research would also benefit from exploring barriers to actual provision.
4.2 Conclusion
The current study revealed that less than half of Victorian community pharmacies stock naloxone, with the supply among these pharmacies also being limited. Future efforts are needed to increase the number of pharmacies that stock and supply naloxone, whilst also addressing barriers such as a lack of confidence to supply naloxone. Pharmacists are an underutilised yet easily accessible health resource; providing targeted training to support pharmacists whilst increasing their confidence is needed.
AUTHOR CONTRIBUTIONS
Each author certifies that their contribution to this work meets the standards of the International Committee of Medical Journal Editors.
ACKNOWLEDGEMENTS
This work was supported by the National Health and Medical Research Council (2016909). Nandini Karthikeyan was supported by a Monash University Eastern Health Clinical School Winter Scholarship. These funding sources were not involved in this research study. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians.
CONFLICT OF INTEREST STATEMENT
Suzanne Nielsen has received untied educational grants to study pharmaceutical opioid-related harm from Seqirus, and is a named investigator on an implementation trial of buprenorphine depot funded by Indivior (no funding received by Suzanne Nielsen personally or through her institution), both unrelated to this work. Other authors declare no conflict of interest.
