(1327) Naloxone Accessibility by Standing Order in North Carolina Community Pharmacies

Objectives: North Carolina (NC) adopted a standing order in 2016 allowing pharmacists to dispense naloxone to individuals without a patient-specific prescription. Despite this standing order, previous studies have indicated limited implementation, which can limit access to naloxone. This study aimed to examine the implementation of North Carolina’s (NC) statewide standing order directly prior to the transition from intranasal naloxone’s prescription only status to over-the-counter status in March 2023. The study also documented the quoted out-of-pocket cost of intranasal naloxone.

Methods: A telephone audit of NC community pharmacies was conducted from March 7th to April 20, 2023. Six trained secret shoppers enacted a standardized script with 202 pharmacies (99 chain, 95 independent, 8 health department pharmacies). Shoppers used REDCap to document if the pharmacy sold naloxone, if a prescription was needed, same-day availability, cost, and if they spoke with a pharmacist or other pharmacy staff. We examined the relationship between naloxone availability as well as out-of-pocket cost by pharmacy type (independent, chain, health department) and rurality utilizing rural-urban commuting areas (RUCA) (RUCA 1: urban core; RUCA 2-3: suburban; RUCA 4-10: rural). An independent sample t-test was used to examine differences in naloxone cost by pharmacy type. A chi-square test and one-way ANOVA was used to determine whether naloxone availability and cost differed by rurality, respectively.

Results: Of the original 202 retail pharmacies, 5 pharmacies were closed or unreachable after 4 calls; yielding 197 pharmacies in the final analysis. Overall, 104 pharmacies (53%) dispensed naloxone according to the standing order. Independent pharmacies were less likely to dispense naloxone according to the standing order in comparison to chain pharmacies (χ2 = 20.58, df = 4, p-value < 0.001). All health department pharmacies (n=8) distributed naloxone free of charge. The average quoted out-of-pocket cost of naloxone was $96.27. The average cost of naloxone at chain pharmacies (Mean=$84.69; SD=$34.90), was significantly lower than independent pharmacies (Mean=$113.54; SD=$36.54) (t(130)=4.571, p< 0.001). Naloxone availability (χ2 = 1.773, df = 4, p-value=0.78.) and cost (F(2,136=[2.378], p= 0.097) did not differ by rurality (Figure 1).

Conclusions: Approximately half of NC community pharmacies audited dispense naloxone according to the statewide standing order, limiting same-day access to this life-saving medication. Quoted out-of-pocket costs for naloxone nasal spray were higher at independent pharmacies in comparison to chain pharmacies, which could be due to store-level policies. Future studies should further investigate cost differences as intranasal naloxone transitions to an over-the-counter product.