Pharmacies can have an important role in the prevention of overdose and other drug-related harms. Yet they’re frequently doing far less than they should in providing essential tools like naloxone and sterile syringes. A new study, published in the Harm Reduction Journal, shines light on this frustrating reality.
“As the need for harm reduction continues to increase, it is important to assess pharmacist participation in and willingness to engage in harm reduction at pharmacies …” the authors wrote. “Few studies examine the broad role of pharmacists in offering harm reduction services in the era of synthetic opioids, the COVID-19 pandemic, and rapidly changing drug policy. Our study aims to examine attitudes, practices, and knowledge of harm reduction services broadly among community pharmacists in Pittsburgh and to identify potential barriers and facilitators of expanded harm reduction services.”
The researchers were led by Caitlin M. O’Brien, a student at the University of Pittsburgh School of Medicine, and included team members from the University of Pennsylvania and from Prevention Point, the long-running harm reduction program based in Philadelphia. They surveyed 88 pharmacists in downtown Pittsburgh.
Over half—54 percent—had previously refused to supply syringes to a customer.
Large majorities of the pharmacists agreed they have a role to play in preventing overdose (90 percent), and that reversing an overdose does not encourage more drug use (85 percent). And 92 percent had distributed naloxone at some point. However, only 30 percent were distributing it more than once a week, and just 29 percent always provided overdose prevention training when dispensing the medication. None of the surveyed pharmacists reported ever having denied a person naloxone.
With syringes, the picture is worse. While 87 percent viewed sterile syringes as useful for preventing disease transmissions, only 73 percent had actually given them out, and over half—54 percent—had previously refused to supply them to a customer.
Though the majority of pharmacists agreed that people who use drugs are being responsible by using sterile syringes, and that these tools should be available without a prescripition, they were much less recepitive to taking a hands-on approach. Only half agreed with the idea of having a syringe disposal box in their store, and just 32 percent wanted to see syringe services happening on site. For those who do give out syringes, most will never speak with the customer about safe injection practices—and just one pharmacist reported always doing so.
Stigma frequently guides decisions, when a majority admit having denied giving syringes to a person who wanted them. And the reasons Pittsburgh pharmacists gave for not selling syringes raise red flags. “All syringe/needle sales must be a prescription,” some store policies read, despite the fact that Pennsylvania law allows any pharmacy to sell syringes over the counter.
“Due to syringes being found in the parking lot and bathrooms we chose not to sell them due to the risk to other patients,” was another response. And perhaps most damning: “I do not believe enabling or assisting their behavior is going to help them.”
That last statement flies in the face of decades of scientific evidence that syringe provision does not increase drug use, nor overdose, nor crime, and is a safe and cost-effective way of improving the health of people who use drugs.
“Pharmacies are at a breaking point because of COVID. I want less responsibility.”
“Our findings highlight that while most community pharmacists have embraced naloxone provision, pharmacy policies and individual pharmacists continue to limit accessibility of [non-prescription syringes],” the study authors concluded.
What the researchers also heard is that pharmacists feel they have very little time on the job to improve their provision of harm reduction supplies and education; 80 percent cited this reason. “I literally don’t have time for more tasks,” one said. “Pharmacies are at a breaking point because of COVID. I want less responsibility.”
Other concerns mentioned included insurance companies making it harder for pharmacies to get refunded, “clientele that might frequent the pharmacy if a program were in place,” improper disposal of supplies, and “community opposition.”
“Future expansion efforts for pharmacy-based harm reduction services should not only address the time and labor constraints identified by community pharmacists, but also fear-based policy and stigma toward people who inject drugs and harm reduction more broadly,” the study authors wrote.
“There’s an opportunity for education here, to help pharmacists feel like they have two or three talking points they can use with customers.”
Dr. Sheila Vakharia, deputy director of research and academic engagement at the Drug Policy Alliance, told Filter that the findings broadly match past research on pharmacies’ willingness to offer harm reduction supplies. But she acknowledged that even for pharmacists with the best intentions, the pressures of the job present severe challenges to expanding their duties.
“I really do have compassion for them,” she said, “because they are dispensing medications all day every day and having a conversation with every single person … [pharmacists] are overburdened and overworked, especially if they work in a retail pharmacy [and] they’re also doing checkout duty.”
“Obviously there’s an opportunity for education here, to help pharmacists feel like they have two or three talking points they can use with customers,” Vakharia added.
Stephanie Klipp, one of the study co-authors, is a wound care and addiction nurse lead for Prevention Point in Philadelphia, who was previously based in Pittsburgh. She told Filter that it’s vital pharmacies improve at providing harm reduction supplies and education, because residents of too many towns and cities in Pennsylvania have no other option.
Some particularly vulnerable populations of drug users, she continued, including unhoused people, will face stigma from the moment they walk in the door of any store, which makes it difficult for them to buy from pharmacies.
“When they touch the medical system or pharmacies, they are discriminated against and stigmatized.”
“I think they are highly mistreated,” she said. “When they touch the medical system or pharmacies, they are discriminated against and stigmatized.”
“Our participants would probably much rather go to a Prevention Point site, much rather talk to someone from a syringe service program, than go to a pharmacy where there is a chance they will be treated poorly,” Klipp added. “It’s a last resort, probably.”
Cost is also a major barrier to obtaining syringes and naloxone at pharmacies.
“The people we serve would not likely have the cash on hand to buy naloxone or syringes out-of-pocket,” Klipp said. “When they can go to [syringe service program] and access those for free, ideally that’s the best thing to do. But there’s only two cities in Pennsylvania that have those. If you’re in Pittsburgh or Philly, you can access that, but if you’re not, what other options do you have left?”
For people in many locations, one important alternative is getting naloxone and syringes through the mail. An organization such as NEXT Distro, partnering with harm reduction providers in different states, can mail you free supplies. It’s a much-needed service, though there are also limitations here.
“NEXT Distro and some harm reduction programs can legally mail both naloxone and syringes,” Vakharia said. “But again for folks who don’t have a stable mailing address or cannot plan out how much they will need in the future, [it’s a barrier]. Mail order can be super-helpful, but it’s probably for someone whose use is much more managed or who has stuff on hand and is planning for the future.”
Photograph (cropped) by Mike Mozart via Flickr/Creative Commons 2.0
The Influence Foundation, which operates Filter, previously received a restricted grant from the Drug Policy Alliance. Dr. Vakharia is a member of the board of directors of The Influence Foundation. Filter‘s Editorial Independence Policy applies.
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