Since the Food and Drug Administration approved over-the-counter (OTC) naloxone in 2023, pharmacies nationwide have stocked their shelves with the opioid overdose antidote. But despite this policy shift, many pharmacists remain hesitant to sell essential harm reduction supplies.
Researchers recently put this to the test. They sent secret shoppers to all 125 community pharmacies in Austin, Texas, to buy OTC naloxone and non-prescription syringes. Their study, published in JAMA Network Open in February, illustrated how access to harm reduction tools in pharmacies remains severely limited.
The alarming findings included that each of the two items was available at just over half of the pharmacies, and only 20 percent of stores provided both.
The main barrier to accessing OTC naloxone was that stores simply did not carry it. Only 55 percent of stores had a location for naloxone on their shelves. And even among those stores, one in three were sold out. Additionally, under 10 percent of pharmacies sold generic naloxone, which tends to be less expensive than brand-name options like Narcan.
Almost all the pharmacists asked the shoppers follow-up questions about why they wanted the syringes, and many refused to sell them without a prescription.
Stigma appears to have been a major barrier for purchases of non-prescription syringes. The secret shoppers successfully bought these items at 58 percent of the stores, but pharmacy technicians played an active role in blocking access. Almost all the pharmacists asked the shoppers follow-up questions about why they wanted the syringes, and many refused to sell them without a prescription, even though Texas state law does not require a prescription to purchase syringes.
“We had heard anecdotal reports that pharmacists … were unwilling to sell syringes to people without either asking a bunch of follow up questions or having a prescription on file,” lead study author Dr. Lindsey Loera, of the University of Texas at Austin College of Pharmacy, told Filter. “The findings of our study confirmed those anecdotal reports.”
While surveys or interviews of pharmacists may capture what they claim they would do, this in-person secret shopper experiment (also called an “audit study”) revealed their actual, everyday behavior.
“If you go do a phone call and say, ‘Hey, do you sell non-prescription syringes to people who walk in?’ it’s easy for a person to say yes or no,” Loera explained. “When you go in person and do a secret shopper audit … you’re getting the true measurement.”
To maintain consistency across visits, the shoppers went through several rounds of training, including a harm reduction workshop facilitated by the Texas Drug User Health Union. They also stuck to a strict script, asking only for a bag of 10 syringes and responding, “I need to protect myself against HIV and HCV [hepatitis C]” to pharmacists’ questions.
“We took a standardized approach to navigating the conversations,” Loera said.
Even with this rigorous protocol, the shoppers’ identities may have afforded them some privileges. All five secret shoppers were young pharmacy students, and four of them were white women. Based on this study, we don’t know if shoppers from more marginalized backgrounds would have experienced even greater difficulties in obtaining harm reduction supplies. But it would not be surprising if such a finding were later demonstrated.
“It would be great if we could replicate this study utilizing people with lived experience as the auditors,” Loera said, referencing a similar study conducted in Arizona in 2022 with a more diverse group of secret shoppers—which found even bleaker results.
“The findings from this were obviously not great, but I want pharmacists to read this and feel motivated to help this patient population.”
The new findings reflect ongoing tensions between drugstores and harm reduction as OTC naloxone has been rolled out nationwide. While the FDA approved the first OTC naloxone product in March 2023, its initial approval applied exclusively to Narcan, an expensive brand-name naloxone product.
In the following months, the FDA continued to approve additional generic and name-brand options. By September 2023, naloxone had hit the shelves of major pharmacy chains across the United States. Some stores, such as Walgreens, even created their own white-label products.
Despite these major steps forward, this study and related research demonstrate the persistent effects of stigma even after legal restrictions have been loosened. As a pharmacist herself, Loera hopes that these results will remind her peers that providing compassionate care to all customers should be central to their work.
“The findings from this were obviously not great, but I want pharmacists to read this and feel motivated to help this patient population,” she said. “My hope would be that people are willing and able to deliver compassionate care.”
Rather than villainizing pharmacists, Loera emphasized the importance of education in bridging gaps in care for people who use drugs. She highlighted the need for pharmacy personnel to seek out training and resources to better serve this population.
“Most of us pursued our education to help other people. And so I think sometimes just remembering the why—like, why did we pursue our degree? Why did we go into clinical practice?” Loera emphasized. “Remembering why we’re doing our work can sometimes help put into perspective why it’s important to not only engage and provide health care, but to do so in an empathetic and loving way.”
Photograph by Harrison Keely via Wikimedia Commons/Creative Commons 4.0
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