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home : most recent : statewide implications August 14, 2018


5/29/2018 11:36:00 AM
Stigma, awareness still play role in whether pharmacies dispense Narcan
Indiana State Department of Health graphic
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Indiana State Department of Health graphic
This is a dose of naloxone hydrochloride that can be sprayed up the nostril or injected to reverse the effects of an opioid overdose. Staff photo by Tim Bath
+ click to enlarge

This is a dose of naloxone hydrochloride that can be sprayed up the nostril or injected to reverse the effects of an opioid overdose. Staff photo by Tim Bath

Where to get Narcan:
This Indiana State Department of Health resource shows you which entities in your community have been registered to distribute Narcan: https://optin.in.gov/

George Myers, Kokomo Tribune

Narcan, a lifesaving overdose-reversal medication, has become a primary weapon for first responders, families and addicts on the front lines of Indiana’s battle against opioid addiction.

But Indiana University researchers say only one in four Hoosier pharmacists have dispensed Narcan, or naloxone, even though 58 percent of pharmacies stocked the medication and half of all pharmacists have said they are comfortable dispensing it.

So why have so few pharmacists actually supplied Narcan to those in need? Experts point to three factors: cost, stigma and the possibility that customers are not looking for Narcan at pharmacies. 

“This data was surprising given Indiana’s 2016 statewide standing order allowing naloxone dispensing without an exam and the fact that a majority of pharmacists believed the order would increase both naloxone stocking and dispensing,” said Bath Meyerson, co-director of the Rural Center for AIDS/STD Prevention, who led the study and announced its findings earlier this month.

Specifically, researchers at the IU school of Public Health-Bloomington’s Rural Center for AIDS/STD Prevention and the Institute for Research on Addictive Behavior found that chain pharmacies were more likely to stock naloxone.

Pharmacies with more than one full-time pharmacist and “those where pharmacists received naloxone continuing education in the past two years” were also more likely to stock the medication, according to a media release.

But with such a low number of pharmacies actually dispensing Narcan, it’s time to reconsider the process, said Howard County Public Health Project Coordinator Jennie Cauthern.

Cauthern noted that the cost of Narcan at a pharmacy, without insurance, is around $100. Even with insurance, the discount level is dependent on a person’s insurance plan.

And stigma, she added, “is still a major factor in not just getting naloxone but also who is willing to give it out.”

The Indiana State Department of Health implemented in 2016 a standing order that allows pharmacies, treatment centers, nonprofit agencies and other entities to register with the state to distribute Narcan without a prescription.

Framework for the order - specifically legislation called Aaron’s Law that was named after a 20-year-old Indianapolis resident who died of a heroin overdose - allowed families and friends to access the drug one year earlier. The standing order was renewed in June 2017 and will likely be renewed again this summer.

In 2017, there were 682 registered entities – nearly double 2016’s number – in Indiana that distributed a combined 3,942 naloxone kits. More than 3,800 of those kits were intranasal kits. But, the study states, it’s unclear whether each pharmacy that registered with the state actually stocked the medication.

Additionally, not a single nonprofit agency in Howard County is registered through the state to distribute Narcan. Instead, distributors in the area include Walgreens and CVS stores, and even Walmart and Kroger pharmacies.

Cauthern said that when she talked with pharmacists in 2017 if they had distributed Narcan, they told her “no one was coming in asking for it.”

Another route to obtain Narcan can be local health departments. Forty-nine of Indiana’s county health departments have been given Narcan rescue kits and training, according to the ISDH, but Cauthern said that approach can also be fraught with hurdles.

“I think people are warming up to the idea, but there still is stigma out there around naloxone, harm reduction and drug use in general,” she said. “We have great community members who come to the health department, get trained and carry naloxone on them every day in case they come across an emergency situation.

“However, the people that really need it aren’t as willing to come to the health department to get it. The fear of arrest, being labeled as a drug user or someone who has a family member using opioids are major reasons people don’t seek it out.”

In conjunction, added Cauthern, there are many professionals who can’t “overlook illegal activity,” a mindset that contributes to an underwhelming presence of Narcan in Indiana. 

“Taking prescription opioids given to you by a doctor is not illegal but injecting heroin is and yet most people start using legally and move to illegal activity because it’s cheaper and easier,” she said. “I do believe that there are providers who may not want to distribute naloxone because it conflicts with their ethical or religious standards.

“In the end, we are all just human and can make subjective judgements. My hope is that everyone one day can look past the activity and see the person behind the addiction to help them improve their health and their future." 

Combatting that hesitancy has been U.S. Surgeon General Jerome Adams, who served from 2014 to 2017 as Indiana’s state health commissioner. In April, Adams released an advisory urging Americans to carry Narcan, saying “it is time to make sure more people have access to this lifesaving medication.”

Seventy-seven percent of opioid overdose deaths, he said, occur outside a medical setting and more than half occur at home. If Narcan becomes available in everyday settings, specifically residences, overdose death numbers will drop, believe experts.

“To manage opioid addiction and prevent further overdoses, increased naloxone availability must occur in conjunction with expanded access to evidence-based treatment for opioid use disorder,” said Adams.

Others, like Indiana Pharmacists Alliance Executive Vice President and COO Randy Hitchens, believe the demand for Narcan at pharmacies will grow alongside increased awareness.

“It’s never been used at retail; it’s never been handed out to consumers until recently. Obviously with this opioid crisis, it’s created this new world that we live in,” said Hitchens, who supports pharmacies stocking Narcan. “So retail pharmacists haven’t really been involved in filling prescriptions or providing naloxone to patients until the last two years.”

Researchers say the goal will be to predict factors that would indicate pharmacists actually dispensing the medication.

"The question moving forward, and what will be addressed in our future work, is what predicators indicate pharmacists actually dispensing naloxone," said Jon Agley, co-investigator and deputy director of the Institute for Research on Addictive Behavior.

Related Stories:
• Opioid crisis: Knowing Narcan is half the battle

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