Part 2: Assessing the Retail Availability of OTC Naloxone
Opioid overdoses claimed almost 80,000 lives in the United States last year. Many of these deaths could have been prevented if more witnesses—especially people who use drugs and their friends and family—had access to the opioid antidote medication, naloxone. However, although the medication reverses an overdose and restores breathing within minutes when delivered promptly, many communities across the country have not reached sufficient saturation to quell the ongoing crisis. As such, policymakers and regulators have taken a multifaceted approach to improving access, including moving standard-dose intranasal formulations of naloxone from prescription-only to over-the-counter (OTC) status.
While OTC costs remain prohibitively high for many people who use drugs, our analysis in Part 1 of this series indicates that competition is beginning to drive prices down. However, lower retail prices will not matter if the products are unavailable in the communities that need them most. Therefore, in Part 2 of this series on OTC naloxone access, we explain why retail availability matters and examine related research.
The Importance of Retail Naloxone
Due to factors such as cost and stigma, community-based organizations such as syringe services programs (SSPs) are the primary distributor of naloxone to people who use drugs. However, these programs are not available in every community—in fact, at least six states still lack a single operating SSP, and 10 states either prohibit them or lack either explicit or implicit authorization. Furthermore, while every state has some sort of policy allowing prescription-free (but behind-the-counter) pharmacy access to naloxone—via pharmacist prescribing and standing orders—barriers still remain. For example, in some states, these laws require people to fill out time-consuming paperwork or show proof of identification or other documentation to access the medication, resulting in stigma and privacy concerns that deter people from purchasing naloxone from a pharmacist, especially in rural communities. By minimizing the need for interaction with retail staff, OTC status should reduce some of these barriers for approved products.
In addition to potentially closing gaps in physical access to naloxone, retail availability can shape out-of-pocket costs. Specifically, although manufacturer-recommended prices for the drug are under $50 for a two-dose pack, they are often sold for much higher prices, with some retailers selling two doses of brand-name intranasal naloxone for $72 or much more. As we note in Part 1 of this series, people living in pharmacy deserts—or in areas where only one pharmacy carries an OTC naloxone product—may be especially likely to encounter these inflated naloxone prices due to a dearth of competition among retailers.
Assessing the Retail Availability of OTC Naloxone
There are more than 60,000 community pharmacies in the United States, compared to fewer than 500 operating SSPs. The vast majority of Americans live less than five miles from a pharmacy. This makes retail pharmacies a good starting point to fill the naloxone access gap in communities that lack robust overdose prevention services for people who use drugs and their loved ones. However, to do so, naloxone must be both available at a wide range of geographically diverse locations and access via these retailers must be straightforward and stigma-free. In the remainder of this article, we review research on the first year of OTC naloxone to assess its retail availability.
The Studies
| NBC News | In February 2024, researchers for the news organization spent three weeks visiting stores across the United States to identify stocking and product-placement tendencies. They went to 64 stores in 15 states and Washington, D.C. |
| Grace T. Marley et al. (JAMA Health Forum) | A team of researchers from North Carolina universities applied a secret-shopper method to assess the availability and cost of naloxone before and after OTC status across the state. They assessed 192 pharmacies. |
| Jeffrey Liu et al. (Baker Institute for Public Policy) | A team of researchers from Rice University conducted a phone survey of 156 retail pharmacies spread across 26 low-poverty communities and 22 high-poverty communities in Houston. |
Which Stores Carry It
According to a national brand manufacturer, naloxone can be purchased at more than 32,000 locations across the United States, including drug and grocery stores as well as online retailers. But that does not necessarily reflect real-world availability.
In its survey of retail pharmacies and drug stores across the United States, NBC News found that most carried at least one brand of OTC naloxone. However, no convenience stores or gas stations carried the product. More localized studies provide some additional insights into OTC naloxone access.
In North Carolina, for example, scholars found that pharmacy dispensing of naloxone without a prescription has increased since the medication’s transition to OTC status. While only 53 percent of pharmacies were willing to dispense the medication without a provider prescription before the OTC status change, almost 71 percent were willing to do so once the medication had OTC status. Furthermore, this study revealed that chain pharmacies were more likely to dispense naloxone without a prescription than were independent pharmacies.
Researchers working in Houston, Texas, reported similar findings. Of the 156 pharmacies surveyed, 69 percent had some form of naloxone in stock that did not require a prescription to access, 14 percent carried a prescription-free naloxone product but were out of stock, and the remaining 17 percent said they did not carry OTC naloxone at all.
Although these studies are not conclusive or comprehensive, they paint a clear and somewhat consistent picture of the first year of OTC naloxone access in retail drug stores. While the shift to OTC status has greatly improved prescription-free availability of the products and a majority of stores do carry it, access is not yet sufficient to ensure low-barrier access for everyone. Not only should more retail pharmacies be open to dispensing OTC naloxone products, but they must make sure the medication is always in stock so people can access it any day they visit the store.
Another way to expand naloxone availability would be for convenience stores and gas stations to begin stocking it. These locations could help fill gaps in pharmacy deserts and have the potential to serve a novel set of consumers.
Display and Access Locations
Even when naloxone was available on shelves (versus behind the pharmacy counter), all three studies found that OTC access was often hindered by poorly marked shelving locations, lock boxes, and more. For example, 65 percent of the North Carolina pharmacies that dispensed OTC naloxone in the post-OTC phase still kept the product behind the pharmacy counter. Similarly, in Houston, 71 percent of stores that carried OTC naloxone kept it behind the pharmacy counter or in another place (e.g., a locked cabinet) that forced consumers to request access via a store attendant. The NBC News study confirmed these findings as well.
By requiring consumers to ask for OTC naloxone, rather than simply allowing them to find it on store shelves alongside pain medication or other OTC drugs, retailers undermine one of the greatest potential benefits of OTC status: stigma reduction.
Finally, although cost is the focus of Part 1 of this series, it is relevant to retail availability and was briefly addressed in two of the reviewed studies. In North Carolina, researchers found that out-of-pocket naloxone costs for cash-paying consumers (i.e., those without insurance) fell substantially with the shift to OTC status, from almost $91 to less than $63. Nonetheless, this price remains significantly higher than the recommended retail price. Similarly, in Houston, researchers found prices as high as $163.96 for a two-dose pack. These price discrepancies are a cause for concern, as such retail mark-ups can further hinder naloxone access and will disproportionately affect people in areas with fewer retailers carrying the products.
Conclusion
Done right, naloxone access via OTC retail channels has the potential to fill some important gaps and improve availability while the medication’s increased visibility may simultaneously reduce stigma. To optimize the benefits of this approach, we must see:
- A diverse range of stores carrying the product. Independent pharmacies should, in this case, follow the lead of chain stores in their willingness to provide OTC naloxone. Gas stations, convenience stores, and other non-pharmacy locations should consider stocking the product as well.
- Consistent stocking. Retailers should not just carry the product but also ensure that sufficient stock is on hand at all times to meet consumer needs.
- Accessible displays. OTC naloxone should sit on pharmacy shelves or in front of the pharmacy counter, with as few barriers to access as possible. Retailers should consider placement locations that are highly visible, easy to find, and—whenever possible—not behind lock-and-key, thus minimizing the need for consumers to ask store associates for assistance.
- Cost. Retailers should resist the urge to price naloxone above the recommended retail price. Expanded access via a greater number of retailers may help overcome this problem if it encourages competition.
Read Part 1: Exploring Cost and the Emerging Landscape of Naloxone Competition here.