Naloxone accessibility without an outside prescription from U.S. community pharmacies: A systematic review.

Background: Recent evidence has identified limited naloxone accessibility in community pharmacies.
Objectives: To summarize current literature regarding naloxone accessibility without an outside prescription from U.S. community pharmacies and discuss implications on community pharmacists' ability to mitigate the opioid overdose epidemic.
Methods: A systematic review was developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed was searched up to May 12, 2022. References from articles chosen for inclusion were subsequently reviewed to identify additional relevant studies. Peer-reviewed publications reporting new data regarding the accessibility of naloxone from U.S. community pharmacies without an outside prescription (e.g., standing order, protocol) were included. Review articles and articles written in a non-English language were excluded. Individual study data were reported, along with a qualitative discussion of limitations of individual studies and in aggregate. When possible, naloxone accessibility data were also pooled and reported as overall accessibility and further stratified by chain versus independent pharmacies and urban versus rural settings.
Results: Thirty studies were included. Naloxone was in stock in 6867 of 10,934 (62.8%) pharmacies, though this varied greatly between studies (range, 26.4%-96.1%). Chain pharmacies were more likely to stock naloxone than independents (69.7% [range, 35.4%-89.1%] vs. 36.4% [range, 19.1%-89.7%], P < 0.0001). Stocking did not significantly differ between urban and rural locations. A total of 5660 of 8999 (62.9%; range, 23.5%-97%) pharmacies audited were willing to dispense without a prescription, with chain (67.4% vs. 22.2%, P < 0.0001) and rural (69.3% vs. 40.7%, P < 0.0001) pharmacies more likely than independent and urban, respectively. Key access barriers identified included naloxone not stocked, high naloxone cost, and pharmacist misinformation or stigma.
Conclusion: Though limited by study heterogeneity, analysis of thirty U.S. studies revealed naloxone was available without a prescription in less than two-thirds of community pharmacies. Availability varied significantly by study and pharmacy type.
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