(44) Opioid Use Disorder Medication Accessibility in Central and Outlying Texas Counties

Background & Introduction: Texas has experienced a staggering 129% increase in unintentional opioid deaths from 2011 to 2023. This alarming trend underscores the critical need for effective interventions in opioid overdose prevention. The accessibility of naloxone nasal spray (NNS) and buprenorphine-naloxone (BUP/NX) is vital for mitigating opioid-related fatalities. NNS rapidly reverse opioid overdoses, while medication-assisted treatment (MAT) with BUP/NX reduces all-cause opioid-related mortality by approximately 50%.

However, significant barriers hinder access to these life-saving medications. Challenges include medication supply, geographic disparities and cost. Legislation between 2015-2016 enabled providers and pharmacists to dispense NNS without individual prescriptions. Furthermore, the 2023 FDA approval of Narcan and RiVive for over-the-counter (OTC) use and X-waiver requirement removal for prescribing BUP/NX represent substantial regulatory advancements. Even so, obstacles like accessibility, misinformation and stigma persist.

A recent study reported the availability and accessibility of NNS in pharmacies in Harris County, Texas's most populous county. However, the accessibility of NNS and BUP/NX in less populated regional counties remains unexamined. This study aims to assess the availability and accessibility of NNS and BUP/NX in retail pharmacies across smaller Southeast Texas counties, which have some of the highest overdose death rates in the state.

Methods: From April 30 to June 6, 2024, a cross-sectional telephone survey was conducted among community pharmacies in Brazoria, Galveston, Chambers, Jefferson and Orange Texas Counties. Pharmacies were sourced from the Texas State Board of Pharmacy website, with exclusions for expired licenses, inpatient-only services, non-participants or those unreachable after four separate calls. Remaining pharmacies were categorized as chain, independent or other, where “other” included compounding and hospital-affiliated outpatient pharmacies.

Data collection by telephone involved using a standardized script, focusing on same-day availability and dispensing restrictions for OTC NNS and BUP/NX. Information on stock, ordering timelines and pricing was gathered. This approach ensured comprehensive sampling to identify access barriers in metropolitan and outlying areas.

Availability and accessibility of OTC NNS and BUP/NX were compared across pharmacy types using Fisher’s exact test, with similar comparisons among major chains (CVS, HEB, Kroger, Walgreens, and Walmart). Subregional heatmaps were created to illustrate same-day or next-day availability, overlaid with 2023 opioid death rates from the Texas Department of Health and Human Services. Statistical analyses were conducted using SAS version 9.4 and R version 4.4.2, with significance determined at p< 0.05. The UTMB Institutional Review Board approved the project as exempt from oversight.

Results: From a total of 322 pharmacies, 198 met inclusion criteria, including 132 chain, 57 independent and 9 other pharmacies. Among the 124 excluded pharmacies, 80 were not active outpatient community pharmacies, 31 declined participation or did not respond, and 13 had expired/revoked licenses. The survey response rate was 91%.

NNS was available in only 76% of pharmacies, with 54% having at least one restriction to obtaining NNS. Among pharmacies carrying NNS and providing price information, 83% listed cost at or below the suggested retail price of Narcan ($44.99). Chain pharmacies demonstrated the highest same-day availability of NNS (90%) and lower prices (82%), compared to independent (42%, 21%) and other (33%, 11%) pharmacies, respectively (Availability: P< 0.05; Price: P< 0.05). No significant differences in same-day NNS availability were observed among five major chain pharmacies (CVS 84%, HEB 100%, Kroger 100%, Walgreens 94%, Walmart 90%).

BUP/NX was available with same-day access in only 38% of pharmacies. Chain pharmacies had the highest same-day availability at 44%, compared to 28% for independent pharmacies and 22% for other types (P < 0.05). If BUP/NX was unavailable for same-day dispensing, chain pharmacies still reported the highest availability (43%) compared to independent (32%) and other (33%) pharmacies for receiving the medication within one business day (P < 0.05). Among the five major chain pharmacies, same-day availability of BUP/NX differed, with HEB leading (83%), followed by Walgreens (59%), Kroger (59%), CVS (45%) and Walmart (5%) (P < 0.05). When BUP/NX was out of stock, availability within one day varied with Walgreens (63%), followed by CVS (61%), HEB (42%), Kroger (29%) and Walmart (5%) (P < 0.05). The 2023 opioid deaths per 100,000 population varied across counties: Galveston (11.2), Brazoria (11.1), Jefferson (13.1), and Orange (27.5). Geographic disparities were evident and align with greater NNS and BUP/NX access in Galveston and Brazoria counties compared to Jefferson and Orange counties.

Conclusion & Discussion: This study highlights significant disparities in access to NNS and BUP/NX across different pharmacy types and locations. Chain pharmacies generally provide these medications more readily and without restrictions, while independent pharmacies face more barriers. These differences may be attributed to stigma and demographic factors such as age and racial/ethnic composition, which reportedly influence whether populations prefer chain or independent pharmacies.

Barriers to purchasing OTC NNS include placement behind the counter, locked cabinets, or requiring photo identification. These challenges necessitate local policy changes, educational efforts and revised pharmacy procedures to reduce stigma and improve NNS accessibility.

Although chain pharmacies generally offer higher availability, this varies within specific branch chains, suggesting influence by supply logistics and/or company policies. Texas counties often lack adequate resources to combat opioid-related deaths, underscoring the gap between community pharmacies and regulatory standards. A major study limitation is insufficient data on access to providers prescribing BUP/NX or other medications for opioid use disorder (MOUD). Furthermore, the proportion of NNS obtained from pharmacies versus free NNS automats is unclear.

Future research should investigate how regional supply chain constraints, regulatory barriers, pharmacy policies, employee perceptions and MOUD provider access can be addressed to enhance the availability of NNS and BUP/NX.

References: Weiner, Scott G et al. Opioid Overdose After Medication for Opioid Use Disorder Initiation Following Hospitalization or ED Visit. JAMA network open vol. 7,7 e2423954. Jul. 2024

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