Policy changes to pharmacy-based naloxone provision significantly increased uptake among high-risk individuals
Pharmacy-based naloxone dispensing increased in Ontario—particularly among individuals at a high risk of accidental opioid overdose—following changes to the Ontario Naloxone Program for Pharmacies (ONPP), suggests a new study by the Ontario Drug Policy Research Network (ODPRN).
The study, published Nov. 18, examines the impact of two specific changes to the ONPP implemented in March 2018: providing access to intranasal naloxone and removing the requirement to present a government health card at the time of dispensing. This work is part of a broader evaluation of policies relating to the opioid overdose crisis, explained Dr. Tara Gomes, a Scientist at the Li Ka Shing Knowledge Institute of St. Michael's Hospital and ICES, and a principal investigator of the ODPRN.
"One of our research priorities is understanding the way publicly-funded naloxone has been made available across Ontario," she said. "In this study, we wanted to explore how removing barriers to naloxone access impacted uptake of this important harm reduction tool."
According to the study, 199,484 individuals were dispensed a naloxone kit through the ONPP between July 1, 2016 and March 31, 2020. Overall, the ONPP program changes were associated with a 65 percent increase in naloxone dispensing across the province; however the impact of program changes differed among patient groups.
For example, naloxone dispensing increased by 98 percent among current recipients of prescribed opioids and 115 percent among people being treated for an opioid use disorder. Dr. Gomes attributes these findings partly to the introduction of the intranasal formulation of naloxone which may be more accessible to chronic pain patients. According to Dr. Tony Antoniou, a co-principal investigator of the study and Scientist at the Li Ka Shing Knowledge Institute and ICES, this finding is particularly important because people who take prescribed opioids may not perceive themselves to be at risk of accidental overdose—even though prior research suggests that this is not the case.
Additionally, due to the stigma that exists within the healthcare system for people who use drugs, individuals at risk of opioid overdose may not feel comfortable presenting a pharmacist with identification to access a naloxone kit or may not have a government-issued health card to present. Now, they no longer have to do that.
"An advantage to the ONPP is that it provides access to this life saving harm reduction medication at pharmacies, where chronic pain patients and patients being treated for an opioid use disorder are already visiting for their other medication," said Dr. Antoniou.
The availability of the intranasal formulation appeared to be the more impactful of the two program changes. By March 2020, the intranasal formulation represented 73 percent of all naloxone kits dispensed through the ONPP.
"The intranasal formulation is it's relatively simplicity to use," Dr. Gomes said. "Drawing a medication into a syringe and administering it through injection can seem intimidating for some people, whereas the intranasal form is less daunting."
The proportion of naloxone kits dispensed without presenting a government health card changed from zero percent in July 2016 to 37 percent in March 2020, an increase that should be higher, Dr. Gomes said.
"We continue to hear from people in the community that pharmacists are asking them to show identification even though that requirement has been removed," she said. This presents an obstacle for people at risk of opioid overdose who don't have a government-issued health card, or who are uncomfortable identifying themselves out of fear of repercussions within the healthcare system.
The study is the first to quantify the effect of policy changes in an existing program targeting specific barriers to naloxone access. Dr. Gomes hopes the findings of the study can inform the development of pharmacy-based naloxone programs in other jurisdictions to remove barriers to access. Removing potentially stigmatizing requirements for identification has become even more important as the COVID-19 pandemic has increased opioid overdoses across the country.
"We need to make sure that changes are applied consistently to reduce barriers to naloxone experienced by people throughout our healthcare system," she said. "This study shows that optimizing the distribution of multiple formulations of naloxone through community-based pharmacies, while removing barriers to access is effective, and has the potential to save lives."