Over-the-counter naloxone availability at North Carolina community pharmacies: A secret shopper study

Over-the-counter (OTC) naloxone became available for sale at community pharmacies in September 2023. This study examines whether naloxone availability and cost are associated with pharmacy type (independent vs chain), pharmacy rurality, and their interaction.

Using a cross-sectional secret shopper study design, data were collected by phone from a stratified random sample of 600 community pharmacies in North Carolina from November 2023 to January 2024. Trained secret shoppers enacted a standardized script and documented whether the pharmacy: dispensed naloxone, sold OTC naloxone, and offered same-day pick-up. Shoppers also documented the location of OTC naloxone and out-of-pocket cost. Generalized Estimating Equations (GEEs) were used to examine whether naloxone availability and cost varied by pharmacy type (independent vs chain), rurality (urban, suburban, rural), and a rurality*type interaction.

Sampled pharmacies were 48.5 % urban, 11.7 % suburban, and 39.7 % rural, with 50.4 % being chain, 48.2 % independent, and 1.4 % health department pharmacies. Among the 500 pharmacies that sold naloxone, 57.4 % sold the OTC product, which was primarily stored behind-the-counter (62.5 %). Same-day pick-up was available at 82.8 % of pharmacies. In GEE models, rurality was not significant. However, independent pharmacies were significantly less likely than chain pharmacies to sell naloxone, have same-day pick-up, and store OTC naloxone on-the-shelf. Interaction terms were not significant, suggesting that the effect of pharmacy type on naloxone availability and cost did not vary by rurality.

Pharmacy type, not rurality, was consistently associated with naloxone access and out-of-pocket cost. Interventions should address barriers to naloxone access and cost at independent pharmacies.